USE OF COMPLEMENTARY THERAPIES FOR DIABETES MELLITUS BY
JAMAICAN ADULTS IN SOUTH FLORIDA: A FOCUSED ETHNOGRAPHY
by
Raquel A. Brown
A Dissertation Submitted to the Faculty of
Christine E. Lynn College of Nursing
In Partial Fulfillment of the Requirements for the Degree of
Doctor of Philosophy
Florida Atlantic University
Boca Raton, FL
August 2019
Copyright 2019 by Raquel A. Brown
ii
ACKNOWLEDGEMENTS
“It takes a village” (Anonymous).
I am a product of this village and so it is no easy feat to thank everyone who has guided me to this pinnacle in my life. First, I thank God for giving me the grace to make it to this point. Thank you to all my family, friends, colleagues, and my dissertation committee who nurtured me, influenced me and guided my path. I could not have completed this dissertation without the participants whose knowledge was poured out in this paper. The financial assistance I received helped to ease my journey.
To Dr. Lenny Chiang-Hanisko, the Chair of my dissertation committee, thank you for the tireless hours you put into working with me. Thank you Dr. Lenny Chiang-
Hanisko, Dr. Marlaine Smith, and Dr. Susan Love Brown for letting me lean on your expertise. I thank the faculty and staff and my colleagues at the Christine E. Lynn
College of Nursing, Florida Atlantic University for the input and critique that helped me hone my research question.
I am grateful for the financial assistance I received from the following organizations: Gertrude E. Skelly Foundation Stipend; Cross-Country Scholarship; Jonas
Nurse Leader Scholarship; Florida Nurses Foundation Scholarship; and the Florida State
Doctoral Stipend.
iv Special thanks to my siblings, especially my big sister Avis Brown who took care of me at the passing of my mom. Thanks also to Myrtle Thompson who helped me on my beginning journey to nursing school. I am eternally grateful to the village that raised me.
ii ABSTRACT
Author: Raquel A. Brown
Title: Use of Complementary Therapies for Diabetes by Jamaican Adults in South Florida: A Focused Ethnography Institution: Florida Atlantic University
Dissertation Advisor: Dr. Lenny Chiang-Hanisko
Degree: Doctor of Philosophy
Year: 2019
Jamaicans, the largest group of English-speaking Caribbean people living in the
United States (US), have a history of using bush medicine/complementary therapies (CT) in diabetes management. However, no research described the emic views of Jamaican adults regarding how they select the bush medicine they use or how they know these are suitable to manage diabetes. The purpose of this focused ethnography was to explore and describe how Jamaican adults with diabetes mellitus who live in South Florida select and use complementary therapies for managing their diabetes. The objectives were to: (1)
Explore the emic views of Jamaican adults about using CT to manage diabetes mellitus;
(2) Describe the rationale given by Jamaicans adults for using CT to manage diabetes mellitus; (3) Analyze and synthesize the data gathered about use of CT for diabetes by
Jamaican adults to see if their actions have cultural components that can serve as a basis for providing culturally competent care.
iii There were 13 informants, 7 males and 6 females. There were eight key informants who fully met the inclusion criteria, and five general informants who had knowledge of bush medicine and contributed rich data to the study. Key informants were adults with self-reported diagnosis of diabetes mellitus who emigrated from Jamaica and/or their second-generation offspring who live in South Florida; Jamaican adults who used at least one complementary therapy in managing diabetes mellitus for at least one year.
The informants ages ranged from 44-74 years, with a mean age of 59 years. The average years in the US was 25 years. Informants reported having diabetes for as few as 5 years and as many as 31 years. The focused ethnography entailed in-depth interviews and persistent observation. An inductive qualitative content analysis was employed. Five major themes emerged from the data: (1) Jamaicans follow individualized and diverse folk care patterns when using CT; (2) Jamaicans believe CT are affordable folk care promoted by people they can trust; (3) Jamaicans use traditional folk remedies for managing diabetes; (4) Jamaicans are willing to try folk care in the face of uncertainty; and (5) Jamaicans use self-management strategies trusting the wisdom of the elderly.
Leininger’s Sunrise Enabler to Discover Culture Care was applied during the interpretation of the themes.
Results indicate that the Jamaicans who participated in this study value sharing as a community and practice self-management according to cultural tradition. Study findings can be used to guide safe cultural care of Jamaican adults with diabetes who use bush medicine to manage their diabetes by aiding healthcare providers in planning
ii education, creating and implementing related policies, designing future research and applying appropriate practice approaches. It is recommended that future research be conducted in a similar population using community based participatory research. The study population will be partners in the research process and will likely feel more appreciated as they make contributions and recommendations about how to meet their cultural needs.
iii DEDICATION
I dedicate this dissertation to the memory of my late mom Una Priscilla Lawson.
My mom instilled in me the value of books and the importance of reading at an early age.
She was my first teacher in many things including valuing respect for self and others and maintaining relationships with others. I think she had a wealth of knowledge beyond my understanding. Bush medicine was a part of our lives that I did not perceive until recently, and might, along with my professional experience, have influenced my interest in the subject. Rest forever in peace. I love you mom.
USE OF COMPLEMENTARY THERAPIES FOR DIABETES MELLITUS BY
JAMAICAN ADULTS IN SOUTH FLORIDA: A FOCUSED ETHNOGRAPHY
LIST OF TABLES ...... ix
LIST OF FIGURES ...... x
CHAPTER I. INTRODUCTION ...... 1
Phenomenon of Interest ...... 1
Purpose ...... 3
Research Questions ...... 3
Significance ...... 3
Background ...... 4
Connection to Caring Science ...... 9
Researcher’s Perspective ...... 13
Experiential ...... 13
Theoretical ...... 14
Conceptual Definition of Terms ...... 15
Summary ...... 16
CHAPTER II. LITERATURE REVIEW ...... 18
Historical Roots ...... 20
Use of Herbal Remedies and Food for Self-care for Diabetes ...... 21
Religion and Spirituality as CT for Self-care for DM ...... 26
v The Humoral System as CT for Self-care for DM ...... 29
Other CT Used in Diabetes Care within the Caribbean ...... 30
Critical Synthesis of Theoretical and Empirical Foundation ...... 31
Common Practices ...... 32
Infrequent Practices ...... 34
Discussion of gap in knowledge base...... 35
Summary ...... 37
CHAPTER III. RESEARCH METHODOLOGY ...... 38
Research Design ...... 39
Procedure ...... 42
Sampling, Recruitment, Setting ...... 44
Data Generation ...... 47
Data Analysis ...... 50
Establishment of Trustworthiness ...... 54
Study Rigor/Trustworthiness ...... 54
Ethical Considerations...... 60
Respect for Person ...... 60
Beneficence ...... 61
Justice ...... 61
Summary ...... 63
CHAPTER IV. FINDINGS ...... 65
Participant’s Characteristics ...... 65
General Participants ...... 66
vi Key Participants ...... 69
Major Themes ...... 75
Research Question 1: How do Jamaican People with Diabetes Mellitus Use
Complementary Therapies for Managing their Diabetes? ...... 75
Research Question 2: Why do Jamaican people who live in South Florida include
complementary therapies in diabetes management? ...... 82
Research Question 3: What CT are Used by Jamaican People with Diabetes who
Live in South Florida? ...... 91
Research Question 4: How do Jamaican People with DM who use CT Describe
How they Know what CT are Appropriate for Managing Diabetes? ...... 97
Research Question 5: How do Jamaican People Describe or Report Evidence that
the CT they use for DM Work to Reduce or Improve their Symptoms or the
Effects of the Disease? ...... 103
Central Meaning ...... 106
Chapter Summary ...... 114
CHAPTER V. DISCUSSION ...... 115
Discussion of Findings ...... 116
Theme 1: Jamaicans Follow Individualized and Diverse Folk Care Patterns while
Using CT...... 116
Theme 2: Jamaicans Believe CT are Affordable Folk Care Promoted by People
they can Trust ...... 118
Theme 3: Jamaicans Use Traditional Folk Remedies for Managing Diabetes ...... 120
Theme 4. Jamaicans are Willing to Try Folk Care in the Face of Uncertainty ...... 121
vii Theme 5. Jamaicans Use Self-management Strategies Trusting the Wisdom of the
Elderly...... 122
Implications for Nursing ...... 123
Nursing Research ...... 123
Nursing Practice ...... 124
Nursing Education ...... 126
Nursing Policy ...... 127
Study Limitations ...... 128
Recommendations for Future Research and Culture Care ...... 129
Summary ...... 131
APPENDICES ...... 134
Appendix A. Adult Consent Form ...... 135
Appendix B. Recruitment Flyer ...... 136
Appendix C. Script for Verbal Advertisement ...... 137
Appendix D. Sociodemographic Questionnaire ...... 138
Appendix E. Letters of Cooperation ...... 140
Appendix F. Florida Atlantic University IRB Approval ...... 142
Appendix G. Sample Interview Guide ...... 144
Appendix H. Permission to Use Leininger’s Sunrise Enabler ...... 146
REFERENCES ...... 147
viii LIST OF TABLES
Table 1. Comparison of Percentage of Diabetes in Select Caribbean Populations in
2014...... 8
Table 2. Descriptive Statistics...... 66
Table 3. Demographic Characteristics of Sample Population ...... 74
Table 4. Description of CT/Bush Medicine Used by the Participants and Scientific ..... 108
ix LIST OF FIGURES
Figure 1. Leininger’s Sunrise Enabler to Discover Culture Care...... 11
Figure 2. Image of Moringa Tree ...... 79
Figure 3. Recipe for Black Seed Oil ...... 79
Figure 4. Major theme 1 ...... 81
Figure 5. Major theme 2 ...... 91
Figure 6. Image of Cho-cho ...... 93
Figure 7. Image of Dogblood...... 94
Figure 8. Image of Cabbage ...... 94
Figure 9. Image of Cerasee ...... 95
Figure 10. Major theme 3 ...... 97
Figure 11. Major theme 4 ...... 102
Figure 12. Major theme 5 ...... 105
Figure 13. Image depicting central meaning of major themes ...... 106
x CHAPTER I. INTRODUCTION
Phenomenon of Interest
Caribbean people living in the United States (US) are more likely to experience diabetes mellitus (DM), and are less likely to receive adequate and culturally congruent care for their diabetes than their non-Hispanic White counterparts. It is challenging to address the health needs of the vulnerable Caribbean people within the US, who are often not distinguished from other ethnic minorities. People from the Caribbean who live in the
United Kingdom also have higher rates of diabetes and associated mortality than the overall UK population (Goff, Timbers, Style, & Knight, 2014; & Scott, 1998).
Diabetes is an important chronic disease in the US because of its devastating systemic effects as well as the number of people affected. In 2015, it was estimated that
30.2 million adults in the United States have DM, almost 24% of that number were not aware that they had the disease (CDC, 2017). According to the U.S. Census Bureau
(2017), there were about four million immigrants from the Caribbean living in the US in
2010.
Diabetes is a non-infectious chronic disease of epidemic proportions that contributes to the development of other non-infectious diseases such as strokes and heart attacks. The World Health Organization (WHO, 2016) indicated that diabetes would become the seventh leading cause of death in the world by the year 2030. Hyperglycemia has disabling effects on the eyes, nerves, heart, blood vessels, and kidneys, and people may die prematurely (WHO, 2016). Conversely, in the US diabetes holds seventh place
1 in the top causes of death (Centers for Disease Control and Prevention [CDC], 2017).
Heart disease and stroke are among the top five causes of death in the US (CDC, 2014).
Many people succumb to the devastating complications of diabetes. (CDC, 2014;
WHO, 2016). Along with concerns about the effects of diabetes on their overall health,
Caribbean adults are concerned about the undesirable effects of medications for diabetes.
According to Picking, Younger, Mitchell, & Delgoda (2011), Jamaican respondents reported that conventional medicines were far too expensive, produce many side effects, and were not effective when used alone.
People of the Caribbean are known to incorporate complementary therapies in the management of diabetes mellitus. According to Picking et al. (2011), within the
Caribbean community complementary therapies are preferred to the use of conventional therapies alone. Jamaican respondents were in favor of using herbal remedies as a complement to conventional medicines, believing there was no harm in using them together (Picking et al., 2011).
Complementary therapies for diabetes have been used with success by Caribbean people (Mahabir & Gulliford, 1997; Clement, Baksh-Comeau, & Seaforth, 2015). Several reasons influence the use of complementary therapies including culture, economics, and not wanting to rely on conventional therapies (Lowe, Morrison, Bahado-Singh, & Riley,
2012). Some herbs that are used to manage diabetes are said to follow a folklore pattern, while some have scientific evidence proving effectiveness (Lowe et al., 2012).
2 Purpose
The purpose of this study is to explore and describe how Jamaican adults with
diabetes mellitus who live in South Florida select and use complementary therapies for
managing their diabetes.
Research Questions
The central question is: How do Jamaican adults with diabetes mellitus who live
in South Florida select and use complementary therapies for managing their diabetes?
The following are the subquestions:
1. How do Jamaican people with diabetes mellitus use complementary therapies for
managing their diabetes?
2. Why do Jamaican people who live in South Florida include complementary
therapies in diabetes management?
3. What are the complementary therapies used by Jamaican people with diabetes
who live in South Florida?
4. How do Jamaican people with diabetes mellitus who use complementary therapies
describe how they know what complementary therapies are appropriate for
managing diabetes?
5. How do Jamaican people describe, or report evidence, that the complementary
therapies they use for diabetes mellitus work to reduce, or improve their
symptoms, or the effects of the disease?
Significance
Treatment of diabetes is important because of its devastating complications.
However, Prabhakar and Doble (2011) indicated that there is no specific medicine on the
3 market to treat the devastating effects of free radicals that result from excessive glucose levels. Still, Lowe et al (2012) stated that scientific investigations have uncovered antidiabetic properties of some herbs that are used for diabetes in the Caribbean.
Awareness of the history, reasons for using, significance of the therapy to the immigrants, and trends in use of complementary therapies will aid in creating strategies for safe and successful health outcomes for consumers of these services. The researcher will learn the cultural similarities and differences that exist within one group of
Caribbean people, Jamaicans who live in South Florida, by seeing their experiences through the eyes of the participants. Rich data about the cultural practices of the Jamaican people living in South Florida regarding how they incorporate things in their diabetes care that are not expressly prescribed/recommended by their healthcare provider are anticipated. This data that will contribute significantly to new knowledge about culture care of Jamaicans and fill some of the gap in the knowledge base.
The new data is expected to improve the nurse’s capacity to plan culturally relevant education sessions. Nurses will then be able to contribute to the development of culturally relevant policy documents. Nurses and other conventional medical providers will be able to use data gleaned from this study to provide care and guide others about how to provide Jamaicans with care that is culturally sound and safe. The study recommendations should result in ongoing research that will further reduce the gap in knowledge.
Background
Use of complementary therapies for health conditions has been a long-standing tradition in the Caribbean. “Bush medicine” (traditional/folk medicine) was used in the
4 Caribbean before conventional medicine became available in the region (Mahabir &
Gulliford, 1997; Mitchell, 1984; & Soelberg, Davis, & Jäger, 2016). When conventional
medicines became available they were incorporated with the traditional medicines,
though a greater inclination towards the use of “natural” remedies persisted (Lowe,
Payne-Jackson, Beckstrom-Sternberg, & Duke, 2001; & Soelberg et al., 2016).
Historically, the political and economic climate influenced the practice of bush
medicine in the Caribbean. Most of the population being of African descent from the era
of slave trade, suffered oppression and deprivation of societal wealth and elite status
(Barima, 2016; Soelberg, et al., 2016). To overcome the oppression and repression still
experienced after emancipation from slavery, the people turned to religion as a reprieve
(Barima, 2016). In Jamaica, for example, the practice of religiosity/spirituality, included
herbal baths, and other medicinal uses of herbs (Barima, 2016). Thus, between the 15th
century and the 19th century, traditional medicine was used by Caribbean people in their
political struggles to gain power and to rise above oppression.
In addition to the historical influence, social determinants of health contribute to
the increased incidence of diabetes among people of Caribbean heritage and their reliance
on complementary therapies. According to Yisahak, Beagley, Hambleton, and Narayan
(2014), Caribbean people are more likely to develop diabetes and are also less likely to
receive appropriate care for the disease because of lower socioeconomic status and social
disadvantage. Lowe et al., (2001) stated that factors such as access to care, costs of care
and barriers related to culture and linguistics such as doubt about diagnosis influenced the
use of traditional medicine and its concomitant use with conventional medicine.
5 Caribbean traditional medicine has gone through an evolution and today includes
complementary therapies. In the mid to late 1600s the English aristocrats in the
Caribbean attracted conventional medical practitioners. With the introduction of
conventional therapies there was an initial decline in use of traditional medicines
(Steggerda, 1929; Long, 1972; & Mitchell, 1984). However, not all peoples adapted as
there was a general distrust of conventional therapies and practitioners. Traditional
practitioners included some conventional therapies within their practice; whereas,
conventional practitioners adopted some of the techniques used by the traditional
practitioners to gain the trust of the people (Mitchell, 1984).
Complementary therapies generally rely on natural traditional/folk/non-
conventional therapeutic modalities to enhance or supplement conventional therapies.
Conventional therapies are often thought of as synthetic agents that carry a higher burden
of unwanted effects. People of the Caribbean, with exposure to conventional as well as
non-conventional modalities, have shown a distinct preference for the use of
complementary therapy thinking they will lessen some of the adverse effects of the
conventional treatments (Alvarado-Guzmán, Gavillán-Suárez, & Germosen-Robineau,
2009; Davis, 1997; Scott, 1974; & Zayas, Wisniewski, Cadzow, & Tumiel-Berhalter,
2011).
Caribbean is an all-encompassing term for a quite diverse population including indigenous Indians as well as people with heritage from various parts of the world including Africa, China, India, and parts of Europe (Brown, 2019). The Caribbean region is also known as the West Indies and consists mainly of islands in and around the
Caribbean Sea. The exact number of Caribbean adults within the US who are affected by
6 diabetes is unknown (Brown, 2019). This is because Caribbean people are often listed as
African-Americans, or Hispanics/Latinos depending on their language and/or the hue of
their skin. Still, it is known that of those adults who are diagnosed with diabetes mellitus,
12.1% are Hispanics, and 12.7% are non-Hispanic Blacks compared to 7.4% of non-
Hispanic Whites (CDC, 2017).
Many Caribbean people may choose to hold on to their traditional ways of managing health conditions, including use the of complementary therapies. Therefore, immigrants may pass on cultural practices to subsequent generations born in the US. So, as the US sees increasing numbers of immigrants from the Caribbean, acculturation may occur to greater or lesser degrees.
The WHO (2014) supports the preservation of traditional ways of managing health and calls for collaboration of stakeholders who will use appropriate guidelines to ensure safety is maintained while effectively using traditional modalities. The WHO
(2017) recognizes that incorporating complementary therapies in primary care while
including individuals and groups in their healthcare can aid in reducing health disparities
that exist between/and within countries. The Beijing Declaration 2008 called for local
and international collaboration to safeguard the safe and appropriate use of
complementary therapies (WHO, 2014). The US responded to the call by legislating the
inclusion of culturally appropriate healthcare, and provision of complementary therapies
to people who request such services (Patient Protection and Affordable Care Act
[PPACA], 2010).
The following data notes the prevalence (percentage of cases) of diabetes within
the Caribbean in the year 2014 as reported by the WHO (2016).
7 Table 1. Comparison of Percentage of Diabetes in Select Caribbean Populations in 2014
Income group Country Language Male % Female % High Antigua & Barbuda English 10 13.6 High Bahamas English 11 14.3 High Barbados English 11.8 16.4 High St. Kitts & Nevis English 12.8 17 High Trinidad & Tobago English 10.9 14.1 Upper Middle Belize English 7.6 12.2 Upper Middle Grenada English 7.4 12.1 Upper Middle Jamaica English 9.1 14.5 Upper Middle St. Lucia English 13.7 15.5 Upper Middle St. Vincent & the Grenadines English 9 11.7 Upper Middle Cuba Spanish 8.7 11.8 Upper Middle Dominican Republic Spanish 7.8 10.6 Upper Middle Suriname Dutch 10.4 13.5 Lower Middle Guyana English 7.2 10.9 Low Haiti Haitian Creole 6.6 7.1
The illustration shows that higher prevalence of diabetes exists in the higher
income groups in the Caribbean. Women also have higher prevalence of diabetes than
their male counterparts, that was true across all countries irrespective of income. The
converse is true for high-income developed countries, in which lower income groups and males had higher prevalence of diabetes (WHO, 2016).
The US in comparison (not illustrated), had lower prevalence of diabetes in Black
non-Hispanic males than in their female counterparts; while there was higher prevalence
in Hispanic males than in their female counterparts (CDC, 2017). The CDC (2017)
indicated that among Hispanics, the prevalence of diabetes was 12% in Puerto Ricans,
and 9% in Cubans. No other Caribbean groups were identified singly.
Furthermore, according to the CDC (2017), the prevalence of diabetes in the adult
US population varied by county. In South Florida, in Broward, Miami-Dade, and Palm
8 Beach Counties the prevalence of diabetes was 9.5%, 7.9%, and 10.9% respectively
(CDC, 2017). The overall prevalence in Florida was 9.3%, compared to 9.1% in the US
overall (CDC, 2017).
Connection to Caring Science
The provision of culturally appropriate care should start with enquiring why some
practices are accepted while others are not (Leininger, 1995). Leininger noted the
interrelatedness between care and culture, and the necessity to draw on culture to
understand both (McFarland & Wehbe-Alamah, 2015). Leininger (1995) explicated that to give “meaningful care” (p. 9) nurses should practice and make health care decisions that align with the client’s needs and/or lifeways.
According to Leininger (1995), caring across cultures is required to help people to be healthy and avoid illness; this entails understanding people’s values, cultural lifeways, and beliefs. Use of complementary therapies (CT) are not limited to any one people or illness. CT are used for acute and chronic health conditions. Culture care theory is empowering and promotes openness within cultures about the values they wish to keep
(McFarland & Wehbe-Alamah, 2015). Based on Leininger’s theory, to render help to
Caribbean people with diabetes who use complementary therapies to be healthy, one must understand their lifeways and how they perceive caring.
Care. Care is a noun referencing phenomena about assisting, supporting, or enabling actions towards other humans with hopes of improving their conditions
(Leininger, 1995).
Caring. Caring refers to the giving of care to ameliorate conditions affecting humans to improve their lifeways or help them face death (Leininger, 1995).
9 Health. According to Leininger and McFarland (2002), health is a culturally- constituted state of well-being or restoration enabling individuals and groups to function daily. This definition will be used for this study.
Lifeways. Lifeway means behavior patterns, as gleaned from Leininger and
McFarland (2002).
Culturally congruent care. For a caregiver to provide culturally congruent care they are required to be sensitive, and creative; their practice must meaningfully align with the values of those to whom they offer care. This definition is adapted from Leininger
(1995).
Worldview. Worldview refers to how people understand life; it is how people perceive their interaction with the external environment according to their value system.
Leininger and McFarland (2002) explains it as the value, stance, picture, or perspective individuals or groups have as they look out or understand their world.
Emic. Insider’s view (Leininger, 1995, p. 62).
10
Figure 1. Leininger’s Sunrise Enabler to Discover Culture Care. Reprinted from Transcultural nursing: Concepts, theories, research, & nursing (4th ed., insert). By, M. R. McFarland & H. B. Wehbe-Alamah (2018). In M. R. McFarland and H. B. Wehbe- Alamah (Eds.), New York, NY: McGraw-Hill. Copyright 2018 McFarland, M. R., & Wehbe-Alamah, H. B. Reprinted with permission. Leininger’s Sunrise Enabler embodies all the tenets of her culture care theory.
The Sunrise Enabler includes several social structure factors that are said to be predictors
11 of health, wellbeing, illness, healing and the ways in which disabilities and death are faced by people (McFarland, 2018). The graphical depiction of the enabler shows that care expressions, and holistic health informs and are informed by factors such as religious, spiritual and philosophical; kinship and social; cultural values beliefs and lifeways; political and legal; and economic; among other. These factors are also inextricably linked.
The influencers give rise to three major decision and action modes: (1) culture care preservation and/or maintenance, that aids culture groups in keeping traditional healthcare practices that are important to them; (2) culture care accommodation and/or negotiation, that allows care providers to effect contracts for safe culture care of their clients; and (3) culture care repatterning and/or restructuring, in which the partnership between care providers and the culture group creates an environment of change to protect health and wellbeing despite cultural inclinations. The researcher will have to discover meanings in the data indicating a relationship to the factors that influence culture care.
Cultural informants will be the ones to verify the influence of the factors on health, wellbeing, illness, and death (McFarland, 2018).
In this prospective study, the lifeways of Jamaican people who use complementary therapies to manage their diabetes will be described from their point of view. The researcher will seek to describe the participants’ views about the care they expected to receive, versus the care they received as people with diabetes. Additionally, the researcher seeks to uncover if and how the caring experience led to their decisions to use complementary therapies as a means for managing diabetes. The evolving themes
12 will be viewed alongside Leininger’s Sunrise Enabler to Discover Culture Care with
hopes to expose any culture care meanings.
The researcher will also observe for similar or different patterns within the data,
that might be more, or less obvious, as part of the discovery process, another tenet of the
theory. McFarland (2018) asserted that emic and etic factors exerted some influence on
outcomes in health and illness. Emic (folk), etic (professional), and integrative care are
also important tenets of Leininger’s Culture Care theory.
Researcher’s Perspective
Experiential
Based on exposure and previous experiences, I surmise that Jamaican people, coming from a region with similar history may have somewhat similar values and lifestyles. Thus, Jamaican people can be described as a cultural group. I also think that people with diabetes may have developed a culture because of having to contend with similar issues surrounding the disease. Similarly, I feel that people who use complementary therapies may have commonalities that are culturally linked. While
Jamaican people are from diverse ethnic backgrounds, they may display cultural similarities regarding how they perceive illness and apply health/healing modalities to manage related issues.
As a new registered nurse in Jamaica I saw that people with diabetes visited the
hospital in acute cases of illness, but had reservations about taking prescribed
medications, especially insulin—the needle—. Although people sought secondary level
care, some brought in home remedies to supplement what they received in the hospital.
While insulin was accepted as the mainstay to control high blood sugar levels in diabetes,
13 the injections were outrightly rejected by some, still others accepted insulin as a last
resort to get their blood sugar under control. It appears that people were convinced that
their home remedies worked well to hasten the effects of the conventional medicine.
Those observations left an indelible mark upon me. They awakened a new
curiosity about how registered nurses are educated, how they practice, create policies,
and how they conduct research to meet the client’s/patient’s needs to the best of their
abilities. Do registered nurses provide interventions that meet the needs of their clients?
The questions that arose developed into a passion to explore more about traditional
medical practices and whether they were just myths or if they had value within contemporary healthcare. The passion has grown into this quest to work towards achieving culturally congruent care for people who seem to hold on to traditional practices.
Theoretical
I recall that I learned in nursing school that some people first discovered they had diabetes because ants would swarm the urine. I also recall that a positive test for sugar was found on testing the urine swarmed by ants. The people affected were later confirmed to have diabetes. This brings to light that diabetes mellitus can be uncovered through unconventional means. Can culturally congruent care for diabetes then follow unconventional patterns?
Vandebroek et al., (2010) describes traditional medicine in the Dominican
Republic as holistic. Indeed, this could be said of traditional medicine in the other
Caribbean countries as well. Leininger, having a holistic view of individuals, recognized that spirituality, sociopolitical factors, education, economics, technology, philosophical
14 views, and cultural beliefs could influence their health and wellbeing. The traditional nursing and medical model did not honor the holistic outlook that valued peoples’ culture, hence the development of Leininger’s theory of culture care diversity and universality (McFarland & Webhe-Alamah, 2015).
Conceptual Definition of Terms
Complementary therapies. Complementary therapies will be defined as non- conventional/non-mainstream practices used together with conventional medicine to manage health conditions and wellness (National Center for Complementary and
Integrative Health [NCCIH], 2016). Complementary therapies will include but not be limited to the following: herbal therapies, therapeutic touch, massage, spirituality, religion, prayer, relaxation, acupressure, reflexology, music therapy, guided imagery, art therapy, dance therapy, martial arts, yoga, aromatherapy, and biofeedback. The list above includes those complementary therapies named by Smith (2005), Saydah and Eberhardt
(2006), and the National Center for Complementary and Integrative Health (NCCIH,
2016).
Conventional medicine. The National Cancer Institute [NCI] (2017) defines conventional medicine as “a system in which medical doctors and other healthcare professionals (such as nurses, pharmacists, and therapists) treat symptoms and diseases using drugs, radiation or surgery. Other names used in place of conventional are: allopathic, biomedicine, mainstream, Western, and Orthodox (NCI, 2017).
Caribbean people. A diverse group of people who can trace their heritage to one of the Caribbean countries.
15 Caribbean countries. Caribbean countries will be defined as countries in the
Caribbean region identified by the US Census Bureau (2017) and WHO (2011) these are:
Anguilla, Antigua and Barbuda, Aruba, Bahamas, Barbados, Belize, Bermuda, British
Virgin Islands, Cayman Islands, Cuba, Dominican Republic, Grenada, Guyana, Haiti,
Jamaica, Montserrat, Puerto Rico, St. Kitts and Nevis, St. Lucia, St. Vincent and the
Grenadines, Suriname, Trinidad and Tobago, and Turks and Caicos.
Jamaican. For this research Jamaican will be defined as a person who was born
and who grew up in the island of Jamaica within the West Indies; or were born of
Jamaican parents.
Culture. Culture is a term that describes patterns or specific ways of acting,
thinking, and decision-making that are learned, transmitted and shared among a group of
people that determines how individuals within the group and the group as a unit behaves
and reacts in any situation. According to Leininger and McFarland (2002) values, norms,
beliefs and lifeways are learned “intergenerationally” (p. 83) through culture.
Traditional. The term traditional has been used interchangeably with folk
practices. Leininger and McFarland (2002) indicated that traditional care is indigenous or
local folk practice. Leininger described traditional care as emic care that is learned and
transmitted through lay people (as cited in McFarland & Wehbe-Alamah, 2015).
Summary
Diabetes mellitus is a disorder with significant disabling effects that affects people of Caribbean heritage disproportionately. Caribbean people felt that conventional therapies were not natural and were apt to cause untoward effects. There was an
16 inclination toward use of traditional medicines that were thought to be natural and to have fewer side effects. Traditional and conventional therapies were combined because such combinations were thought to make the conventional therapies more effective. Therefore, the research questions were formulated to discover the what, why, and how of CT use by
Jamaicans with diabetes. The research questions were products of the study purpose. The
Jamaicans living in South Florida who use complementary therapies for managing diabetes will be studied to discover the extent to which culture influences their healthcare practices. The researcher intends to explore the themes using Leininger’s Sunrise
Enabler.
17 CHAPTER II. LITERATURE REVIEW
The use of herbs for medicinal purposes has been a long-standing Caribbean tradition that started with the original inhabitants of the region, the Amerindians. Many of the herbal remedies used are considered everyday food items in the respective countries.
Qualitative reports from Caribbean respondents with diabetes indicate that complementary therapies show effectiveness as treatment modalities. Two quantitative studies also report effectiveness of CT in reduction of blood glucose levels in Caribbean participants with diabetes. However, studies also exist that do not support the effectiveness of complementary therapies.
This review of the literature presents a deeper understanding of the context of CT as they relate to this research. The review begins with an exposition of the historical roots from which CT in the Caribbean were derived. It includes use of herbal remedies and food as CT for self-care for diabetes, religion and spirituality as CT for self-care for diabetes, and the humoral system as CT for self-care for diabetes. Other use of CT by the
people are also described. The literature synthesis is discussed in detail as it pertains to
common as well as infrequent practices related to CT use. There is a discussion about the
gaps in knowledge that were identified including the link to caring science.
The United States of America has been a haven for peoples of many lands, not in the least are people of the neighboring Caribbean islands. Evidence shows that people who migrate to other lands at times maintain their lifeways, be they different from, or like
18 the practices of their newfound home. The use of complementary therapies is one of
those practices that Caribbean people have maintained.
Complementary therapies for medical conditions are rooted in the traditions of
Caribbean people. When Caribbean people migrate to the Unites States (US), they often
continue to use their trusted complementary therapies for common health conditions. A
study by Scott (1974) that examined healing practices of ethnic groups including
Bahamians, Cubans, Haitians, and Puerto Ricans who live in Miami, found that each group carried their own traditional health and healing practices from their country of origin.
Complementary therapies are employed in healthcare for various reasons including the chronic condition diabetes mellitus. Complementary therapies were shunned in Western medicine because they were considered non-scientific modalities
(Smith, 2005). However, thanks to the work of nurses and other scientists, complementary therapies are being recognized for their potential to support health and healing (Smith, 2005; & Smith, 2012).
Complementary therapies are preferred by some consumers concerned about the side effects of conventional treatments (Picking et al., 2011). The researcher anticipates that treatment that minimizes adverse effects will be beneficial and greatly appreciated.
Complementary therapies may be suitable in such situations.
Complementary therapy use in the Caribbean occurs as a part of systems of care
that may be used singly or in tandem with each other. These systems are relatable and include the humoral system, religion and spirituality, and eating for health and well-
being. The systems of care are intimately tied into beliefs about what causes ill-health,
19 and how to maintain health and cure/treat ailments/maladies. Moreover, these systems of care seem to have been passed on from one generation to another and evolving from a mixture of cultures.
In the last half century, there have been great strides in technology, including advances in medical devices and conventional medications Yet, herbal remedies have maintained relevance in the health and welfare of Caribbean migrant communities present in the US. An example can be seen in a study by Vandebroek et al., (2010) that showed that a bi-country study of people of the Dominican Republic residing in their home country and those residing in New York, US reveals that those living in the US continue to use traditional herbal remedies, whether obtained personally or from specialists in the Dominican Republic. This review of the literature considers the historical basis that influenced development of complementary therapy use in the
Caribbean.
Historical Roots
The history of complementary therapy use in the Caribbean can be traced to the first known inhabitants of the region, the Amerindians. The Amerindians are the indigenous peoples of the Americas who were called Indians because when Christopher
Columbus arrived in the Caribbean region he mistakenly thought he had arrived in India
(Senior, 2003). Later, on realizing his error Columbus referred to the region as the New
World, or the Americas. Another term used to describe the region is the West Indies. The
Term Amerindian does not describe a single group, but rather various groups of indigenous peoples that includes Mayas, Incas, Arawaks, and Taínos, among others.
20 According to Clement et al. (2015), the Amerindians used plants that were
indigenous to the area in their healthcare rituals. In addition to the Amerindian, other
groups of people who arrived in the Caribbean region brought with them flora (plant
material), which they eventually incorporated with the local flora for medicinal use.
European settlers brought Africans as slaves, and later indentured Asian Indian laborers
who had inherent knowledge of medicinal plants (Clement et al., 2015). Each group of
people that arrived in the region contributed to the development of traditional medicine in
the local area in which they resided.
It was a cultural norm for the caregivers to come from within the family unit.
Delgado (1979) stated that to maintain cultural integrity, Puerto Ricans living in New
York often turned to the mother or grandmother in the family for healing services. They
would explore external sources of healthcare when those within the home were
unsuccessful (Delgado, 1979).
Despite different practice patterns, most often migrants utilized their herbal
remedies first, and then may have incorporated spiritual practices such as prayer and then
perhaps conventional medicine depending on the response or lack thereof to the herbs
(Scott, 1974; Davis, 1997). Puerto Ricans may have chosen to return to Puerto Rico, and
Bahamians to Bahamas for specialized care from traditional healers when they felt all
systems had failed in the US (Scott, 1974).
Use of Herbal Remedies and Food for Self-care for Diabetes
Several studies about medicinal use of plants, described those used for diabetes among people of the Caribbean. These data were narrative and written words by participants. Plants and plant derivatives were used to maintain health and cure illnesses.
21 Throughout the literature it was found that despite the vastness of the region and distance between many of the countries, several of the plants were used similarly across the nations. Caribbean participants used well known foods and some lesser known herbs as
CT. Bananas, onion, garlic, green tea, Nopal (prickly pear cactus, Nispero (loquat or
Chinese plum), lemon juice, vinegar, cerasee/caraili/bitter melon (Momordica charantia), cinnamon bark and pills, mauby bark, aloe, and celery were among the herbs named
(Caban & Walker, 2006; & Smith, 2012).
In the Caribbean tradition, most of the plants were self-grown, or obtained through spiritual/religious leaders (Lowe et al., 2001). They were taken orally in the form of solid or liquid substances. The methods used to obtain these herbs are inherently a part of the system used. Therefore, users of herbal remedies tend to participate in self- administration of care, and/or seek assistance of herbal specialists including religious and spiritual healers.
Health practices within the family unit were usually based on an extensive knowledge of botanicals developed with years of experience (Delgado, 1979). Herbs that were not easily acquired were obtained at local “botanicas” or even via mail from Puerto
Rico (Delgado, 1979). People of the Dominican Republic and Puerto Rico who lived in
New York, used Nopal, and Nispero to lower blood glucose levels (Caban & Walker,
2006).
Participants stated that they recovered faster when they used herbal therapies and conventional medicine together. Seventeen percent of 104 participants, stated that they used herbs to cure their diabetes (Zaldívar & Smolowitz, 1994). Zaldívar & Smolowitz did not name the herbs that were used. Furthermore, Quatromoni (1994) noted that Puerto
22 Rican and Dominican Republic participants living in Massachusetts who had non-insulin
dependent diabetes mellitus (NIDDM), also called type 2 diabetes, used tropical fruits,
boiled eggplant, grapefruit juice or skins, and lemon juice mixed with olive oil as
traditional remedies to treat diabetes. Mahabir & Gulliford (1997) conducted a study that
include Afro-Trinidadians, Indo-Trinidadians, and Mixed Trinidadians. Afro and mixed
Trinidadians were more frequently reported to use bush medicine for diabetes. The
following plants used as medicine for diabetes, were associated with hypoglycemic
activity: Momordica charantia, Aloe vera, Catharanthus roseus, Allium sativum, and
Panax ginseng. Neurolena lobate, Leonotis nepetifolia, Annona muricata, Bontia
daphnoides, Cymbopogan citratus, Cassia alata, Citrus sp., Phyllanthus amarus, Cordia
curassavica, were other plants commonly used by participants.
In Trinidad and Tobago, Lans (2006) found that participants used the following
herbs to treat diabetes: Antigonon leptopus, Bidens alba, Bidens pilosa, Bontia
daphnoides, Carica papaya, Gomphrena globose, Bixa orellana, Catharanthus roseus,
Cocos nucifera, Laportea aestuans, Momordica charantia, Morus alba, Phyllanthus
urinaria, and Spiranthes acaulis. Animal studies involving the herbs named above,
showed varying outcomes, which included: (a) decreased fasting glucose levels; (b)
reduction in serum glucose levels in rats that were induced with diabetes; (c) prevention
of diabetes in non-obese rats; and (d) prevention of degeneration of pancreatic beta cells that could result in diabetes (Lans, 2006). Those results hold promise for validation of the
oral reports from people of the successes they have from use of the herbs. Scott (1998)
indicated that most West Indians used herbal remedies to complement prescribed
23 regimens. The remedies included Bush teas, bitters, evening primrose oil, fresh garlic and
garlic tablets, laxatives, and water.
In the Netherlands, immigrants from Suriname used 16 species of plants for
diabetes (van Andel & Westers, 2010). Bitter tonics and vegetables (Quassia amara,
Momordica charantia, Aloe vera, Cecropia sciadophylla, Salanum and macrocarpon)
were consumed to bitter the blood and lower the symptoms of diabetes. Out of Jamaica,
of several health conditions surveyed, participants with diabetes reported the highest uses
of complementary herbal therapies (Delgoda, Younger, Barrett, Braithwaite, & Davis,
2010). Fifty-four participants practiced herb-drug co-administration for diabetes. The herbs used include: Aloe vera, Momordica charantia, Allium sativum, Satureja viminea,
Citrus aurantifolia, Salvia serotina, Bidens pilosa, Cassia occidentalis, Psidium guajava,
Opuntia cochenillifera, and Morinda citrifolia. Picking et al. (2011) indicated that among
Jamaican adults, the following herbs were used concomitantly with Metformin to treat diabetes: Momordica charantia, Aloe vera, Andrographis paniculate, Morinda citrifolia, and Opuntia cachentillifera. The aim of that study was to estimate the number of people who used herbs while on prescribed medicines. However, the results brought out important findings, for example: people with higher education used herbs and prescribed
medications about the same rate as people without schooling. That is a striking finding
because education tends to be linked with better economic status, and the trend in this
study showed that people who had higher income and insurance coverage for their
prescriptions tended to use the herb-drug combination less than those who lacked
insurance and had lower incomes. The effects of the concomitant use of herbs and
24 prescription medications on the medical condition for which they were used were not discussed.
Smith (2012) found that 30 Afro-Caribbean women living in Southwest Florida believed that Momordica charantia, Cinnamomum verum, Colubrina arborescens, Aloe vera, Apium graveolens, and bush tea (unspecified) lowered blood glucose. These women were from Trinidad, Jamaica & Curaçao. Participants felt that the herbs lowered their blood glucose levels and hoped to one day stop taking prescription medications altogether with continued use of traditional medicines (Smith, 2012). In Trinidad, Clement et al.
(2015) conducted a study using a random selection of participants thought to be most knowledgeable about use of herbs. Reports from participants indicated that the plant species that were used for diabetes included: Gomphrena globose, Catharanthus roseus,
Bidens pilosa, Eclipta prostrata, Neurolaena lobate, Parthenium hysterophorus,
Vernonia amygdalina, Crescentia cujete, Dolichandra ungus-cati, Tournefortia hirsutissima, Bixa orellana, Rhipsalis baccifera, Carica papaya, Bryophillum pinnatum,
Leonata nepetifolia, Mimosa pudica, Tamarindus indica, Hibiscus rosasinensis,
Azadirachta indica, Bontia daphnoides, Phyllanthus amarus, Piper tuberculatum,
Antogonon leptopus, Genipa Americana, Morinda citrifolia, Spermacoce verticillate,
Cecropia peltata, Lippia alba, Cheallacostus speciosus, The herbs named above may seem repetitive because other researchers have identified them within their lists of herbs for diabetes. Clement et al, (2015) were able to find only “sparse” (p. 25) clinical evidence in the literature, but reported that cell cultures, isolated tissues, and laboratory animal studies may support the use of herbs. Clement et al. seemed to be surprised that
“cooling” was one of the most popularly reported use for the plants, and that the hot-cold
25 balance was still prominent in health belief in rural communities in developing countries
(Clement et al., 2015).
A total of five species of plants were said to be used for diabetes in the 20th century as well as in contemporary [2014] times in the U.S. Virgin Islands (Soelberg et al., 2016). These plants are: Canella winterana, Colubrina elliptica, Guaiacom officinale,
Phyllantus niruri, and Stachytarpheta jamaicensis. This goes to show that people continue to believe that these plants have value in treating diabetes despite growth in contemporary medicine. Giovannini, Howes, and Edwards, (2016) mentioned 16 species of plants that were used to manage diabetes in Belize. 11 species of plants exhibited hypoglycemic effects: Momordica charantia, Neurolena lobata, Persea americana,
Hamelia patens, Bursera siamruba, Carica papaya, Bixa Orellana, Cecropia obtusifolia,
Acosimium panamense, Catharanthus roseus, Acromia aculeate. Extracts from these plants were found to produce hypoglycemia in laboratory studies (Giovannini et al.,
2016).
Religion and Spirituality as CT for Self-care for DM
Religion and spirituality play an important role in the traditional medical practices in the Caribbean (Schumacher, 2010; Picking et al, 2011; & Cohall, Scantlebury-
Manning, Cadogan-McLean, Lallement, & Willis-O’Connor, 2012). Gomez and Gomez
(1985) state that persons who are oriented towards folk-healing may view certain health conditions from a lens of morality, the supernatural realm, and religious convictions.
Cohall et al., (2012) infer that Barbadians’ use of herbal remedies might be grounded in the Christian Biblical persuasion because of conclusions drawn from the use of herbs in the Bible. For example, The Good News Bible lauds the healing properties of the tree of
26 life, “…On each side of the river was the tree of life, which bears fruit twelve times a year, once each month; and its leaves are for the healing of the nation” (Rev. 22: 2
Today’s English Version).
Magical thinking and the use of spirituality can also be traced to the Amerindians.
Arawak Indians associated death and sickness to the evil influences of rival tribes in other villages (Farabee, 1967). Amerindian history of the Maya and Incas also sheds light on the Shaman also known as the medicineman who while not being a priest, played a major role in religious and ceremonial practices (Wissler, 1922; Corlett, 1935). The Shaman, oftentimes a woman, gained power and favorable outcomes through fasting and praying, and use of plants as well as animals during their healing rituals (Wissler, 1922; Corlett,
1935).
African religious and magical practices such as obeah and myal complex influenced the healthcare for generations spanning from the slave era to the present
(Lowe et al., 2001). The African religious practices for health and healing were significant for the slaves because the practice was by slaves and for slaves whom were trusted more than the slave owners to give the healthcare needed. As Christian missionaries from across the globe began to evangelize within the Caribbean, some
Christian practices were adapted and/or adopted into the native traditional practices for health (Lowe et al., 2001). Thus, religion and spirituality became part of a complex system of health.
Over the years study after study reported the importance spirituality played in the healing of Caribbean participants. Specifically, in relation to diabetes, participants stated that, “God will give us strength to deal with diabetes” (Quatromoni, 1994, p. 872).
27 According to Zaldívar & Smolowitz (1994), most participants in a study of 104 participants, -including 43% Dominican Republic, 8% Puerto Rican, 8% Cuban adults- with diabetes in the United States, reported that religion, priests and God, play a role in the care and control of their diabetes. Jamaicans, St. Lucians, and Trinidadians were among the participants in Scott’s 1998 study, in which participants felt that praying or
“invoking” (p. 411) spiritual assistance was a way of coping with diabetes (Scott, 1998).
One woman felt that divine healing would cure her from her diabetes (Scott, 1998).
A review article by Caban and Walker (2006) cited that in the Dominican
Republic and Puerto Rican population in New York, God, priests and spiritualists were included in the treatment plan for diabetes. On exploration of the articles referenced by
Caban and Walker, one article was found that directly addressed use of spirituality in
Cubans and Puerto Ricans. Interviews with Latinas, including those from Puerto Rico and
Cuba, revealed that spirituality and faith in God provided peace and strength to cope with diabetes (Adams, 2003). This article was among the articles in the review by Caban and
Walker.
In Adams’ 2003 study religious faith was frequently mentioned as an external support system. “Inner peace found with spirituality”, was credited for greater clinical stability. “He [God] expects us to help ourselves. We should not do things that will hurt us” (Adams, 2003, p. 262). According to Smith (2012) 90% of participants interviewed believed that prayer was a complementary treatment to control type 2 diabetes.
Though most of the studies about spirituality and diabetes care in the Caribbean population were qualitative in nature, one quantitative study was found. Newlin et al.
(2003) conducted a quantitative study, comparing African Americans and Afro Caribbean
28 women in New England, who had type 2 diabetes. Newlin et al. examined spirituality as a
self-management strategy for type 2 diabetes in black women to explore if a relationship
existed between spiritual well-being, emotional distress, glycohemoglobin (HbA1C), and
blood pressure (BP) levels. The cross-sectional study by Newlin et al. (2003) examined
among other variables the effect of spiritual well-being on HbA1C. Newlin et al. also
measured emotional distress as a predictor of glycemic control. Mean spirituality scores
were high indicating high levels of spirituality. Scores on the Problem Areas in Diabetes scale (PAID) were low indicating low levels of emotional distress. Thus, spirituality mediated emotional distress associated with DM. These variables were measured over 12 weeks.
The Humoral System as CT for Self-care for DM
Humoral medicine is steeped in the tradition of Latin America and the Caribbean.
The humoral medicine concept derived from Europe and describes good health as the balance among blood, phlegm, black bile and yellow bile, and includes “hot and cold”, and “wet and dry” elements in the body (Lowe et al., 2001). According to Clement et al.
(2015) rural communities across the developing world maintain health and restore balance by using cooling to treat conditions considered to be hot, while treating conditions thought to be cold with heat. Herbs were commonly used to maintain a balance of heating and cooling in the body, especially during the onset of certain health condition. Fever, constipation, and skin ailments are examples of hot conditions (Clement et al., 2015). Diabetes mellitus is a hot condition (Sutherland, Moodley, & Chevannes,
2014). Momordica charantia, an herb that was previously described as being used to
29 bitter the blood, is also known as a cooling agent. Therefore, it would create balance in
someone with diabetes by counteracting the heat.
Other CT Used in Diabetes Care within the Caribbean
Not all articles in this review of the literature fit neatly in the categories named above regarding complementary therapies used for diabetes in Caribbean people. Though herbs are mostly taken internally by oral ingestion, in Barbados herbal preparations have been used to treat diabetic wounds (Carrington, Cohall, Gossell-Williams, & Lindo,
(2012). An experimental study of the anti-infective properties of Justica secunda of the
Acanthaceae family, commonly known as Bloodroot in Barbados, was done because people were using it to treat diabetic wounds (Carrington, et al. 2012). Despite the reported usefulness of the herb for infected diabetic ulcers by the local populace, the chemicals extracted from the plant proved to be ineffective against clinical strains of
Staphylococcus aureus, Pseudomonas aeregunosa, and enterococcus feacalis that were harvested in that study (Carrington, et al. 2012).
Cawich, Harnarayan, Budhooram, Bobb, Islam, and Naraynsingh (2014) also studied external use of herbs for diabetes. Cawich et al. (2014) studied diabetic foot ulcers, a sequela of diabetes that can lead to lower limb amputations. The study by
Cawich et al. (2014) included adults in Trinidad and Tobago who were of East Indian descent. This study found that there were no differences in the rate of amputations, or in- hospital mortality between groups who used medical therapy only, and those who used the herb Kalancoe pinnata as a complementary therapy to treat diabetic foot ulcers.
The study by Gordon, McGrowder, Young, Fraser, Zamora, Alexander-Lindo, and Irving et al. (2008) seemed to be an anomaly when looking at complementary
30 therapy use in Caribbean people. Gordon et al. (2008) selected 231 participants with type
2 diabetes in Cuba. The participants were randomly assigned to three treatment groups:
Hatha yoga (exercise), physical therapy (exercise), and a control group. Significantly
lower fasting blood glucose (FBG) values were observed between the managed exercise
groups and the control group at three and six-month periods after interventions (p <
.0001). So, whereas Hatha yoga exercise may not necessarily be a traditional complementary therapy that was selected by the people, it is a complementary therapy that was found to be effective for managing diabetes in a Caribbean population.
Critical Synthesis of Theoretical and Empirical Foundation
In this review of the literature, of the articles that strictly addressed diabetes mellitus, all the participants had only type 2 diabetes except participants in one study by
Cawich et al. (2014). Ninety-four percent of the sample observed by Cawich et al., had type 2 diabetes. While some studies mentioned only Caribbean participants, others included Hispanics/Latinos of non-Caribbean origin, still others compared Caribbean participants with Caucasians and/or African Americans.
This section provides a slight hint of the diversity of the Caribbean population.
The sample explored by Cawich et al. (2014) were all from Trinidad and Tobago.
However, they were of East Indian, African and Mixed ethnicities. Afro-Caribbean women hailing from three countries (Trinidad and Tobago, Curaçao, and Jamaica) were studied by Smith (2012). While Gordon et al. (2008) studied a sample of Cubans. Cubans are usually classified as Hispanics. In all, 10 Caribbean countries were mentioned by name, Belize, Cuba, Curaçao, Dominican Republic, Jamaica, Puerto Rico, St. Lucia,
Suriname, Trinidad and Tobago, and the U. S. Virgin Islands.
31 Common Practices
As can be seen from the literature, herbal treatments are quite popular complementary therapies used for diabetes in the Caribbean. Inclusion of herbal remedies into the treatment regime was apparently seamless because the herbs may have been readily available and relatively inexpensive. Carili (Momordica charantia), Aloes (Aloe vera), Olive-bush (Bontia daphnoides), and Seed-under-leaf (Phyllanthus urinaria) are preferentially used for diabetes in Trinidad and Tobago because they reduce blood glucose levels (Mahabir & Gulliford, 1997).
According to Lans (2006) Aloe vera, Catharanthus roseus and Momordica charatia may be safe, and more formal evaluations are justified. Glomphena globosa,
(White bachelor button) is also used to treat diabetes in Trinidad (Clement et al., 2015).
The use of Tilia europa is noted as treatment for diabetes in Cuba (Cano & Volpato,
2004).
A decades old study by Davis (1997) might have discovered a thread still true today, that of a general mistrust of conventional therapies among users of folk remedies because of known or unknown side effects. In one study Jamaican respondents stated that conventional drugs on their own were no good (Picking et al., 2011). The reason most frequently cited by Jamaicans for using herbal remedies is that they work (Picking,
Delgoda, Younger, Germosen-Robuneau, Boulogne, & Mitchell, 2015).
Apart from the distrust of conventional therapies and conventional medical practitioners, the relationship between the traditional medicine users and the healer was an important part of the healing process for Caribbean people. The women in the family were the attendants, and the relationships established gave those being cared for a sense
32 of nurturance (Delgado, 1979; Davis, 1997; & Schumacher, 2010). Schumacher (2010)
utilized Leininger’s culture care theory and ethnonursing method to discover the meaning
of care practices for Dominicans living in rural Dominican Republic. Presence of family,
respect and attention, and use of folk and professional practices are highly valued by
people of rural Dominican Republic (Schumacher, 2010). Based on the findings of
Schumacher, people of rural Dominican Republic used conventional medicine as well as
herbal remedies. However, they valued family and feeling respected by caregivers more
highly within the selected system of care. Furthermore, Delgado (1979) stated that the
Puerto Rican culture views herbal remedies as personal, family-oriented and holistic. In contrast to the holistic orientation of people who use traditional health systems, conventional medicine has viewed mental and physical health as separate systems.
Persons who have a holistic view of health who are referred for mental health services may reject this system of care (Delgado, 1979).
Afro-Caribbean women described using herbs with conventional medication for managing their diabetes (Smith, 2012). According to Delgoda et al. (2010), participants showed greater trust in CT over either single use of conventional medicine or herbal medicine. Nevertheless, not all authors agreed. Participants interviewed by Amirehsani &
Wallace, (2013) differed. Amirehsani & Wallace, (2013) found that most participants thought it was safer to use prescription medicine alone, rather than using CT; the difference was almost 2:1.
The foci of the studies were varied. Though most of the articles on herbal use focused on lowering blood glucose levels (Quatromoni, Caballero, Milbauer, Brunt,
Posner, & Chipkin, 1994; Zaldívar & Smolowitz, 1994; Mahabir & Gulliford, 1997;
33 Scott, 1998; Caban & Walker, 2006; Lans, 2006; Delgoda et al., 2010; van Andel &
Westers, 2010; Picking et al., 2011; Smith, 2012; Amirehsani & Wallace, 2013; Clement
et al, 2015; Giovannini et al., 2016; & Soelberg et al., 2016), the article by Cawich et al.,
(2014) focused on treatment of diabetic foot infections.
Several researchers reported on the success of complementary therapies for
diabetes among Caribbean participants. Smith (2012) acknowledged that over 50% of
participants experienced lowering of glucose levels when herbs were used. Caribbean
born Latino/Hispanic participants interviewed by Amirehsani and Wallace (2013)
reported effective use of herbal remedies. Afro-Caribbean women listed herbs for diabetes that they used along with the medicines prescribed by their doctor (Smith, 2012).
Among complementary therapies used by Caribbean people, spirituality, faith, prayer and God were frequently discussed by authors (Scott, 1998; Adams, 2003; Caban
& Walker, 2006; Amirehsani, 2011; Smith, 2012; & Amirehsani & Wallace, 2013).
Interviews of participants revealed that spiritual interventions worked for them. Smith
(2012) reported that ninety percent (90%) of participants used some form of spiritual-
based practices. Only Newlin et al. (2003) reported use of complementary therapy that
resulted in outcomes that were not significant. Newlin et al. (2003) stated that a
significant relationship was not observed between HbA1C, spiritual well-being and
emotional distress.
Infrequent Practices
The ethnically diverse Caribbean community uses “commonplace”
complementary therapies such as herbs, and spirituality for self-management of diabetes.
Yoga exercise was less commonly found in this community. However, according to
34 Gordon et al. (2008), Hatha yoga and exercise reduced fasting blood glucose over a six- month period.
Discussion of gap in knowledge base.
Caribbean participants did not seem to use complementary therapies apart from spirituality, and herbal therapies for diabetes. Nevertheless, studies involving other populations have conveyed that acupuncture, homeopathy, relaxation, and “other” complementary therapies have been found effective for management of diabetes (Lynch,
Fernandez, Lighthouse, Mendenhall, & Jacobs, 2012; Popoola, 2005; & Schoenberg,
Stoller, Kart, Perzynski, & Chapleski, 2004). Several participants were concerned about lack of coherence between conventional therapy and their cultural needs (Adams, 2003,
& Scott, 1998). A common thread is that most of the studies examined in this review relied on participant reports to confirm effectiveness of complementary therapies for managing diabetes.
The diversity of Caribbean adults is evident in their language and ethnic makeup.
Several different languages or dialects are spoken, the main languages being English,
French, and Spanish. Diversity studies within the United States have compared African-
Americans, Hispanic-Americans, and non-Hispanic Whites. Studies of the diversity among Hispanic-Americans have been conducted. However, few researchers (Adams,
2003; & Smith, 2012) examined Caribbean people looking at the diverse ethnicities that are present. The articles reviewed were limited to those in English and might inadvertently limited the review of the literature since the Caribbean is so diverse and
English is not the only spoken or written language.
35 Several gaps in the literature were identified: (a) Few researchers (Cawich et al.,
2014; Gordon, et al., 2008; & Newlin et al., 2003) collected data to determine the effectiveness of complementary therapies in use by people of the Caribbean who have diabetes; (b) Limited studies were found (Smith, 2012) that explored Caribbean people understanding about complementary therapies (CT) use for diabetes; (c) Studies did not indicate if Caribbean people had knowledge of and used CT apart from herbal treatments, spirituality and yoga; (d) The author has not uncovered any studies that explore how
Jamaican adults select complementary therapies they used in diabetes management; (e)
Few studies (Cawich et al., 2014) reported on complementary therapies used for complications of hyperglycemia experienced by Caribbean people with diabetes; and (f)
Nurses seem to be underrepresented in presenting research exploring use of complementary therapies for diabetes among Caribbean people .
Therefore, future research should aim to reduce the gap in knowledge identified above. Ethnography can be used to explore how Caribbean adults describe their relationship with CT to tease out the selection process and how they use complementary therapies in managing diabetes mellitus and its sequelae. More innovative approaches are needed to explore and examine how Caribbean people determine the effectiveness of their chosen complementary modality.
Link to caring science.
The people’s worldview is the likely influencer that determines willingness to use complementary therapies. Therefore, it is essential that providers offering healthcare services to Jamaican people have some insight into their worldview. An important step toward this goal is conducting a cultural assessment. According to Leininger as cited in
36 Wehbe-Alamah (2018), the cultural assessment involves systematically identifying and documenting the things that hold meaning for individuals and groups within their cultural domain from a holistic viewpoint.
Understanding patterns of communication is an essential part of cultural assessment Wehbe-Alamah (2018). Body movements (kinesics), interpersonal/personal space (proxemics, culture, social and cyclic time, and body touching are patterns of communications that will vary within and between cultural groups and will help the nurse understand not only diverse cultures, but also himself/herself (Wehbe-Alamah, 2018).
Leininger’s presented her Sunrise Enabler as a holistic assessment tool for uncovering culture-care factors that might provide insight into the practices of South Florida residing
Jamaicans adults with diabetes who use CT.
Summary
The literature review explored what is already known about CT use for diabetes not only in Jamaica, but the wider Caribbean. Researchers having explored practices of
Caribbean people in relation to CT use for diabetes found that herbal remedies and spirituality were recurring themes. History and belief systems played a role in the ongoing use of CT for diabetes.
CT use followed self-care patterns and was thought to be holistic. The critical synthesis led to the identification of gaps in knowledge. There is a perceived link to caring science that can help the researcher to discover new data by conducting cultural assessment. The next chapter will give details of the processes involved in the discovery.
37 CHAPTER III. RESEARCH METHODOLOGY
The purpose of this study was to explore and describe how Caribbean adults with diabetes mellitus who live in South Florida select and use complementary therapies for managing their diabetes. A heterogeneous Caribbean populace was sampled to arrive at an understanding about the differences and sameness that exist in how they use complementary therapies for managing diabetes mellitus. The researcher sought to answer the questions:
1. How do Jamaican people with diabetes mellitus use complementary therapies for
managing their diabetes?
2. Why do Jamaican people who live in South Florida include complementary
therapies in diabetes management?
3. What are the complementary therapies used by Jamaican people with diabetes
who live in South Florida?
4. How do Jamaican people with diabetes mellitus who use complementary therapies
describe how they know what complementary therapies are appropriate for
managing diabetes?
5. How do Jamaican people describe, or report evidence, that the complementary
therapies they use for diabetes mellitus work to reduce, or improve their
symptoms, or the effects of the disease?
38 Research Design
Ethnography as a qualitative methodology falls within the realm of human
sciences. The human sciences emerged during the late 1800s and was spurred by a
German philosopher by the name of Wilhelm Dilthey (Erickson, 2018). While, Dilthey
was not the first to think of social inquiry, he took a different approach than others such
as Comte, who sought to follow the lines of the natural sciences. Dilthey’s approach
focused on understanding meaning and action pertaining to life events (Erickson, 2018).
Sociologist such as Weber and Simmel, and phenomenologists in philosophy such as Husserl and Heidegger were influenced by Dilthey’s ideas (Erickson, 2018). Social sciences and human sciences were aligned and gave birth to cultural studies. These evolved as paradigm shifts from positivism. Cultural studies have three strands: a humanist strand concerned with creativity of the underprivileged; a structuralist strand concerned with the relationship of linguistics and power; and a Marxist strand concerned with the realist view and how their methodology connected social, political, and economic structures to phenomenon under study (Hall as cited in Saukko, 2018).
The human sciences were geared toward understanding, as opposed to proof or
prediction (Erickson, 2018). The Marxist and post-structuralist eras occurred simultaneously and like cultural studies were concerned with social, economic, and political factors and the realist view that aimed at uncovering reality (Saukko, 2018).
Realism is an approach to ethnography that has been used by anthropologist in which the participants’ views were relayed in the third person voice (Creswell, 2013).
Ethnography was used by social reformers Booth and Dubois as they advocated for social change in the early 20th century (Erickson, 2018). Early ethnographers made no 39 claims to representing the emic views as they described the everyday lives of the people
they studied. Rather, they felt the behaviors they observed were self-evident as objectively presented (Erickson, 2018). However, this changed as Malinowski was said to accurately report “nuances of local meaning and its daily conduct” (p. 40) as he conducted field work in the Trobriand Islands (Erickson, 2018). Thenceforth, ethnographic descriptions include the meanings and perspectives, in other words, the emic views of the people being studied (Erickson, 2018).
The term ethnography, as used to describe the way of life of local people in colonized areas, was used by anthropologists around the latter part of the 19th century
(Erickson, 2018). Ethnographies were said to differ from travel reports because they were more accurate and comprehensive; there was even a manual to guide observation and interviewing (Erickson, 2018). According to Erickson the goal of ethnography was to describe the whole lifeway of the people being studied.
Ethnography grew out of anthropology and has evolved as other disciplines including health care related disciplines adopted the methodology to explore culturally- based questions (De Chesnay, 2015; & McFarland, 2015). Ethnography entails immersion in the daily lives, and observation and interviews of the people participating in the study (Creswell, 2013). The rituals and customary social behaviors of the culture group are described in detail by the researcher. A culture-sharing group must be identified, cultural themes selected, the type of ethnography determined, fieldwork conducted, and analysis of the descriptions performed (Creswell, 2013).
Ethnography is a qualitative research approach dedicated to obtaining direct cultural or social experiences through observation, participation, interviews, written and 40 photographic media among other forms of data sources (Atkinson, Coffey, Delamont,
Loftland, & Loftland, 2001). Ethnography may be classified in several ways. (a) Critical ethnography, (b) Realist ethnography (c) Traditional ethnography, (d) Visual ethnography, and (e) Focused ethnography. Critical ethnography includes advocating for marginalized groups, outcomes are geared toward empowering the participants (Creswell,
2013). Realist ethnography uses a traditional approach; an objective report of the participants’ description is usually given in the third person voice (Creswell, 2013).
Traditional ethnographies describe cultures as they are and requires the researcher to be in the field for at least one year (De Chesnay, 2015). Critical ethnography is as described above and often involves political activism (De Chesnay, 2015). Visual ethnography entails the use of media such as films and photos to understand the culture sharing group
(De Chesnay, 2015). In focused ethnography, intense field work usually takes place over shorter periods of time than in a traditional ethnography, contact with participants may not be continuous, and research questions usually have a narrower focus than in traditional ethnography (De Chesnay, 2015). Focused ethnographies are more commonly conducted by professionals who are not anthropologists. For this proposed study, a focused ethnography will be used.
A focused ethnography allowed the researcher to explore the lifeways of
Jamaican people with diabetes who use complementary therapies. The researcher had intermittent, but intense contact with the participants. In a focused ethnography, the people in the micro culture are not required to know each other; the focus then is on the behaviors and experiences that are common within the microculture (De Chesnay, 2015).
In this case, observations were made for common behaviors and experiences in Jamaican
41 people with diabetes who use complementary therapies. Participants were recruited by
the help of key informants, and snowballing.
This study includes Jamaican participants who use complementary therapies to
manage their diabetes (key informants) and participants who had knowledge of and could
provide in-depth information about CT used by Jamaican people. The study questions
were geared towards discovering information about the cultural lifeways of Jamaican
people regarding how they determined what complementary therapies may have been
effective for managing their diabetes. A qualitative approach was appropriate because
relatively few studies have been uncovered related to the use of complementary therapies
for diabetes in the Jamaican population. Ethnography is the qualitative design that best
aligns with discovering cultural practices. Therefore, an ethnographic approach was
applied.
Procedure
According to De Chesnay (2015), honesty and professionalism are characteristics
that will help in establishing trustful relationships with personnel who will allow access
to the field. These personnel are the gatekeepers, also known as stakeholders or key
personnel. Gatekeepers are cultural brokers who provided entrée to the cultural group.
They are people familiar with the microculture who can influence their participation in the study. A gatekeeper is typically a respected leader in the community (McFarland &
Wehbe-Alamah, 2015). Gatekeepers were identified by observing who were the people whom might have potentially blocked or allowed access to participants. Gatekeepers
were identified by noting who the participants sought to guide them as a leader.
Gatekeepers were also identified by networking with people while asking questions about
42 where Jamaican people who use complementary therapies might gather or seek services.
In a doctor’s office, gatekeepers might be one of, or all the following people; the office
manager, the chief nurse, or the chief doctor. In a church, the gatekeeper might be the
priest or chief pastor, or it may be a lay leader, or other congregant in the church.
Gatekeepers helped to identify participants for the study.
Gatekeepers gave entrée to two doctor’s offices in Central Broward County where
recruitment occurred. Statements of cooperation were made with two doctor’s offices.
The researcher made observations within the community to discover where Jamaican
people who use complementary therapies obtained services. Individuals were recruited
using the IRB approved flyers and IRB approved verbal advertisement.
Checks were made to ensure that all consent forms were signed and appropriately
witnessed before data collection started. After consent was obtained the researcher asked
participants to complete a sociodemographic survey. The sociodemographic survey and
consent forms were available in English and were in plain language that a lay person
could understand.
Appointments were made if necessary to meet at a place and time that was
convenient for the participants. Consent was obtained from each participant. The
participant was asked to complete the sociodemographic survey. The interview and
observations commenced thereafter. Participants chose to be interviewed and observed
either at home, in a room at one of the doctor’s offices where recruitment occurred; at a
restaurant; or at their place of business. In-depth interviews were done. Most interviews were audio-recorded. The recordings were generally transcribed within 72 hours of
43 collecting same. Thick descriptions were developed based on field notes and audio-
recorded data.
The study purpose was explained to all participants prior to and during the time of
obtaining consent. Participants were advised that they may withdraw from the study at
any time and there would be no negative consequences. Fieldwork was done in
environments in which the participants felt comfortable.
An observer-participant role was assumed. Observations in the field were guided by Spradley (1980) three levels of observation [descriptive, focused, and selective]. The questions in the interview guide were targeted towards gaining Jamaicans adults’
understanding about diabetes and complementary therapies (CT) and their views about
how these therapies impact their diabetes care to describe how they select and use these
unconventional methods in managing their diabetes.
Sampling, Recruitment, Setting
Recruitment of participants took place in communities in and around Central
Broward County in South Florida including two doctor’s offices. Purposive sampling was used, and participants were encouraged to refer other potential participants (snowball sampling). Eight key participants and five general participants were interviewed. The key participants in this study were those persons who used bush medicine/complementary therapies; whereas, general participants are people who may have innate knowledge or
who may have been self-taught about bush medicine/complementary therapies. The key
participants met all the inclusion criteria for the study, whereas the general participants
were only required to have knowledge of bush medicine.
44 Sampling. Purposive sampling was used. Purposive sampling is also known as purposeful sampling, judgmental sampling, or theoretical sampling, and is so called because it is guided by the study purpose (Tappen, 2016). According to Tappen (2016), the selection of the culture, subculture or ethnic group is the starting point for the sampling process in an ethnography. Creswell (2013) stated that three strategies should be considered when using purposeful sampling in qualitative research: (a) who should be the participants; (b) the sampling strategy; and (c) sample size.
Jamaican people are just as diverse in their ethnic makeup as the Caribbean is diverse. The who to include in this study, was guided by the study questions, a concept described as opportunistic and following the ethnographic tradition (Creswell, 2013). The sample size in an ethnography is not clearly defined in the literature. Creswell (2013) suggests collecting data until there is clarity of how the cultural group operates. To satisfy the ability to gain rich data the researcher aimed to achieve a sample size of between 10-20 persons. The researcher explained the purpose of the study, and the inclusion and exclusion criteria to persons with whom personal contact was made. Any questions they had about the study was answered to ensure they fit the inclusion and exclusion criteria and understand their roles as participants.
Inclusion criteria. The inclusion criteria were as follows:
. adults who emigrated from Jamaica and/or their second-generation
offspring who live in South Florida
. who use of at least one complementary therapy in managing diabetes
. self-reported diagnosis of diabetes mellitus for at least one year
Exclusion criteria. Exclusion criteria were:
45 . adults who are not capable of making autonomous decisions
. minors, that is, individuals less than 18 years of age
. pregnant or breastfeeding women
Recruitment. Statements of cooperation were sought from health centers/doctors’ office, places of worship, centers/market places where participants receive complementary therapies. Statements of cooperation were secured with two doctors’ office. These were accepted by the Florida Atlantic University Institutional Review
Board (FAU IRB). The researcher identified key personnel in the doctors’ offices who aided with recruitment through the snowball technique.
One-on-one contact was also made with individuals in the community. FAU IRB approval was obtained prior to contacting people in the community. On initial contact with potential participants the researcher explained the purpose of the study, the procedure for consenting to the study, and the risks and benefits of participating. They were advised that signing a consent form is a requirement for participating in the study, and that declining to participate would not affect the care they receive.
The gatekeepers were advised of the inclusion and exclusion criteria and the purpose of the study. The gatekeepes helped in identifying individuals who fit the inclusion criteria. Prospective participants were vetted to ensure they met the inclusion criteria and were willing and capable of consenting to participate in the study. A total of thirteen participants were recruited.
Setting. The study setting, known as the field in ethnography, is the place where fieldwork occurs. The selection of the field is a practical decision influenced by the
culture and the people to be interviewed (De Chesnay, 2015). One must consider
46 languages to be used, and budget constraints when selecting the setting (De Chesnay,
2015).
Study settings were places that serve Jamaican people and/or where they felt comfortable to interact with the researcher. The field included two doctor’s offices in
South Florida. Participants were also met at home or other place of their preference that was comfortable for both the participant and researcher.
Data Generation
The hallmark of data generation in ethnography is extensive fieldwork. Fieldwork is the process of gathering information in the “field”, that is, the setting in which the participants live or work (Creswell, 2013). Fieldwork was comprised mainly of observation and in-depth interviews.
An observer as participant role was assumed while being immersed in the field.
As a reminder, the field in this study was participants’ homes, doctor’s offices, restaurants and place of business. Hence those are the places in which they were observed and interviewed.
Observation, a key data collection tool in qualitative research, involves the five senses and is the “act of noting phenomenon in the field” (p. 166) and recording the same for science (Creswell, 2013). Observations were made of the participants as they interacted in the field, their conversations, and their activities, guided by the research purpose and questions as suggested by Creswell (2013).
Descriptive observations were applied early on entering the field. The researcher became familiar with the field through observation. The researcher observed the interactions between the staff and the clients. The researcher also made note of any
47 scents/odors that may provide clues to the use of complementary therapies. The
researcher paid keen attention to accents, tone of voice, pitch, and words that may be associated with the culture.
Self-observation in the situation was also imperative. Reflexivity was employed as descriptive observations occurred. While observing, the researcher took care to avoid misconceptions and bias. The researcher took care not to identify self as a part of the study group rather than as a researcher (Lincoln & Guba, 1985). As the data collection and analysis proceeded the researcher used focused observation to realize that more data could be gained while asking less questions. Therefore, the interview guide was modified. For example, condensing the following questions “where did you get information to try this?”; “who suggested it/them”; and “what did they tell you?”, into
“how do you know this would work?”. Focused observation was also used to realize voids left by unasked questions and create follow-up questions for participants. Focused
observation homed in on areas identified in the preliminary analysis of the data. The foci
were geared toward answering the research questions and addressing the study purpose.
Another question that was formed based on the focused observation is “how do you know
you can use this?”. At a deeper level, selective observation was used to identify themes.
Interviews provide clarity for observations in qualitative research. Like in
observations, interview questions were guided by the research purpose and question to
ensure a systematic process ensued. The participants being interviewed will have the
opportunity to make powerful contributions which may direct the path the study takes
(Tappen, 2016).
48 In-depth interview lends itself to exploring complex healthcare issues (DiCicco-
Bloom & Crabtree, as cited in De Chesnay, 2015). Open-ended interviews might provide
surprising new insights and stimulate more questions to draw out important issues as
inferred by Tappen (2016). Semi-structured interviews have the following characteristics as outlined in Tappen (2016): usually consist of open-ended questions; responses are
moderately flexible; there is some discretion on the part of the interviewer to prompt or
reword a question. In-depth, open-ended, semi-structured interviews were conducted. See appendix G for sample questions that guided the interview. A sample of the semi- structured interview guide follows:
1. What was your initial reaction when your doctor said you have diabetes?
2. Did your doctor immediately prescribe medications to treat your diabetes? If no,
what was the original plan. If yes, what medication/s were prescribed?
3. Did you fill your prescription or take the medication immediately? If not, why
not?
4. Did you try any home remedies or other treatment?
5. Where did you get information to try this?
6. Who suggested it/them?
7. What did they tell you?
8. What did you use first?
9. Do you use, or did you use that along with what the doctor prescribed?
10. How frequently did you use it/them?
11. How did you use it/them?
49 I asked informants how they knew about the CT they were using, and to describe
how they knew that the CT they opted to use was effective. I also asked them how they knew that their selection was right for them since there seemed to be so many options based on their responses. Observations and interviews were used to obtain descriptions of and elicit meanings of their experiences. The researcher interviewed participants while using an audio-recording device to record the interviews. Each participant was interviewed for about 35 to 90 minutes. The data collection and data analysis were concurrent. According to Lincoln and Guba (1985), prediction of the timeline cannot be done with naturalistic inquiry. The timing of the inquiry will be based on practical circumstances, rather than a fixed schedule (Lincoln & Guba, 1985).
Spradley’s three levels of observation includes observing language, tone of voice, and pitch when interacting with a culture group. The observation technique is followed through in the reflexivity. The observations contribute immensely to the data collected.
As is customary in qualitative research, data were collected until no new trends were observed. Thick descriptions were made of each experience throughout.
Data Analysis
The analysis of ethnographic data is meant to elicit an understanding of the culture or subculture under study (Tappen, 2016). Three possible subcultures exist in this study. One related to Jamaican people, the second related to people with diabetes, and the third related to people who use complementary therapies. The ethnographer’s role is to find meaning in the data, that is, the observations and interviews, as they relate to the cultural group. To achieve this, an inductive qualitative content analysis was performed.
50 Tappen (2016) inferred that ethnographic data analysis should begin at the first point of contact with key personnel. Therefore, data analysis began with the initial observations and self-observations on entering the field. Creswell (2013) lists the following steps that are involved in the data analysis process: (1) data organization, (2) reading through the database, (3) coding themes and organizing them, (4) data representation, and (5) interpretation of the data. These steps do not occur in a linear fashion, but rather are iterative and interconnected (Creswell, 2013). Data were organized and represented using Atlas.ti 8 computer assisted qualitative data analysis software
(CAQDAS). The qualitative data analysis followed an iterative pattern and occurred as data collection progressed. The themes are looked at through the lens of Leininger’s
Sunrise Enabler.
Data organization. Tappen (2016) recommends organizing the notes with their sources. Tappen also stated that it is important to record the participant’s language in the manner that characterizes them and the setting to maintain cultural and personal meaning.
Because an inductive content analysis was done emphases on words, mispronunciations, tone of voice and hesitations were recorded as suggested by Tappen. Data were transcribed as soon as possible after they are collected, notes that were condensed or abbreviated were expanded. According to Tappen, this step serves dual purposes; it will ensure that the notes are readable and allows one to review previous work for future planning.
Audio-recorded data were transcribed with Microsoft Word and uploaded into
Atlas.ti 8 by the researcher. Atlas.ti 8 is a computer software that was used to sort and organize the data in preparation for analysis. Data were organized into document groups.
51 Transcribed data were managed using Atlas.ti 8. In Atlas.ti 8 the transcripts were grouped based on the source of the data. Examples of groups were female participants, and general participants. The sociodemographic survey data was input into SPSS v. 25 to produce descriptive statistics.
Reading through the database. Initial exploration of the database should include notes/memos that will have been written in the margins of the transcript or fieldnotes
(Creswell, 2013). The transcripts were read through as they were transcribed. Transcripts were read through several times. Initially, transcripts were read, then read again line by line. Transcripts were analyzed to detect patterns in the data.
Coding and organization of themes. Each transcript was read again line-by-line.
Similar data were grouped based on the attached meaning, so they could be easily retrieved for further analysis. Dedicated groups of data that are similar were named with tags called codes. Initial codes were read through to elicit subthemes. As subthemes emerged, coding continued until a succinct amount of codes were created. Content analysis was used to detect emerging themes as patterns in the codes were identified. The patterns identified formed the major themes.
Initial codes were created at a more concrete level. The level of abstraction increased as major themes emerged. Preliminary analysis of initial codes assigned to the data aided in modifying the questions for the interviews that followed.
Interpretation of the data. As in the qualitative tradition as described by
Creswell (2013), themes were developed and interpreted. The codes created were interpreted to gain an emic view of the population. Meanings were put to the elicited themes. The researcher verified that the interpretation of the data is correct. This was
52 attained by ensuring that persistent observation was done in the field and thick
descriptions were written. Member checking was also done with a key participant. Other
forms of verification include triangulation, peer debriefing, prolonged engagement, and
auditing (Lincoln & Guba, 1985).
Similar data from individual quotations/quotes were grouped. These were the
initial codes. The initial codes were explored, and further analysis led to the formulation
of subthemes. Groups of subthemes became major themes. Several data points could fit
into more than one category. Therefore, the structure of how the data is represented
should not be taken to mean the relationships were linear, or that there were no
associations from code to code or subtheme to subtheme. Member checking was applied
to assess if the meaning ascribed to the themes were in line with that of Jamaican adults
who use complementary therapy in the management of diabetes. Peer-debriefing was also done with the principal researcher.
The participant’s voice is presented throughout in quotes. The quotes presented are mainly in English but is interspersed with Patois, the Jamaican dialect. Language is a hallmark of culture and the use of patois indicates the comfort level the participants had with the researcher as they all started out speaking standard English. Along with the language, the culture was evident in the plants that were used.
Data representation. Representing the data means tabulating and/or creating figures with the meanings derived from the textual data (Creswell, 2013). The figure may be in the form of a comparison table, a matrix, or alternately a hierarchical tree diagram
(Creswell, 2013). Narrative descriptions are presented along with figures and tables.
Atlas.ti 8 was used to produce figures from the coded data. Descriptive data was input in
53 SPSS v. 25. from which tables were created. Table 4 was created to show the plants used
for diabetes by the participants in this study. The researcher included the scientific name,
the plant source that was used and what the scientific literature had to say about the
effectiveness for diabetes.
Establishment of Trustworthiness
Study Rigor/Trustworthiness
The term trustworthiness is used interchangeably with study rigor in qualitative research (Tappen, 2016). Trustworthiness speaks to the quality of the research. According to Meyrick as cited in Tappen (2016), trustworthiness can be summed up in the principles of transparency and systematicity. Other terms associated with trustworthiness in qualitative research are credibility, transferability, dependability, and confirmability
(Lincoln & Guba, 1985).
Trustworthiness is the term used to describe measures to ensure the quality or integrity of qualitative research (Tappen, 2016). According to Tappen, systematicity, transparency, credibility, transferability, dependability, and confirmability are terms coined by experts in qualitative inquiry to describe the measures that can be taken to ensure the integrity of qualitative research. Each quality measure is described below along with how they were applied in this study.
Systematicity and transparency. Systematicity sums up the process of connecting each step of the research in a logical manner so that the method aligns with the purpose in an apparently seamless way (Meyrick, as cited in Tappen, 2016). On the other hand, transparency pertains to actions the researcher takes to ensure that the procedures performed to meet the research conditions are clarified each step of the way;
54 for example, explaining why a focus group might be deemed necessary after individual
interviews. Tappen (2016) stated that transparency can be partially achieved by
presenting an audit trail.
Transparency. Meyrick (2006) stated that the details of the data collection process and documentation of any changes in techniques or focus is imperative to determine if the qualitative research is “good” (p. 805). Meyrick further stated that this process would allow anyone reading the procedure to determine for themselves whether the methods and any changes in data collection are sound decisions. The methodology section of this study is described in detail. The researcher identified a gap in the literature from which the study question was derived. Study objectives were formulated based on the study question. The objectives of this study were to:
1. Explore the emic views of Jamaican adults who use complementary therapies
(CT) to manage diabetes mellitus
2. Describe the rationale given by Jamaicans adults for using CT to manage diabetes
mellitus
3. Analyze and synthesize the data gathered about use of CT for diabetes by
Jamaican adults to see if their actions have cultural components that can serve as a
basis for providing culturally competent care
The study question determined the method selected to fulfill the study objectives.
Methodological rigor is described by the researcher and should contribute to achieving
transparency.
55 Systematicity. The procedure for the analysis of the data should be steadily
applied and the data collection written with enough details to allow others to be able to
confirm how categories were formed and the steadiness of the process (Meyrick, 2006).
This procedure was described by Meyrick as systematicity. The data generation and
analysis sections are written to allow onlookers to view the process and decide for
themselves if systematicity was maintained.
Credibility. Lincoln and Guba (1985) stated that one can achieve credibility in qualitative research through prolonged engagement, persistent observation, triangulation, negative case analysis, peer debriefing, referential adequacy, and member checking (p.
301). According to Tappen (2016), prolonged engagement aids in establishing credibility.
Thick description will help to establish the study’s credibility (McFarland & Wehbe-
Alamah, 2015). Thick descriptions can be achieved through persistent observations, and
continuous exploration and labelling of relevant data points until one’s initial conclusions
can appear erroneous, or, be more deeply understood (Lincoln & Guba, 1985).
Prolonged engagement was achieved by spending enough time in the field
conducting one-on-one in-depth interviews to learn about the culture, build trust with
participants, and check for distorted information. Thick descriptions were used to relay
the meaning of the participants. Persistent observations were conducted in the field.
Member checking was performed by sharing preliminary study findings with a key
participant who contributed feedback regarding the code assignments. This feedback was
incorporated as the analysis progressed. Peer debriefing was also performed with the
principal investigator and another member of the research team.
56 Transferability. The quantitative equivalent to transferability is generalizability
(Tappen, 2016). Transferability is contrasted with external validity although the two
cannot be paralleled (Lincoln & Guba, 1985). Qualitative researchers usually do not
aspire to achieve generalizability but may compare their research findings with others’.
This research used thick descriptions that will allow other researchers to compare
whether the findings are transferable to their situation.
Dependability. Dependability can be achieved by conducting audit trails throughout the research process. An audit trail refers to records that are compiled as the research proceeds and includes field notes, summaries of the research, coding schemes, process notes, investigator reflections, questionnaire guides, etcetera (Tappen, 2016).
Dependability of the findings of qualitative inquiry can be verified by an audit of the data, findings, interpretations, and recommendations (Lincoln & Guba, 1985).
Audit trails were used for this research. The researcher maintained a code book that includes field notes, researcher reflexivity and adjustment to interview guide. An ethnographic report was written. Reflexivity is included in the ethnographic report that describes how possible bias might have entered the research, and how that was mitigated.
The researcher explored the data obtained and compared it to the literature making notes of similarity in findings.
Confirmability. Confirmability is akin to maintaining objectivity in quantitative research (Lincoln & Guba, 1985). The audit trail is the main technique used in confirmability (Lincoln & Guba, 1985). Lincoln and Guba (1985) stated that the reflexive journal is an important part of the audit. Confirmability in qualitative research allows the researcher to include his/her perspective and reactions in the analysis. An ethnographic 57 report was done that includes any biases or prejudices on the part of the researcher as suggested by McFarland (2015). The researcher returned to the literature to explore reports were previously made that are similar to those she received in this study. The audit trail will help in confirmability. The reflexive journal is included below.
Reflexivity
During the observations the researcher employed reflexivity to assess her own thoughts and actions to ensure the research would continue while following the ethical guidelines to protect human subjects and ensure the data would be valid. On entering the field, descriptive observation revealed some possibility of bias in the recruitment process.
The researcher found herself thinking that she can tell who to approach to recruit for the study because of their appearance. That strategy was recognized as possible bias because
Jamaicans are of mixed heritage and may appear Caucasian, Chinese, East Indian or various shades of brown to darker hues. That strategy for recruitment would not be feasible because the way Jamaican adults dress is not distinguishable from the general population in which they reside. Also based on experience, the researcher is aware that
Jamaicans will also adapt to speaking with an accent mimicking that of the society in which they live. On realizing this potential bias, the researcher adapted her stance to presenting the study purpose to those she encountered as potential participants and allowing them to state that they did not qualify because they did not meet the inclusion criteria, or they met the exclusion criteria.
During the first interview the researcher thinking she had clearly explained the purpose and the inclusion criteria and that they were understood, observed herself trying to find some reason to include the interviewee as a key participant. As the interview
58 progressed the participant repeatedly said he did not believe in non-conventional treatments and would not take anything not prescribed by a doctor. Later, on conducting focused observation and on conferring with the primary investigator it was decided that this data would be used as a general participant because although he did not use CT he had knowledge of the same that added value to the study.
Reflexivity also helped the researcher to notice missed opportunities. As the data was being transcribed the researcher observed that she missed opportunities to ask relevant questions based on data the participants provided. For example, a general participant supplied data indicating that individual experience different results when complementary therapies are used. The researcher missed an opportunity to ask the participant “how do you know how much to give each person since individual results vary?”.
A very important observation brought out through reflexivity is that the researcher is an outsider though from others looking on she might appear to be an insider. The researcher was born in Jamaica and came to the US as an adult. Therefore, being a
Jamaican, she might seem to be an insider by some. However, being a student of medical sciences who studied and having promoted conventional medical therapies might make her an outsider in the eyes of the target population, users of complementary therapies
(CT). Several persons who met the inclusion criteria and agreed to participate, later declined to sign the consent form. Others stated that they would participate but did not; that might have been because the researcher was viewed as an outsider. Therefore, recruitment was challenging.
59 During the data collection phase, the researcher tried to maintain an observer as participant stance to avoid being treated as a member of the group thereby compromising the data. That was also a challenging feat because as participants got comfortable in the presence of the researcher, they interacted as if the researcher was a long-lost friend.
Other challenges that arose during data collection were missed opportunities to ask more about certain plants because the researcher had either heard of them in daily life or had read about them in the literature.
The content analysis started by spending a lot of time reading the transcripts. The researcher coded and changed the codes several times. Each time the dataset was explored the meaning ascribed may cement or seem alien. Therefore, many hours were spent mulling over the data. The data with ascribed codes were presented to a key participant who checked and gave feedback regarding how the codes fitted the data. One suggestion by the key participant was to relocate a dataset and code to a different subtheme. On further exploration of the dataset the suggestion was implemented.
Ethical Considerations
Research ethics are standard rules created to prompt researchers to abide by behaviors that are acceptable when conducting research. The principles of respect for persons, beneficence, and justice make up the foundation for research ethics (Tappen,
2016). These principles were maintained to protect all participants in this study.
Respect for Person
The principle of respect for person consists of two parts, one that addresses autonomy of the individual, and the other is slated to protect individuals with limited abilities to make their own decisions (Tappen, 2016). Autonomy is the ability to make 60 decisions as an individual. Respect for person was honored by providing participants with enough information to help them decide if they wished to participate. Participants were informed of the research purpose, the risks and benefits, the consent process, and how the results will be used. Further, they were advised that they may withdraw from the study at any time even after consenting to participate. That is, they have autonomy to participate or not. Children, people who are incapacitated, prisoners, and other vulnerable people were not included in this study.
Beneficence
The principle of beneficence is often paired with maleficence, these principles together obligate the researcher to be kind to participants, prohibit actions that can bring them harm or danger, and provide them with the maximum benefits that can be obtained from the research (Tappen, 2016). This research is a low risk study. All measures were taken to ensure no participant were harmed because of this study.
Justice
The principle of justice addresses who should be the recipients of the proceeds of research and who should shoulder its negative consequences (US Department of Health and Human Services [HHS], 1979). Justice calls for equity in treatment of participants
(HHS, 1979). Participants were treated fairly. No negative consequences were imposed upon participants. Each participant received a $10 Publix gift card as approved by the
Florida Atlantic University Institutional Review Board (FAU-IRB).
Approval to conduct the study was obtained from the FAU-IRB. Approval was also sought from the administrators of the doctors offices/field sites where participant recruitment occurred. Informed consent was obtained prior to starting the study. The 61 rights and responsibilities of the participants, and the obligations of the investigator were
explained. The participants were advised that only those who consent will be included in
the study, and that failing to consent will have no negative consequences. Participants
who were recruited through the doctors’ offices were advised that their treatment or visits
to the center would not be affected if they declined to participate in the study.
Benefits. No direct benefit to participants is expected, however, gift cards of 10
dollars each were provided after completion of the interview and observation. Though
individual participants may not have benefitted from this study, the results will add to the
body of nursing knowledge regarding culturally relevant care.
Risks. The study posed minimal risks to participants. No participant experienced discomfort during the study. All reasonable precautions have been taken to ensure confidentiality of participant identity and data are maintained. Audio-recording devices were locked in a safe storage area until upload of data to a secure encrypted storage system, the Biomedical Healthcare Research Informatics Core (BHRIC). Audio materials and field notes were stored separately from consent forms. Transcribed data were encrypted and kept on the BHRIC. Audio-recordings were deleted after being uploaded to the BHRIC.
Informed consent process. Approval for the study was sought from the FAU-
IRB. The researcher obtained informed consent from individuals who met the inclusion criteria prior to starting interviews. The study was explained, and individuals had a chance to read the consent form and ask any questions they had related to the consent procedure and the study. When the researcher was satisfied that the individual understood and freely agreed to participate, then he/she was asked to sign the consent form.
62 Participants were required to sign the consent form in the presence of the researcher. The researcher signed as witness to the participant’s signature. Participants received a copy of the consent form.
Informed Consent Document. The consent form was written in standard English.
It was written so that someone at a grade eight reading level should understand the content. The consent document included data storage procedure, and how long the data will be kept.
Privacy and confidentially. Each interview was audio-recorded using a digital recorder. Audio-recordings were locked away in a safe storage area to which only the researcher had access until it was uploaded to the BHRIC. The consent forms were locked in a separate safe storage area, so should a breach occur there will be no way of linking the consents to the participants. Audio files and transcriptions were encrypted and saved to the BHRIC. Data will be deleted in five years.
Summary
The various steps in the research rests on the philosophical foundation of the method. This chapter outlined the philosophical foundations of ethnography. It also explained the rationale for selecting focused ethnography as the research methodology to answer the research questions. Each step of the research including the process of recruitment, data collection and storage, and protection of human subjects is described.
The procedures the researcher followed to establish trustworthiness are described in detail.
The researcher appropriately applied the focused ethnography approach to the sample population of informants. Interviews and observations were adapted according to
63 the circumstances and how previous questions were answered. The researcher maintained the integrity of the research by following the protocol.
64 CHAPTER IV. FINDINGS
“When yuh read Psalms 68 and it seh sing unto God, sing praises to His name extol Him that ride upon the heavens by His name Jah. And when you look into the Bible you see Jah, it’s the biggest, it’s more bold than any other, any other letter form in the Bible at that time. So that hit me and I said wa a serious something that yuh nuh (So that really got my attention and I said, what that is a serious thing, do you understand) So that made me ahm, lean more to that natural state of life” (Julio)
This chapter presents the participants’ words as their personal understanding
about how and what guides their ways of selecting and using bush medicine. The way
they talk and the common expressions they use tell of their comfort when interacting with
the researcher. The researcher hopes to convey the meaning intended by the participants
as they share their relationship with diabetes and bush medicine while living in South
Florida. Pseudonyms were used to ensure the privacy of the participants is protected.
The chapter is organized by first presenting characteristics that describe the participants. Sociodemographic data are presented in two tables. Next the researcher presents how the major themes developed with the way the themes address the research questions.
Participant’s Characteristics
Notably there were about equal number of male and female participants in the total sample. Most participants self-identified as Jamaicans. The youngest participant was
44 years and the oldest was 74 years with mean age of 59 years of age. One participant
65 declined to supply his date of birth, which could affect the mean age calculation. The mean number of years in the US was 25 years. Participants were diagnosed with diabetes for as few as five years or as many as 31 years. For the most part the general participants were not asked to and did not disclose their health status.
Table 2. Descriptive Statistics
N Minimum Maximum M S D
Years in US 12 13 36 25 7.37
Age in Years 12 44 74 59 8.26
Diagnosis Years 9 5 31 16 8.27
General Participants
The five general participants in this study each had different stories to share about how they know about CT. They are Sara, Noah, Micah, Marcus, and Tony. They worked in different ways. Three of them were influenced by their grandmother, be it negative or positive, while two were stimulated by personal or family illness to pursue knowledge of
CT.
Sara. There was one female among the five general informants. Sara has been a pharmacist for over 30 years and maintains her pharmacist license in Jamaica. She did not indicate how many years she has been in the US. Sara manages a store where she offers various options as alternatives or complements to conventional medicine. She assists clients with diabetes in monitoring their blood sugar levels. Sara stated that she creates some of the formulas and hires someone to make them. My observation is that
66 Sara is calm and takes charge when interacting with her clientele, whether in person or on
the phone. She believes the alkaline water is excellent to prevent and treat chronic
illnesses. Her use of complementary treatments started with the alkaline water. She used
it in her household for her husband and child who were diagnosed with chronic diseases.
She believes it has prevented her family from getting other chronic diseases and the ones
already diagnosed are controlled.
Noah. Only one general participant Noah, self-identified as American. He stated
that his culture was Guyanese and that he was of Arab heritage. Noah declined to include
his date of birth and annual income on the sociodemographic survey. Noah manages a
food establishment. There is a menu board with juices for a variety of chronic diseases
including diabetes. There is also a flyer about the black seed oil and its benefits. He
believes in the black seed oil because he uses it himself. He explained how often to use
caraili/Chinese caraili/cerasee (bitter melon), mauby, and the black seed oil for diabetes.
He suggested that he grew up knowing these things.
Micah. Of the general participants, Micah, reported having and being treated for diabetes mellitus. Micah stated he did not use bush medicine. However, he was able to provide insight about the use of bush medicine and why he refrained from using the same. Micah met all the inclusion criteria for participating in the study as a key
participant apart from his exception to the use of bush medicine. However, he
commented that he liked the Rastafarian diet because it is healthy. He socialized with his
Rastafarian friends when in Jamaica. Micah saw changes in his friends who used bush
medicine for diabetes. His stated that his friends stopped taking conventional medicine,
lost weight and looked healthy. Micah has not taken bush medicine because he has
67 recollections of the “concoctions” his grandmother made when he was growing up. They were not pleasant to the senses and he decided that is not something he would take.
Marcus. Marcus sported dreadlocks. He was born and raised in Jamaica. He spoke with a Jamaican accent but listed his identity as other. Marcus stated he was human. He owns his business of supplying alternative or complementary therapies. He also sells items associated with the Jamaican culture for example, Ludo (a board game).
His stall had many things with the colors of the Jamaican flag and colors associated with
Rastafarianism. Marcus is passionate about plant-based diets and medicines. He believes bush medicine should be incorporated with conventional medicine. Marcus’ grandmother used herbal medicine, but this was not passed down to him. Marcus started using bush medicine over a decade ago when he had a health crisis and started researching natural things for himself. He became so engrossed that six years later he decided to get into business promoting natural health remedies.
Tony. Tony embraces his Jamaican heritage. He wears dreadlocks too.
Dreadlocks have been popular with Rastafarians, but Tony has not identified with that faith group. Tony’s grandmother was an herbalist and a self-taught midwife. Tony voiced that his grandmother was not educated in the formal school system but was gifted to do the things she did. He credits his grandmother with his knowledge about plants. Tony kept a pocket journal with information about the plants. He is proud to share his knowledge of plants with people he encounters. Tony works on a farm in Broward
County. Most of the plants he talked about exist on the farm.
68 Key Participants
Whereas the general participants were mostly male, the key participants were mostly female. There were five females and three males among the key participants. The names used for the key participants are: April, May, June, Julienne, Octavia, Julio,
Augusto, and Jonas. The following is a brief description of the encounter with each key participant.
April. I met April at her home. She was modestly dressed in a pair of mid-thigh shorts and a short-sleeved top. One could not tell her nationality or ethnicity from the way she dressed. Her hair was wavy and caramel colored. She had it pulled back in a pony-tail. She was dark-skinned. I entered through the front door of her home and we settled in the dining room where I did the interview and observations. The area appeared well-kept and clean. We sat at the dining table across from each other. I did not see any artifacts or other items in her home that indicated that she was Jamaican. She spoke standard English with a slight Jamaican accent.
After brief greetings I brought out the consent form and sociodemographic survey. She completed the preliminary paperwork. I gave her a copy of the consent form.
I quickly scanned my interview guide. When she indicated she was ready I turned on the audio-recording devices. I brought two as a safeguard should one fail.
April appeared relaxed and un-hurried throughout our talk. She did most of the talking with little interjection from me. Her voice tone changed from what sounded like serious concern when she talked about the journey from when she was first diagnosed with diabetes, to more jovial when she talked about trying bush tea that was familiar to
Jamaicans. She sounded sad when she spoke about her experience with a conventional 69 medical provider whom she thought did not address her concerns regarding side effects of the conventional medicine. She also sounded sad when she talked about monitoring her food intake and the need to cut down on starchy foods and sugary drinks. We completed the interview and I thanked her for sharing her journey with me. I turned off the recording devices. She was willing to participate in a focus group should one be necessary. I took her phone number and we parted company.
May. May chose to be interviewed at home. I arrived at her apartment and was made to feel comfortable. I reviewed the study purpose, inclusion criteria and the consent process with her. She signed the consent form and filled in the sociodemographic survey.
As I sat on her sofa in the living room I was observing the environment. It was clean and well organized. I could not see any items that I could relate with CT for diabetes. During the interview I asked the participant if she had any of the CT that she spoke about on hand. She showed me a tea bag that she uses.
May’s skin tone was fair. Her name and skin tone gave the impression that she had Chinese in her lineage. Her hair was black and straight. She wore it short. May spoke
English well with a Jamaican accent. Her voice was easily heard. However, I think she might have had some issues remembering the timelines about when she started using CT versus conventional treatments. At the end of the interview I thanked her and left.
June. I met June at the spot she suggested. It was an outside seating area with tables at a coffee-house. The informant was coming from work and was dressed business- casual. I arrived a few minutes before her and waited in my car until she arrived. As we sat down I explained the study purpose to her again. We reviewed the consent and data collection procedures. She read and signed the consent form. I witnessed her signature by 70 signing the form in the appropriate spot. I gave her a copy of the consent form and explained that I would not be using her name during the interview and that it would not appear in my written reports.
I turned on the audio-recorders. I sat across from this key informant and watched her face as she was talking. She appeared very jovial and animated. She laughed a lot.
Especially when she talked about the bush medicine that she used for her diabetes. It was almost as if she was in disbelief that it worked. As I listened to her I thought she sounded credible. She was fluid in her speech and did not supply any contradictory statements. I could not help being amazed myself that she said the results were seemingly dramatic.
After stopping the audio-recordings two times, I turned them on again almost immediately because she had so much more data to add that held my interest.
June spoke English well, but had interjections of Patois. She spoke with a
Jamaican accent and her speech was clear and audible. June was dark brown, and her hair appeared to have been permed. June trusted her family members who introduced her to
CT. She did not say specifically, however, based on what she said I think that her brother is a healer in his community in Jamaica. Her brother knows the herbs he suggested she use, and it is apparent that people trust him to give them various herbs for different ailments. June, having seen the results from others, trusted her brother in Jamaica to recommend a bush that she reported helped to reduce her blood sugar and A1C.
Julienne. I interviewed Julienne in a private room across from the doctor’s office where we met. The room was a moderately sized area with chairs towards the wall and a coffee machine on a small table across from the chairs. The only natural light came from the doorway if it was left ajar. We closed the door for privacy and utilized the artificial 71 lighting. Julienne attempted to make coffee but had some difficulty using the machine, so the task was abandoned. We sat down with one chair between us on which I placed the audio-recorder. When I started reiterating the research process Julienne stated she did not realize it was such a formal procedure. I explained to her the importance of maintaining the integrity of the research. She got comfortable, read the consent, and completed the sociodemographic survey. I presented her with her copy of the consent form and enquired whether she had any other concerns or questions. I turned the recorders on and started the interview. It went smoothly. Julienne had a slight lisp. She spoke mainly English with little Patois in-between. Julienne was medium-tan in skin tone.
She smiled a lot. Julienne seemed to have good relationships with and fondness for older people. Her friends were older people who gave her advice about how to use bush medicine.
Octavia. I interviewed Octavia in a room at the doctor’s office while she waited to be seen. She appeared a bit anxious and did not wish to be recorded. Octavia was dark- skinned with dark straight hair that she wore short. She appeared to be of East-Indian descent. Octavia spoke fast. She said she had not received direct information about use of
CT for diabetes from any person, but having grown up in Jamaica, she was familiar with bush medicine. She decided to try some when she received her diabetes diagnosis. At the time of the interview she said she was having some pain but wanted to go through with the interview anyway.
Julio. Julio’s interview took place at the doctor’s office the same day he was recruited. Julio was moderately dressed in shirt and slacks. Initially he did not wish to participate because of his “state of mind”. He started talking about the death of his wife 72 and how devastating it was for him. We chatted a bit as I encouraged him. After a while
he said he felt better due to our conversation. He opted to participate. We made an
appointment to meet at another place and time for the interview.
Eventually he spoke with me before he left that day. I explained the study purpose
and the recording procedure. Julio completed the sociodemographic data form after
signing the consent. During the interview he appeared very comfortable and talked freely.
He started out in standard English but intermittently spoke Jamaican Patois. Based on the fluency and freeness with which he spoke I thought he was being truthful. He is a self-
described naturalist. Julio was dark tan.
Augusto. Augusto came to the doctor’s office. He agreed to be interviewed while
he waited to be seen. He asked about incentives for participating and how I would benefit
from the research. I let him know the risks and benefits of the research and that it was in
partial fulfillment of my degree program. He was concerned about the time commitment.
I addressed al his concerns as I explained the research purpose along with the processes
involved.
As we sat in the room, a chair or two between us (this is the overflow waiting
room that I used for the interviews at the doctor’s office because it offered privacy), my
equipment was on one of those chairs. Augusto read the and signed the consent
document. He completed the sociodemographic survey. I turned on the audio-recorder.
During the interview, there were moments when Augusto lowered his voice.
73 Augusto was dark-skinned. He spoke English and Patois. At times he would leave his sentences unfinished and start a new line of thought. I wondered if he was hallucinating. I am not sure that I had gained his full confidence.
Jonas. Jonas too was interviewed on the day he was recruited. He, like Octavia, did not wish to have his voice recorded. Jonas became ill on the job and had to be taken to the emergency room where he was told he had diabetes. He refused the conventional medicine. He also refused to be hospitalized. Jonas attempted to control his blood sugar on his own, but eventually took the insulin prescribed until his sugar was at a satisfactory level. He talked about being from a family of herbalist and knowing the bush medicines would work even before he tried them. Jonas was dark tan. He spoke mostly standard
English. He appeared relaxed and conversed with ease.
Further sociodemographic characteristics of the participants are outlined in Table
3.
Table 3. Demographic Characteristics of Sample Population
Characteristics Number Percentage Gender o Male 7 54 o Female 6 46 Education th o 12 grade 2 15 o Partial college 7 54 o College graduation 2 15 o Graduate college 2 15 Insurance o None 3 23 o Public 6 46 o Private 3 23 o No answer 1 <1 Employment o Employed 8 62 o Out of work 2 15 74 o Unable to work 1 <1 o Retired 1 <1 o Other 1 <1 Annual Income o $15000 ~ $25000 3 23 o $25001 ~ $35000 2 15 o $35001 ~ $50000 3 23 o >$50000 2 15 o No answer 3 23 Marital Status o Never married 2 15 o Married 5 39 o Separated 2 15 o Divorced 3 23 Self-identity o Jamaican 10 77 o American 1 <1 o Other 2 15
Major Themes
The researcher examined the data in context of the research questions. First, raw data/quotations were grouped and coded. After careful exploration and analysis, the data were allocated to code groups that that were assessed to answer the research questions.
Five major themes emerged, most had at least 2 subthemes. The major themes are (1)
Jamaicans follow individualized and diverse self-care patterns while using CT; (2)
Jamaicans believe CT are affordable folk care promoted by people they can trust; (3)
Jamaicans use traditional folk remedies for managing diabetes; (4) Jamaicans are willing to try folk care in the face of uncertainty; and (5) Jamaicans use self-management strategies trusting the wisdom of the elderly.
Research Question 1: How do Jamaican People with Diabetes Mellitus Use
Complementary Therapies for Managing their Diabetes?
Codes. The first question asked, how do Jamaican people with diabetes mellitus use CT for managing their diabetes? Five codes were formed from the informant’s 75 quotes: (1) Jamaicans use CT intermittently, (2) Jamaicans combine CT or use them singly, (3) Jamaicans use plain or processed plant material in self-care for DM, (4)
Jamaicans prepare simple recipes when using CT in diabetes management, and (5)
Jamaicans adjust lifestyle when using CT in diabetes management.
Jamaicans use CT intermittently. Informant responses provided rich data.
Informants talked about not using bush medicine continuously. Jonas said:
“After six months it [periwinkle] didn’t work anymore. Same thing with the cerasee, you shouldn’t use it continuously, it’s good to switch because if you use the one thing over it masks the sugar”. Other informants talked about their experiences with bush medicine. Several of them modified the way they used bush medicine based on previous experience or what they observed in others who used them. The code, Jamaicans use CT intermittently was applied as informants said:
“…and a even tell other people seh the cerasee is not really good to drink consistently” (Julio) “No, no, no. I don’t do it like that. I drink one for a period of time, then stop, then wait, then I drink the other for a period of time…I drank it maybe for a month, then I would stop, then I would go back again. It’s not something that I stay on continuously…You just drink like maybe a cup in the morning, and maybe a cup at nights when you go to bed” (Julienne) “the cerasee I use two and a half weeks on, two and a half weeks off”
(Jonas)
“I did not use the same time with the medicines because I did not want to corrode the liver” (Octavia) Jamaicans combine CT or use them singly. The informants combined the CT in various ways or used them alone. May expressed that she used ginger in her mixture as she felt it would help with stomach issues she experiences. Despite combining the plants
76 Jonas felt he only benefitted from one at a time because there would always be one that is
stronger and the strong one would prevail. Supporting quotes are:
“the soursop, the beetroot, the bee pollen, the pineapple, and some of the flax seed…So you don’t want more of five at a time…You put them in and you blend them yeh, and you, and you drink that” (Tony) “I aah blend it. Sometimes with orange juice sometimes with water. Like a little bit of orange juice, you know because there is still a lot of sugar in that [brief pause] and so sometimes I mostly use water” (Augusto) “Just boil it like tea, that's how I did it” (June)
“After I peal the pawpaw and thing I blend up the skin. I like ginger because of my stomach problems, so I blend it up in ginger and make like a smoothie” (May) “if you use the combo the strong one will work because they all have their potencies” (Jonas) Jamaicans use plain or processed plant material as self-care for DM. Sara, a general participant, supplies CT to patrons who visit her store. She supplies the CT in their natural form or in processed states. Key participants in this study mainly used plants in their natural form. The following quotes support the code Jamaicans use plain or processed plant material as self-care for DM.
“We have it in the form of capsules as well as liquid, bitter melon juice…It’s always gonna be just combinations of certain natural fruits or herbs. Of course, concentrated extracts in some cases” (Sara) “Turmeric, turmeric, they say that turmeric is good for almost anything yuh nuh. Yuh sprinkle dat pony uh food, yuh put it ina yuh drink an ting (You sprinkle it on your food, you put in it your drink and such things)” (Julio) “Sprinkle it on things that I was eating [cinnamon]…I would get it in the tea bag form [cerasee]or people would bring the actual, weh yuh call it (what do you call it) the leaves…You can drink it hot…so when I drink it hot I would still put, add a little honey into it, not sugar because it would be defeating the purpose…or I’ll have it cold. If I have it ice cold then I just brew it, put it in the fridge, allow it to cool and then drink it as if I’m having a drink. But that’s unsweetened” (April)
77 “You drink it, drink it like water…I used the Guinea hen weed in the morning and the moringa in the morning, or twice a day” (Octavia) “A friend supplies me with the moringa, so I told the them the other day that I was getting the tea bags and that it's more convenient” (May) Jamaicans prepare simple recipes when using CT in diabetes management.
Jamaicans follow simple recipes for preparing CT used in diabetes management. This is evident from the data below.
“just put it in the cup and put water on it” (May);
“that’s what they told me, that I should boil it and drink, drink it”
(Julienne)
“some of them you don’t over-boil them. But like, like the ahm, pepper elder you have to boil it good. Some of them you just ah, let them boil a little and. INT: So like for how many minutes? Huh? INT: about how many minutes? I think it’s like 15 minutes. A tea is like 15 minutes because is just the essence yuh getting out of it. INT: okay! If you want it for like medicinal purpose you have to boil it longer” (Tony) “chew one or two moringa seeds” (Jonas)
78
Figure 2. Image of Moringa Tree “The black seed oil has to stay in the body. You need to drink it twice a day every day…The black seed oil you take two teaspoons twice per day, one teaspoon in the morning, one teaspoon in the evening…The Chinese caraili (bitter melon), you cook and eat at least once per week” (Noah)
Figure 3. Recipe for Black Seed Oil 79 Jamaicans adjust lifestyle when using CT in diabetes management. Several of these Jamaican participants who engage in use of CT for diabetes walk, check their sugar regularly, and observe their dietary intake. It is obvious from the data below why this code was named as it is.
“So when you doing that you have to be, I find that it is more effective when I monitor what I eat also…so cutting down on too much starchy foods, the sugar, the sugary drinks…It wouldn’t be true to say that was just these things that were, that were helping…Because I do adjust my diet at the same time…So to help me ahm to manage the diabetes” (April) “You have to walk when you take the bush medicine or the other medicine. I drank a lot of water also” (Octavia) “The bush started in 1991. It was a conscious decision. I started using it up here, so I continued to use it in Jamaica” (Jonas) “So, you have to really stay on top if you are taking your doctor’s prescribed medication and you are using any of those herbal drugs that they say will help or aid in the sh, diabetes. You have to be constantly watching your blood sugar” (Julienne) Subthemes. The iterative process resulted in the development of subthemes. Two subthemes, Jamaicans use CT in diverse ways for self-care and Jamaicans create conscious self-care plans to use with CT, were formed.
Jamaicans use CT in diverse ways for self-care. Responses from both general and key participants indicated their tendency to combine or mix different CT. The had different approaches to treating diabetes with bush medicine. The codes, Jamaicans use
CT intermittently, Jamaicans combine CT or use them singly, and Jamaicans use plain or processed plant material as self-care for DM intersect to form the subtheme Jamaicans use CT in diverse ways for self-care.
Jamaicans create conscious folk care plans to use with CT. Recipes were also used by the informants. Apart from using recipes the informants made lifestyle
80 adjustments while using CT. The researcher saw an interrelation between the codes
Jamaicans adjust lifestyle when using CT in diabetes management and Jamaicans prepare simple recipes when using CT in diabetes management. Her interpretation is Jamaicans create conscious folk care plans to use with CT.
Major theme. The two subthemes described above gave rise to the major theme.
Jamaicans follow individualized and diverse folk care patterns while using CT.
Jamaicans follow individualized and diverse folk care patterns while using CT evolved from the data. This major theme addresses the first research question, how do Jamaican
People with Diabetes Mellitus Use Complementary Therapies for Managing their
Diabetes? It is represented in Figure 4 below.
Figure 4. Major theme 1
81 Research Question 2: Why do Jamaican people who live in South Florida include
complementary therapies in diabetes management?
Because I just believe that one day it might just work…because these natural things you find sometimes they do work after a while…and I just said, you know, but even with the natural herbs or whatever, I didn’t see the numbers really going down, so… I still took it you know because I figured one day it will help, because following the old wives’ tale that says that you know, these, these homeopathic remedies are better than the prescription drug” (May) Codes. Several participant quotes are presented below to address the research question, why do Jamaican people who live in South Florida include CT in diabetes management? The codes named are derived from the participant quotes.
Jamaicans get other health benefits from CT used for diabetes. This code,
Jamaicans get other health benefits from CT used for diabetes, addresses question two.
Associated data are:
“if you take the soursop leaf, you pray you won’t have pressure and sugar and all that good stuff” (May)
“Natural herbal cocktail that is specific for helping to balance the blood sugar…and coincidentally, they also help to balance the cholesterol, and help to maintain the blood pressure…As a matter of fact the CBD which is like the cannabis extract is another very good thing I found for diabetes. It helps with the diabetes and also the blood pressure” (Sara)
Turmeric, turmeric, they say turmeric is good for almost anything yuh nuh…But, but yes,dem seh it good fi joint pains (it is said to be good for joint pains)” (Julio)
“Soursop leaves…I used it for other reasons though, but it must have given me some benefits for the diabetes as well…But that is mostly for hypertension” (Jonas)
“The callaloo is a nerve builder and it is a blood builder. It’s, it, it build your blood… Well papaya is extremely good for you. You know what it does? It, it open yuh appetite (It opens your appetite) yuh nuh, it clean yuh system (It cleans your system). And if you don’t have a good appetite, it clean yuh system (it cleans your system)…Oh the pineapple, pineapple,
82 pineapple. Pineapple is the energy-builder. If you get up in the morning and you doan (don’t) have any energy just get piece of pineapple… Alright, so the cucumber, if you juice it, it restore yuh skin yuh nuh. That’s why they use, the woman use it over them eyes and all that stuff (and that’s why women use it over their eyes)… The soursop is good, the bark the leaves, and the fruit. It good for yuh nerves (It is good for your nerves, It good for cancer, It good for diabetes, Everybody use it” (Tony)
Jamaicans base their use of CT for diabetes on improved symptom control.
Another code is Jamaicans base their use of CT for diabetes on improved symptom control. See the data below.
“Well sometimes they say they gradually wean off the doctor prescription, especially if the doctor tells them they are borderline…cause they check there blood sugar in the mornings and when they start doing the natural supplements, they are better controlled…So they don’t have, getting those peaks and troughs in the level, in the sugar level” (Sara) “and sometimes when yuh tek dem (when you take those) natural medications, the bush medication and thing yuh feel good ina yuh self (you feel good within yourself)…you just feel energetic…when yuh tek di tablet mentally you are thinking, you are wondering if this thing is working (when you take the tablet, mentally you are thinking, wondering if it works). But when yuh tek di bush yuh jus feel seh it work, yuh nuh (but when you take the bush you just feel it works, do you understand)…with the bush you just feel purity…yuh jus feel better (you just feel better) that’s how I feel” (Julio) “It lowers the sugar and I don’t have the same stomach issues that I have with the medications” (April) Jamaicans use CT to reduce or eliminate the side effects of conventional medicine. Several participants mentioned that they used CT to escape the undesirable effects of conventional medicine.
“So, I’ve never really, I’ve never really want to take Insulin. Like I see some a my friends sticking themselves in their leg and all that, An mi nuh waan do dat (And I do not want to do that)…Because the metformin when yuh teking the metformin (when you are taking the metformin)…And you not eating you, you really feel weak It mek you feel extremely weak (it causes you to feel extremely weak)…The Glipizide, I don’t know what is in the Glipizide, but it makes the sugar go down. So sometimes my sugar level is so low that I feel weak and start perspiring…yuh nuh, yuh do 83 really, yuh do really have a, a dark urine when you take the Metformin, but yuh jus feel seh it clog yuh up (do you understand? Your urine is not really dark when you take the Metformin, however you feel as if it creates a blockage within you). I do no, I do no, but that’s the feeling I get (I do not know, but it’s a feeling I get” (Julio) “I took the Insulin for about a month, but after I found that the Insulin was lowering my blood sugar too much. So my primary care, ‘cause I visited the primary care after. So the primary care took me off the Insulin and ahm prescribed another medication along with the Metformin…No. I had stopped taking the medicine just, just temporarily to try an alternative thing because of the side effects of the medication…Which was either causing stomach cramps causing me to go to the bathroom more regularly and, the doctor I was visiting at the time, when I asked him to change my medication he only prescribed a lower, what he referred to as a slower, slow doh?” (April) “The Metformin gave me cramps in the stomach and diarrhea. I was told my system needs to get used to the medicines, and that I need to take the medicines with food and never on an empty stomach. I have blood works at frequent intervals to check how my kidneys are functioning to make sure the medicine is not damaging my kidneys. Diabetes damage my eye sight and I am not able to see to read. Sometimes trifocals are required in order to see” (Octavia). Jamaicans in South Florida have easy access to bush medicine. Plant remedies could be found in ordinary places. Participants had choices where to obtain them. The data that supports this code follows.
“A friend supplies me with the moringa, so I told them the other day that I was getting the tea bags and it’s more convenient…I had to go to the supermarket to get that in the ahm tea form in the box…I asked someone coming up from Jamaica to bring me some of the dried cerasee” (May) “My brother got it” (June)
“I know of cerasee from Jamaica, so, but I was able to get it here also. People would bring it, bring it up from ahm, because I started drinking that from, from before I came to Florida…I would get it in the tea bag form or people would bring the actual ahm, weh yuh call it (what do you call it) the leaves” (April) “Somebody was staying by me, asked for it and I told her I know where to get it…You can get it any place in Florida, just drive to some out of the
84 way place and you see it on the roadside…Passing golf places you see them running on fences” (Jonas) “from someone’s backyard…I'm not going to buy that when that grows wild” (Augusto) CT used by Jamaicans are relatively inexpensive. In additional to the ease of access, CT used by Jamaicans with diabetes who live in South Florida are relatively inexpensive. Informants did not have to purchase the CT they used. Plant leaves were commonly used.
“it’s just a matter of having some lemon juice in water…When they travelled back from Jamaica they would bring the cerasee leaves” (April) “Well at that time, they said that you could use the, the guava leaf which is good, alright, or the cinnamon” (Julienne) CT Jamaicans use require no special training to prepare. The key informants prepared the CT that they used. Noah, a general informant, indicated that he learned to prepare the CT from experience working in the food establishment.
“Just to put it in the cup and put the water on it” (May)
“Just boil it… now I, I ahm have pots with aloe… Yeh, and I'll cut that in three after I peal it. I blend it like a, blend it with a little juice… if I'm going to boil it then now I’ll just cut it in the two, or three pieces and not peal it. Just drop it in the pan, just wash it” (Augusto) “Just boil it like tea. That's how I did it…Just make a cup of tea” (June)
“jus draw it like you drawing a bag a tea (just steep it like you are steeping a tea bag)” (Julio) “If I’m drinking water, I just put the lemon juice in the water… they would bring the cerasee leaves, and I would brew it…Ahm, it’s just putting it in a pot with water, depending on the strength that you want, you use the amount, and boiling it…so when I drink it hot I have to still put, add a little honey into it not sugar because it would be defeating the purpose…Or I’ll have it cold. If I have it ice cold then I just brew it put it in the fridge, allow it to cool and then drink it as if I’m having a drink, but that’s unsweetened” (April)
85 “I got them in Jamaica, dried them and brought them up…Boil them, not too strong not too weak. The liver does not like anything too bitter So you can’t make it too strong. The moringa can be cooled and put in the fridge” (Octavia) “Each sprig with about one dozen leaves [periwinkle]. I used 2 sprigs. Boiled it until the water changes color…Three leaves to a cup of water [soursop]. That is more established…Mango leaf steeped in water put in in the refrigerator, and drain in the morning and drink it…Ali vera (aloe vera), put it in the water, drain in the morning and drink…Well boiling it is how you extract what you need” (Jonas) “From experience working here, the caraili you just cook it…the mauby you boil it and drink it” (Noah) “That’s what they told me, that I should boil it, and, and drink it” (Julienne) Jamaicans in South Florida who use CT talked about lack of trust in conventional medical providers. Julienne stated that she would not stop taking the medicine prescribed by her doctor, still she will not disclose to her doctor her use of bush.
These are some of data to support that code:
“this present doctor I just saw him for the first last week, so I never mention, got a chance to mention all those things” (May) “You can’t tell doctor you’re taking it. No doctor is gonna say okay use, tell you okay go ahead and drink that. No! they’re not gonna tell you that…He will never tell you that, even if he uses it for himself. He’s not gonna tell you, go ahead and drink it, No. Cause he’s writing you a prescription, so he’s not gonna tell you that. When you take something like that you are doing it at your own risk. (Julienne) “you know and I do my own research online and ahm you know and the pills they say to help, even though what has thrown me in a tailspin, there was one I was taking and I saw there was a class action ahm law suit about the drug…So I came in to the doctor and he said well you don't have to use it anymore, so, that's telling me that, you know ahm, some of these drugs are experimental. Because, I would think that if you know if you are prescribing these stuff and they are not helping the cause the way people are taking them, then you should be able to say you know what let's discontinue this” (Augusto) Rather than accepting the prescription, even if the doctor wrote the prescription they come in and tell me what’s going on…(Sara)
86 Jamaicans who use CT are connected to supporting people in their community.
Informants talked about people they were connected to who told them about CT. These people were friends, acquaintances, family, and respected elders.
“I kinda come from a family of herbalists” (Jonas)
Well my friend, they knew I was diagnosed with it. and once you are diagnosed with stuff there is always people trying to tell you, oh you can use this you can use that, you don’t have to take the doctor’s medicine cause it’s gonna kill you…that’s what they told me” (Julienne) “Doctor Sabie says mucus is the only thing that, that really give you, really destroy your system” (Tony) “Well you know, growing up in Jamaica you hear about all these things, and all the old people used to tell you, if you take the soursop leaf you pray you won’t have pressure and sugar and all that good stuff. So, you know through the years you know, you hear the old people giving all this advice. So I decided, well I see them, they were healthy, they never had any complaints, and tried their bush tea and lived up to 90, 80, 80, 90…following the old wives’ tale that says you know, these, these ah naturalized homeopathic remedies are better than the prescription drugs” (May) “I didn’t know about it before my sister came to visit, aah you know she is also a diabetic, so she was the one who told me about it” (June) “Well just talking to people who are struggling with it, with diabetes”
(Augusto)
“Friends, just friends…elderly people…because mi jus, a jus figure that they would work” (Julio) “Because the person that recommended that I try it is not somebody who is diabetic…but they were referring to their family member who had diabetes…who used it and they say I should maybe try it” (April) CT users reveal innate feelings about Jamaican folk-belief. Jamaican adults had their own beliefs about how CT work. That comes out in these quotes.
“If I was to like do one or the other for say, more than just the once a week…I, I would see a drop in my blood sugar” (Augusto)
87 “Because mi jus, a jus figure that they would work (I just figured that they would work)” (Julio) I believe in it, whether they work or not I do not know, but I believe in them…believe in it yeah, as they say, belief kill and belief cure, so I’m one of those” (May) “I believe in holistic healing…To me it means everything works together, not just one aspect. I want to see non-conventional and conventional medicine work together” (Marcus) Jamaicans who use CT for DM illustrate beliefs about health and causes of illness. The Jamaicans in this study seem to have strong convictions regarding the origins of diabetes and how it should be managed. Jamaican informants commented on their thoughts about what caused diabetes and thereby how it might have been avoided.
“So sometimes the body is just overstressed, overworked from toxic stuff that we are taking in” (Sara) “because I think diabetes is a curse yuh nuh…So, dem, dem kina food weh yuh grow up pan yuh nuh (So the types of food that we grew up eating) If our people had knowledge that those things were starchy, and the meat wasn’t good, too much meat wasn’t good yuh nuh. Probably if I grew up, if my people were of the Rastafarian faith and they were giving me the ital yuh nuh that sort of food; probably I wouldn’t, I would just detest meat totally, yuh nuh, and no flesh thing. But I don’t know, the, the diabetic thing to me is a curse pon (upon) people…When yuh read Psalm 68 and it seh, sing unto God, sing praises to His name, extol Him that ride upon the heavens by His name Jah. And when you look into the bible you see Jah. It’s the biggest, it’s more bold than any other, any other letter form in the bible at that time. So that hit me, and I said, wa a serious something that yuh nuh (So that really got my attention and I said, what, that is a serious thing, do you understand). So that made me ahm, lean more to the natural state of life” (Julio) “You just think about what you are putting into your body, and the medications, from I was even younger I never liked taking medication, even for headaches” (April) “It must be something that is in you from you are growing up…I believe diabetes has something to do with the system from you were growing up, and the stress. So it’s not just how you eat it has to do with the stress as well. Some people says it’s the starch, it’s the rice and the white flour. How do the Philippinos, Chinese and Japanese eat rice all day long and they do not have diabetes, only the Black people?” (Octavia)
88 “Although I know that dem seh sugar is not good, sugar ahm, invite cancer and all dat sorta ting yuh nuh (although I know it is said sugar is not good, sugar invites cancer and such things, do you understand)” (Julio) “Anything that create diabetics create cancer create diabetes…So you can change it. You can just change the word from cancer to diabetes…Mucus is that what, that’s what build diabetes…a have low blood pressure so salt don’t trouble me at all…cause I always have it coming up…So is not the salt is the problem…Is the processed foods” (Tony) Subthemes. Four subthemes evolved from those codes These subthemes are (1)
Jamaicans believe CT provide gratifying benefits, (2) CT are accessible folk care, (3)
Jamaicans who use CT function within a network of people they trust, and (4) CT users realize faith in folk beliefs. The associated codes are listed below.
Jamaicans believe CT provide gratifying benefits. Jamaican informants voiced a dislike of conventional medications for various reasons. Additionally, they.had expectations of the formal healthcare system that were not met. The codes associated with Jamaicans believe CT provide gratifying benefits are:
a) Jamaicans get other health benefits from CT used for diabetes
b) Jamaicans base their use of CT for diabetes on improved symptom control
c) Jamaicans use CT to reduce or eliminate the side effects of conventional
medicine
CT are accessible folk care. Three codes are linked to the subtheme CT are accessible folk care. These codes show that CT are inexpensive, available, and easy to prepare. The codes are listed:
a) Jamaicans in South Florida have easy access to bush medicine
b) CT used by Jamaicans are relatively inexpensive
c) CT Jamaicans use require no special training to prepare 89 Jamaicans who use CT function within a network of people they trust. The researcher feels that Jamaicans who use CT function in a network of people they trust.
Data shows that participants felt they could not tell their conventional medical provider that they were using bush medicines. On the other hand, they trusted the persons who introduced them to CT. The subtheme describes the codes that follow:
a) Jamaicans in South Florida who use CT talked about lack of trust in
conventional medical providers
b) Jamaicans who use CT are connected to supporting people in their
community
CT users realize faith in folk beliefs. Their beliefs about the cause of disease, how to keep well, and how to manage illness appeared to influence Jamaican adult’s reason for using CT within diabetes management. Hence, the attached codes.
a) CT users reveal innate feelings about Jamaican folk-belief
b) Jamaicans who use CT for DM illustrate beliefs about health and causes of
illness
Major theme.
Jamaicans believe CT are affordable folk care promoted by people they can trust. The major theme identified out of this data is Jamaicans believe CT are affordable folk care promoted by people they can trust. It aptly describes the enmeshing of the subthemes. The researcher worked through the data to create codes that could adequately depict the meaning of the data. Then from the data to the subtheme to this major theme.
Key participants spoke of their expectations to get relief from unwanted effects of conventional medicines. The representation of the relationship of the major theme
90 (center) to the subthemes (four spokes coming from major themes out to subthemes) and
the codes (on either side of figure) can be seen in Figure 5.
Figure 5. Major theme 2
Research Question 3: What CT are Used by Jamaican People with Diabetes who
Live in South Florida?
And alright, the cucumber now, the cucumber…Is, is gonna help with the diabetes Because the diabetes affect you skin yuh nuh (Because the diabetes affects your skin, do you understand) (Tony)
The third research question asked, what are the CT used by Jamaican people with
diabetes who live in South Florida? The CT/bush medicine that were used related
somewhat to how they were used. Similar things were also said by different participants.
Therefore, some of the data is repetitive.
Codes. The content analysis revealed that complementary therapies for diabetes were generally ingested in the form of drinks, though it was also consumed in a powdered 91 form sprinkled onto food. The drinks were taken as smoothies and as liquids or powders
added to cool drinks or water. However, the most common form identified from the data
was hot tea. The following is an alphabetic outline of the CT named by the participants.
CT that were identified by participants to be similar or were identified to be similar
through the literature were grouped as one. Alkaline water, Aloe vera/ali vera/sinkle
bible, Apple (Jamaican), Black seed oil, Blood sugar balance/Ayurvedic herbs (amla,
bitter melon, aloe vera), Buma, Cabbage, Callaloo, Cashew fruit, CBD-cannabis
extract/Marijuana, Cerasee/bitter melon/sorasee/caraili/Chinese caraili, Cho-cho,
Cinnamon, Cow foot bush, Dogblood, Guava leaf, Ginger, Guinea hen weed, Gully
bean/Susumber, Jack-in-the-bush, Jackfruit, June plum, King-of-the-forest, Lalu, Lemon,
Lime, Mango leaf, Mamee bitters, Mauby, Moringa/Merengue, Neem, Papaya/pawpaw,
Passion fruit, Pepper, Plantain, Search-mi-heart, Strong back, and
Turmeric/Tambric/Tameric.
Jamaicans use plant remedies they think are natural and pure following folklore for managing diabetes. This code captures some of the descriptive terms used by the participants. The data is quite expressive.
“natural medicine…natural whatever you want to call it…naturalized homeopathic remedies” (May)
“The good old herbs…the leaves may be about this broad [makes shape in the palm of her hand] and there is a split in it just like the hoof of the cow, so I say, here goes the cowfoot, the name cowfoot bush…What do you call it? bush” (June)
“Natural supplement…It’s like a natural cocktail…natural herbal cocktail that is specific for helping to balance the blood sugar…natural stuff” (Sara)
“Sometimes I think the natural stuff works better than the conventional medicine…but with the bush you jus feel purity” (Julio)
92
“soursop leaf” (Micah)
“Moringa…Guinea hen weed…cerasee” (Octavia)
“Periwinkle…king of the forest…cerasee…strongback…moringa seed…soursop leaf…mango leaf…ali vera (aloe vera)” (Jonas) “Mauby…black seed oil…caraili…Chinese caraili…cerasee” (Noah)
“Guava leaf…cinnamon” (Julienne)
“the cucumber… cho-cho…Susumber is good for the diabetes (Tony)
Figure 6. Image of Cho-cho
INT: So what is the susumber? You know yuh nuh, we call it gully bean…June plum…There is one that is not here that is very important, that will regulate yuh (your) blood and help with diabetes, called pepper elder… cashew fruit… Jack-in-the-bush… search-mi-heart… Jackfruit… pepper… Ginger… tameric (turmeric)… Well the ginger and the lime is a, is a simple alkaline drink… This is the passion fruit, it have vitamin C 93 antioxidant… papaya… Jamaican apple… plantain… dandelion… merengue (moringa)… callaloo… lalu… dogblood… mamee bitters… Guinea hen weed… cabbage” (Tony).
Figure 7. Image of Dogblood
Figure 8. Image of Cabbage
94 Jamaicans use bush medicine in self-care for DM. The term bush is used by
Jamaicans. It is a common folk term used to describe herbal remedies. The linked data are:
Oh yes, I was taking all the Jamaican bush, bush teas…I started with the cerasee tea, then I went to the soursop tea, then I tried the moringa, and I think the pawpaw, the pawpaw skin” (May)
cerasee once a week, Yeh, then after a while like I told you I couldn’t find it so I stopped…and then ahm just recently, I ahm, I started using ahm aloe vera” (Augusto) “soursop leaf” (Micah); “cowfoot bush” (June)
“Marijuana tea…ali vera (aloe vera) water…sinkle bible (aloe vera)…cerasee…cinnamon…papaya extract tea bag” (Julio)
“Cinnamon…lemon juice…cerasee tea” (April)
“Moringa…Guinea hen weed…cerasee” (Octavia)
“Periwinkle…king of the forest…cerasee…strongback…moringa seed…soursop leaf…mango leaf…ali vera (aloe vera)” (Jonas); “Guava leaf…cinnamon” (Julienne).
Figure 9. Image of Cerasee
95 Jamaicans use plain or processed plant material in self-care for diabetes. Most
of the plants described by participants were used in their natural form, however,
participants also described processed CT. Several quotations follow:
“We’ve gotten very good results with the bitter melon. We have it in the form of capsules, as well as liquid; Bitter melon juice” (Sara)
“And mi use to drink some a di ahm marihuana tea also INT: for the sugar? Yeh (yes) INT: okay And, ali vera water INT: mm Ali vera INT Aloe vera? Yeh dat dem call sinkle bible (that is what they call sinkle bible)” (Julio)
“Ali vera, put it in the water. Drain in the morning and drink” (Jonas)
“The black seed oil comes already prepared. It is cold pressed” (Noah)
“Ginger, and we never talk about the ginger or the tameric (turmeric) INT: Ah Well the ginger and the lime is a, is a simple alkaline drink” (Tony)
Subtheme. The subtheme sums up the data describing the CT used by Jamaican people with DM who live in South Florida. Because of the nature of the data only one subtheme emerged, Jamaicans use traditional folk remedies for managing diabetes.
96 Jamaicans use traditional folk remedies for managing diabetes. This subtheme depicts the relationship of the data with the codes. As a reminder the codes are (1)
Jamaicans use plant remedies they think are natural and pure following folklore for managing diabetes, (2) Jamaicans use bush medicine in self-care for diabetes, and (3)
Jamaicans use plain or processed plant material in self-care for diabetes..
Major theme. As can be seen from the data, the cerasee (bitter melon) is a common traditional remedy for managing diabetes among Jamaicans. A few informants used aloe vera and moringa. Only one informant mentioned the use of cowfoot bush.
Jamaicans use traditional folk remedies for managing diabetes. As only one subtheme exists to answer research question three, the subtheme therefore becomes the major theme as well. This is represented in figure 10.
Figure 10. Major theme 3
Research Question 4: How do Jamaican People with DM who use CT Describe How they Know what CT are Appropriate for Managing Diabetes?
Well you know growing up in Jamaica you hear about all these things, and all the old people used to tell you, if you take the soursop leaf you pray you won’t have any pressure and sugar and all that good stuff…So you know
97 through the years you know, you hear the old people giving all this advice, so I decided, well I see them they were healthy, they never had any complaints and tried their bush tea and lived up to 90, 80, 80, 90. So I said well let me give it a try (May) The question is, how do Jamaican people with diabetes mellitus who use CT describe how they know what CT are appropriate for managing diabetes? The data reveals that a few of the informants were not sure that the bush would help or that they had unexpected results from the treatments. Informants also described unpleasant characteristics that were observed with some of the bush. Julienne was concerned about possible herb-drug interaction or herb-herb interaction that might be unknown by users.
There were some reported occurrences of improved blood sugar control while using CT.
Codes. On observation of the data no strict provider-client relationship was observed. Caribbean adults with diabetes used a chain of referral based on word-of- mouth from acquaintances to guide their decisions about whether they use bush medicine.
Jamaicans choose CT for managing diabetes based on their trust in knowing elders. When the participants were asked how they know what CT to use for diabetes there was a resounding of older people. By their responses the bush medicine users in this study gave the impression that it really mattered where they got the information regarding using bush. Their words follow:
“Friends, just friends and elderly people…Elderly people” (Julio)
“Old folk” (Jonas)
“Older people, older people…Old folks from the old grandma school. They were not young but old people. It’s old people tell you about plants, young people don’t really know” (Julienne) “INT: So Tony how did you know about these things man? Well it’s it’s over the years yuh nuh My grandmother, and we have to dwell with this bush (we had to dwell with the bush)… Yeh, well my 98 grandmother now she was the, the village midwife. And she didn’t went to any college to learn all these things (and she did not go to college to learn these things) She was naturally gifted. She was naturally gifted, and if a lady couldn’t get to the hospital in time she was the one they would call. They call her miss goodie [laughs] (Tony) “old people” (May)
“a friend” (Augusto)
“I took it because it was my sister who said it” (June)
“Friends, just friends, and elderly people” (Julio)
“Friend” (April); “Old folks” (Jonas)
After several informants echoed that elderly people were important in their decision to use CT, I asked of Julienne what was special about elderly people. Her response was;
“Because, what is special about the old people? …they depend on the stuff of the soil…and watches the sun and the moon”. Jamaicans determine the appropriateness of the CT they use for diabetes based on the characteristics. A few participants mentioned that some plants were bitter, or otherwise unpleasant and that characteristic bitterness aided in the way the plants combatted high blood sugar. One key participant, Julienne, stated that the plants were chemicals just like synthetic medicines; the difference being that they were plant chemicals. General participants felt that alkaline substances and antioxidants are the CT that are suitable for managing diabetes. The following quotes shows how the informants talk about the characteristics of the CT:
“It is bitter” (Jonas); “Caraili or Chinese caraili is a green vegetable. You can eat it or boil it as a tea. Jamaicans call it cerasee. It is bitter…the mauby too is also bitter” (Noah)
99 “You don’t know it’s still a chemical, but it’s a plant chemical” (Julienne)
“Yeh (Yes) the callaloo is alkaline yeh (yes)… The pumpkin is extremely good it is it’s fibrous… The cho-cho have a lot of antioxidants, is a lot of water for yuh system, so (The cho-cho has a lot of anti-oxidants, it is a lot of water for your system)…This is Jack-in-the-bush…A very good tea bush…The cerasee is bitter you know, and all bitters good for diabetes (all bitter things are good for diabetes) All bitters that can be eat, that is drinkable (all bitters things that can be drunk)” (Tony) “It taste horrible but…I just believe one day it might just work” (May)
“The smell, I don’t know if I can do that…That’s one thing I can’t really stand the smell” (Augusto) “Ever since I was a little kid my grandmother would make some
concoction, you would not want to take it.” (Micah)
“Because the sorasee bitter and stuff (because the cerasee is bitter and stuff). And if yuh drink yuh can drink Guinness because the Guinness bita yuh nuh (and do you know if you drink you can drink Guinness, because the Guinness is bitter)” (Julio) “It’s not a pleasant taste” (April).
Jamaicans opt to use CT knowing individual results will vary. The following quotes say much more than I could to describe this code.
“What works for some people may not work for others. Things don’t work for everybody the same. Some people come back and say that really works, while some others did not have similar results. So the results vary. It works for some and for others it may not work” (Marcus) “…so it can have adverse effects. So, it’s just like you’re taking a chance drinking something that is not, that you don’t really know what it is going to do to you” (April) “Everybody’s body chemist is different. Everybody’s chemist is different. What agrees with you may not agree with me. Everybody’s metabolism breaks down different” (Octavia) “Different people have different response. It depends on how your body reacts” (Noah)
100 “Everybody is individual. It’s different. For me, yes. For someone else, might be no…I can only speak for myself. Cause everyone you know will arrive at their different stop” (Julienne). Jamaicans apply trial and error to ascertain the appropriateness of CT. Both key and general informants described what appears to be trial and error method trying to discover if the CT they selected was an appropriate choice.
“Oh God, I mix them up. I, I, I, was trying everything all the time. And sometimes I feel like I was overdoing it, cause as you just asked if I did it one at a time. I just did every bloody thing to see if I could lower this sugar” (May) “I am driven by results. I adjust if the client comes in and says it does not work as well” (Sara) “…I didn’t, but the initial amount that I used worked, so I continued to use it…well, it helped my mother” (Jonas) “Well I did not know it would take a while, is just by you drinking it and watching your level. You can see your levels when you drink it, and your levels when you don’t drink it along with the doctor’s meds” (Julienne) Subtheme. The subthemes that emerged are: (1) Jamaicans who use CT rely on characteristic appeal and the wisdom of the elderly, and (2) Jamaicans express that CT they use in diabetes management are not certain to work.
Jamaicans who use CT rely on characteristic appeal and the knowledge of the elderly. Informants seem to have faith that the information passed on by older folks, especially regarding the characteristics of various bush medicine, was enough to guide their use of these therapies. The codes Jamaicans choose CT for managing diabetes based on their trust in knowing elders and Jamaicans determine the appropriateness of CT they use for DM based on the characteristics fit within this subtheme.
Jamaicans express that CT they use in diabetes management are not certain to work. This subtheme embodies the codes Jamaicans opt to use CT knowing individual
101 results will vary and Jamaicans apply trial and error to ascertain the appropriateness of
CT.
Major theme. The major theme Jamaicans are willing to try folk care in the face of uncertainty sums up the data.
Jamaicans are willing to try folk care in the face of uncertainty. The participants talked about their experience with bush medicine. They disclose their uncertainties about the results and how different plants may have varying results based on the individual using them. Folk care are not certain to work but are supported by the elderly in the community. This informal referral system was also used to determine which bush medicine they used. Jamaicans are willing to try folk care in the face of uncertainty describes how informants determine appropriateness of CT. The data is represented in figure 11 below.
Figure 11. Major theme 4 102 Research Question 5: How do Jamaican People Describe or Report Evidence that
the CT they use for DM Work to Reduce or Improve their Symptoms or the Effects
of the Disease?
“Medicine in those days is not like now. Now we have a lot of things that can readily help us. But in those days, the very old people all they knew about is the earth. They drink that, it will get rid of this headache. If you start taking that, it will stop your stomach from hurting. So they really didn’t know about certain types of medication. And sometimes in those days, people could not afford it, to even go to the doctor. And if the doctor even try to prescribe something, they could not afford to buy it…And in those days people depended upon the stuff from the soil” (Julienne) Codes. To explore if the data supplied an answer to the question, how do
Jamaican people describe or report evidence that the CT they use for diabetes mellitus
work to reduce or improve their symptoms or the effects of the disease? The researcher
started by exploring the quotes. General informants had personal experience with CT and
therefore had strong belief that they work, and that they should be used in disease
management. Key informants expressed that they expect them to work eventually.
Jamaicans trust that bush medicine will work based on its longevity. This code
provides a snapshot of the data.
“These things have been around a long time before you and I, before the manmade medicines” (Marcus) “Yeh man (yes man). Because yuh si (you see) from the bush yuh nuh (you know), as the little man a while ago was saying dat (that), that’s where most medicines come from” (Julio) “Old folk, they people been around for a long time before me and I am 73 years. So these things have been around a long time” (Jonas) Jamaicans trust the value of CT based on information passed down to them.
“Well you know, growing up in Jamaica you hear about all these things..so I decided, well I see them they were healthy, they never had any complaints and tried their bush tea and lived up to 90, 80” (May) “Because I, I grew up in Jamaica knowing that you know, cerasee was always a good tool to fight diabetes” (Augusto) 103 “And all the old people used to tell you…So you know, though the years you know, you hear the old people giving all this advice…So I said well, let me give it a try” (May) Jamaicans who use CT experience decrease in their blood sugar and A1C. The data that supports this code follows:
“Okay my blood sugar would run maybe like sometimes 140. If I do the cinnamon with the meds I’d be down maybe sometimes to 100, 99” (Julienne) “Because it was so low. I remember I got like 87, 110, something like that, which I didn’t get with the medication…I have seen changes…in the blood sugar…and in the A1C, yeh…And it was so, the sugar was so under control” (June) “But now it’s under control. It is so good that sometimes I get hypoglycemic because it’s too low” (Jonas) “The combination of both things might have been working, I don’t know…It was WELL controlled…I was under like, if I would take it in the morning it was always like under 100. So that was well controlled” (May) “Anyhow, drinking the cerasee and thing bring it down. Drinking the cerasee tea and all that sort of thing, taking the medication…Whenever I drink the sorasee (cerasee) you know it’s very low, almost non-existent” (Julio) Jamaicans who use CT monitor their blood sugar and A1C. Six of the eight key informants reported routine monitoring of their blood glucose levels. Meanwhile, one general participant assisted her clients in blood glucose monitoring. Therefore, informants were able to state how the bush medicine affected their blood sugar and/or
A1C.
“So, I know if I am using it I need to, I can’t miss my, evaluating my sugar level. I have to stay. Cause then, you know, I could be low and I’m drinking it still, just drinking it and not watching numbers and that could be dangerous…Because I was testing every day, so you know something is working or not” (Julienne) “And it was so, the sugar was so under control. The readings were so, I’m sorry I didn’t bring more…Yeh, I’m saying yeh, my A1C, it was for the first time that my A1C was at what you may call a good level or something like that…seven” (June)
104 “Cause they check their blood sugar in the mornings” (Sara)
Subthemes. The apparent subthemes are (1) Jamaicans trust generational information and (2) Jamaicans report empiric data to support diabetes management with
CT. These subthemes flow from the quotes and support the major theme Jamaicans use self-management strategies trusting the wisdom of the elderly.
Major theme. Not all participants gave specific data to support their reports that
CT they use for diabetes reduce or improve their symptoms.
Jamaicans use self-management strategies trusting the wisdom of the elderly.
Informants seemed to trust the wisdom of the elderly based on confirmation by blood glucose and A1C levels. Hence the major theme. It is represented below in Figure 12.
Figure 12. Major theme 5
105 Central Meaning
that’s what they told me, that I should boil it and drink, drink it…Well my friend, they knew I was diagnosed with it. and once you are diagnosed with stuff there is always people trying to tell you, oh you can use this you can use that, you don’t have to take the doctor’s medicine cause it’s gonna kill you…that’s what they told me (Julienne) The major themes describe factors associated with CT use. Several participants
were in disbelief when they were initially told by their provider that they had diabetes.
They described how they came to use CT that they commonly refer to as bush medicine.
Figure 13 below shows the major themes and one central meaning. The central meaning is the final interpretation of the data.
Figure 13. Image depicting central meaning of major themes The data show that folk care involved self-management with diverse traditional
practices. The Jamaicans acted by using self-management that were learned and shared
106 from older folks. They used different means, but their behaviors were based on their shared goal of achieving diabetes control. Although the means used by Jamaicans in this study are different there is an established pattern of using diverse treatments in folk medicine for managing diabetes in this ethnic group. Looking back at the definition of culture in chapter one, one can discern that the Jamaican adults in this study who have diabetes and who use CT to aid in diabetes management act like a cultural group. Hence, the central meaning is cultural norms and variations characterize the way South Florida residing Jamaican adults with diabetes mellitus use CT.
Table 4 lists information about some of the herbs identified in this research and what the scientific literature reports about their usefulness for diabetes. It provides valuable information pertaining to the actions of herbs used in diabetes management and can be useful for not only Jamaicans but other ethnic peoples that use these measures for chronic disease management.
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Table 4. Description of CT/Bush Medicine Used by the Participants and Scientific Evidence of their Effects
Common name Source Effect Evidence (scientific name) Alkaline water Drinking Alkaline water is a potent free radical scavenger Kim, M-J., & Kim, H. K. (2006) (Mineral water) water and produced anti-hyperglycemic effects on insulin deficient streptozotocin-induced diabetic mice, and insulin resistant animal model Aloe vera/ali vera/ Gel powder, Most clinical research show that oral intake of Natural Medicines. (2019) sinkle bible extract, raw aloe vera can reduce FBG by 30-46.6 mg/dl and (Aloe vera) crushed A1C by 0.41-1.05% in adults with prediabetes leaves, fresh and diabetes. One analysis of 92 persons showed extracted a larger overall reduction of FBG in people juice whose baseline FBG was 200mg/dl or more. Apple (Jamaican) Bark Alcoholic and aqueous extracts reduced FBS Bairy, K. L., Sharma, A., & Shalini, A. 108 (Syzygium (extract) significantly with single administration in (2005) malaccense) normal rats. Chronic administration of both extracts showed significant hypoglycemia effects as compared to control. Avocado (Persea Seed “Avocado seed increased liver glycogen storage Uchenna, U. E., Shori, A. B., & Baba, Americana) in spontaneous hypertension rats fed on basal A. S. (2017) diet and normal rats fed on high sucrose diet. Avocado seeds can lower blood glucose and cholesterol and enhance liver glycogen storage in rats.” Banana/plantain Fruit Musa acuminata exhibited low glycemic index, Adedayo, B. C., Oboh, G., Oyeleye, S. (Musa acuminata) (extract) anti-oxidant activities and inhibits glucosidase I., & Olasehinde, T. A. (2016) activity that could possibly justify its use for type 2 diabetes. Black seed oil Seed A preliminary clinical study shows that oral use Natural Medicines. (2019) (Nigella sativa) of black seed powder, 1g twice/day for 3-12
Common name Source Effect Evidence (scientific name) months lowers FBG by 17-26%, and A1C by 5- 15% compared to baseline in people who were using medicines for diabetes. Results were significant at 3 and 9 months when compared to placebo, but not at 12 months. Buma No data was found describing use of buma for No data found in general search (Buddleja diabetes in the scientific literature marubifolia) Cabbage Leaf Animal and in vivo research shows some Natural Medicines. (2019) (Brassica oleracea) evidence that cabbage possibly produces hypoglycemic effects. Theoretically, additive hypoglycemic effects may be seen with other
109 herbs such as devil’s claw, fenugreek, garlic, guar gum, horse chestnut, among others. Callaloo Leaf (extract) A significant fall in blood glucose levels Girija, K., Lakshman, K., Chandrika, (Amaranthus viridis) (P<0.05) was observed in normal rats on the 14th U., Ghosh, S. S., & Divya, T. (2011) day at 400mg/kg orally. Significant drop in blood glucose level (P<0.01) was also seen on the 21st day of the study at 200mg/dl. Cashew Bark Scientific research found significantly reduced Alexander-Lindo et al. as cited in Lowe (Anacardium (extract) blood glucose concentrations in test animals et al., (2012) occidentale) CBD-cannabis Extract Repeated treatment restored physiological Comelli, F., Bettoni, I., Colleoni, M., extract/Marijuana thermal pain perception in streptozotocin (STZ)- Giagnoni, G., & Costa, B. (2009) (Cannabis sativa) induced diabetic rats without affecting hyperglycemia. It provides protection against oxidative damage in STZ-induced diabetes that contributes to the development of neuropathy.
Common name Source Effect Evidence (scientific name) Cerasee/bitter Fruit, fruit Some preliminary research shows improved Natural Medicines. (2019) melon/sorasee/caraili/ juice, fruit glucose tolerance, reduced blood glucose levels, Chinese caraili pulp, extract and lower A1C in people with type 2 diabetes. (Momordica charantia) Cinnamon Capsules Analysis of several clinical trials have found that Natural Medicines. (2019) (Cinnamomum taking cassia cinnamon 120 mg to 6 g daily cassia) significantly reduces FBG by an average of 24.59 mg/dl. Different dosage forms seem to have different effects. No significant results seen in patients with type 1 diabetes. Cho-cho (Sechium Fruit extract Oral administration of 200mg/kg prevented body Sonali, M., Mumtaz, S. M. F., &
110 edule) weight loss and significantly (P,0.01) decreased Debnath, R. (2013) blood glucose levels on day 0, 7, 14, and 21 in Alloxan-induced diabetic rats. Cow foot bush Leaf Crude ethanolic extract of the aerial parts of the Lopes et al. (2013) (Pothomorphe plant demonstrated preeminent antioxidant peltata) activity Cucumber (Cucumis Seed Hydroalcoholic and buthanolic extracts were Minaiyan, M., Zolfaghari, B., & Kamal, sativus) effective in reducing blood glucose level and A. (2011) controlling loss of body weight in diabetic rats compared to control after 9 days of continued daily therapy. Dandelion (Cassia Leaf Preliminary laboratory research suggests that Natural Medicines (2019) occidentalis) dandelion might increase insulin secretion. Dog blood (Rivina Unknown No scientific data was found that described the No data found in general search humilis) use of dog blood for diabetes. Guava (Psidium Leaf (water Psidium guajava aqueous extract caused a highly Rawi, S. M., Mourad, I. M., & Sayed, guajava) extract) significant decrease in serum glucose D. A. (2011)
Common name Source Effect Evidence (scientific name) concentrations without noticeable change in insulin level compared to the non-treated diabetic rats. Guinea hen weed Leaf The hexane extract caused reduction of fasting Christie, S. L., & Levy, A. (2013) (Petiveria alliacea) glucose after two weeks of treatment (P<0.01) in diabetic rats, but it was not sustained. Jack-in-the-bush/Jack Flowers, leaf, No scientific data was found linking Jack-in-the- No data found in general search ina bush (Eupatorium stem bush to diabetes treatment odoratum) Jackfruit (Artocarpus Leaf Preliminary clinical research suggests that Natural Medicines. (2019) heterophyllus) Jackfruit leaf extract 10ml/kg one hour before GTT attenuates the percentage increase in blood
111 glucose at 1.5 and 2 hours after eating compared to control in patients with diabetes. June plum (Spondias Unknown No scientific data was found for use of June No data found in general search dulcis) plum for diabetes Lalu (Lactuca Unknown No data was found supporting the use of lalu for No data found in general search ludoviciana) diadetes Lemon (Citrus Juice Some coumarins in lemon reduce free radical Natural Medicines. (2019) limon) generation by inhibiting production of nitric oxide. In animal models of diabetes, a diet containing lemon flavonoids results in reduced measures of oxidative stress after 28 days of treatment. Mamee bitters Unknown Mamee bitters was not found in the scientific No data found in general search literature Mango (Magnifera Seed (kernel Significant (P<0.05) improvement in FBG, Irondi, E. A., Oboh, G., & Akindahuns, indica) flour) hepatic glycogen, A1C, lipid profile, plasma A. A. (2016) electrolytes, hepatic and pancreatic
Common name Source Effect Evidence (scientific name) malonaldehyde, and the liver function markers of the diabetic rats were seen when compared to control diabetic rats over 21 days. Mauby (Colubrina Bark Scientific data was not found supporting use of No data was found in general search elliptica) mauby for diabetes Moringa (Moringa Leaf One preliminary study shows that having 50 g of Natural Medicines. (2019) oleifera) moringa drumstick leaves reduces PPG level by 7% in people with type 2 diabetes not on hypoglycemic drugs, compared to a standard meal without the drumstick leaves. Neem (Azadiracahta Leaf, flower, Evidence exists that neem may have Natural Medicines. (2019) indica) twigs hypoglycemic effects
112 Pak choi Unknown No scientific data was located that support the No data found in general search use of pak choi for diabetes Papaya/pawpaw Fruit Preliminary clinical research found eating Natural Medicines. (2019) (Carica papaya) fermented papaya fruit 3g daily for 2 months can lower fasting and postprandial blood sugar levels by 13.3% and 10% respectively when compared to baseline levels in people with type 2 diabetes Periwinkle Leaf powder In diabetic rats lowering of plasma glucose and Rasineni, K., Bellamkonda, R., (Catharanthus increase in plasma insulin were observed after 15 Singareddy, S. R., & Desireddy, S. roseus) days and by the end of the experimental period (2010) glucose had reached the normal level, but insulin had not. Decreased hepatic and muscle glycogen content and alterations in the activities of enzymes of glucose metabolism as observed in the diabetic control rats was prevented with C. roseus administration.
Common name Source Effect Evidence (scientific name) Pineapple (Ananas Leaf “After sub-acute treatment, Anona cosmosus Xie, W. et al. (2006) comosus) (AC) can inhibit the development of insulin resistance in high-fat diet-fed and low-dose streptozotocin-treated diabetic rats following the test of loss of tolbutamide-induced blood glucose lowering action…AC application inhibited the development of insulin resistance in HepG2 cells Pumpkin (Cucurbita Pulp Glucose level decreased significantly (P<0.001) Mahmoodpoor, A. et al. (2018) pepo) in three days during administration of Cucurbita maxima. Insulin dose decreased (P=0.06) during the three days. Search mi heart Unknown Scientific data was not found that reported use of No data found in general search
113 (Rhytidophyllum search-mi-heart for diabetes tomentosum) Spanish needle Leaf, flower “Bidens Pilosa water extract reduced blood Bartolome, A. P., Villaseñor, I. M., & (Bidens pilosa) (extract) glucose, increased blood insulin, improved Yang, W-C. (2013) glucose tolerance, and reduced the percentage of A1C, in long-term and one-time experiments in rats.” Soursop (Annona Fruit extract A dose dependent reduction in α amylase and α Adefegha, S. A., Oyeleye, S. I., & oboh, muricata) (pericarp, glucosidase (enzymes linked to type 2 diabetes). G. (2015) pulp, and The effective concentration caused a 50% seed) antioxidant activity. The pericarp was most effective, while the seed was least effective. Turmeric (Cucuma Extract Preliminary clinical research shows that taking a Natural Medicines. (2019) longa) turmeric extract that contains 750 mg curcumin twice per day for 9 months reduces the number of people with prediabetes who develop diabetes compared to placebo.
Chapter Summary
This chapter presented the emic views of a sample consisting of 8 Jamaican adults
with diabetes (key informants) and five general participants who live in South Florida
regarding their use and/or knowledge of complementary therapies for managing diabetes.
The data is represented in tables and figures. Data for descriptive statistics were
generated using SPSS v. 25. Output describing how the codes relate to the subthemes and
major themes were created into figures from Atlas.ti 8.
The researcher described the process whereby data were reduced to codes. Codes
were further reduced to subthemes. The subthemes gave rise to five major themes that
answered each of the five research questions.
The findings showed that there are diverse ways in which CT are applied to manage diabetes mellitus. All informants did not agree on the paths to follow when using
CT or the results that were achieved. Despite uncertainties, Jamaican CT users trust the wisdom of their elders. Those informants who had not seen the results they expected felt that the bush medicine will eventually work.
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CHAPTER V. DISCUSSION
Bush medicine is a common name assigned to traditional medicine in Jamaica and
the wider Caribbean. Bush medicine was used widely to treat many ailments including
diabetes mellitus. The data obtained from participants in this study indicate that several
Jamaican adults with diabetes have a worldview that allows them to use bush medicine
and conventional medicine for managing their diabetes. The literature indicates that there has been a longstanding tendency in Jamaica to use bush medicine and conventional medicine together; therefore, the use of complementary therapies to treat diabetes is not a passing fad, or a new trend in the Jamaican community. However, what this study adds to what is already known is a deeper perspective. The thick description derived from participants adds insider knowledge about how they think about bush and diabetes. This study also adds knowledge about how culture influences health practices.
This chapter is a discussion of the study findings. As patterns in the data are discussed Leininger’s Sunrise Enabler to Discover Culture Care is interwoven in the discussion regarding interpretation of the patterns/themes.
At the study outset the researcher started with a central question, how do
Jamaican adults with diabetes mellitus who live in South Florida select and use complementary therapies for managing their diabetes. Five subquestions spun off from the central question and guided the creation of the interview guide. This discussion is organized around each of the major themes as each is associated with a subquestion.
Recommendations are made for the future of culture care and research. 115
Discussion of Findings
Jamaicans grow up being taught proverbs/wise sayings that may have been taught formally in school or informally at home. These proverbs may guide the way many live and are often repeated like mantras. At least one such saying came out during data collection, that is “belief kill and belief cure” (May). Usually these sayings are handed down from one generation to the next through word of mouth in a similar fashion to the use of bush medicine and so they may go hand-in-hand.
Jamaican participants in this study echo what has been found in previous studies, a belief that bush can successfully treat diabetes mellitus. Studies involving other cultural groups have conveyed that acupuncture, homeopathy, relaxation, and ‘other’ complementary therapies are effective for managing diabetes (Lynch et al., 2012;
Popoola, 2005; & Schoenberg et al., 2004). However, only one participant in this study,
May, used the term homeopathy and she used it to describe the bush.
Caribbean people who believe in CT often included spirituality as a mode of CT
(Scott, 1998; Adams, 2003; Caban & Walker, 2006; Amirehsani, 2011; Smith, 2012; &
Amirehsani & Wallace, 2013). However, less than half of the participants in this study referenced spirituality in their discourse about use of CT for managing diabetes.
Nevertheless, all participants talked about their health beliefs whether it related to the use of bush or their thoughts about what causes diabetes.
Theme 1: Jamaicans Follow Individualized and Diverse Folk Care Patterns while
Using CT
This theme came out of the question, how do Jamaican people with DM use CT for managing their diabetes. The interpretation of the data reveals that diverse and 116
common patterns of CT use exist in this population. Jamaicans commonly use bush/plant- based medicine to manage diabetes. Still, there is diversity in the way these plants are used. Another commonality found is that most participants used the bush to make teas.
For the most part simple recipes were used. Diversity exists in the way the teas were used. Some participants had it hot, while some had it cold.
The cultural values, beliefs and lifeways of the people seems to play a role in how CT are used. Quite a few of the participants prepared teas. They voiced that was how they were told to use the bush. The use of teas was also evident in the literature.
Researchers (Scott, 1998; & Smith, 2012) have recorded the use of bush teas to complement conventional medicine. Lowe et al., (2012) asserted that culture influenced the use of CT in Jamaicans.
Several key participants relayed that bush medicine on its own is not effective, but also requires them to make conscious decisions, combining traditional and conventional medicine. On exploring the data in relation to Leininger’s Sunrise Enabler, the researcher sees a possible link to technological factors. Bush medicine is seen as a low technology option for treating diabetes. As the participants incorporated bush medicine they were involved in self-monitoring of their glucose levels. Self-monitoring of glucose requires a more sophisticated level of technology use.
The participants used low technology methods in how they used the bush for example: “Sprinkle it on things that I was eating (April); Just boil it like tea (June); and drink it like water (Octavia). Though they were not asked to describe their monitoring process, nor did they volunteer that information the glucose monitoring systems available tend to be relatively advanced technological devices. 117
Their recipes were simple. The recipes mainly included boiling. Boiling is also
relatively low-tech. A few participants used a blender, a more high-tech mode than boiling. Combining the plants also seemed to be a simple process because participants followed the recipes they were given. Hence, I would say both low and high technology methods were employed by these participants.
Generic/folk/emic care was the mainstay for employing CT in diabetes care by
Jamaican adults. Although there were general participants who gave advice about and supplied CT, the key participants in this study did not report consulting a professional provider or traditional healer. They followed the advice of “old folks”. They also prepared the plants themselves.
Based on their statements I think Jamaican adults in this study are attempting to preserve/maintain their cultural practices. They seemed to be acutely aware of the possible dangers of bush medicine but were committed to using the same. They also used integrative care. Their commitment to use CT led them to integrate blood sugar monitoring in their folk care.
Theme 2: Jamaicans Believe CT are Affordable Folk Care Promoted by People they can Trust
A large data pool was gathered that addresses the research question, why do
Jamaican people who live in South Florida include CT in their diabetes management. The theme Jamaicans believe CT are affordable folk care promoted by people they can trust emerged on analyzing the data. The rich data described under this major theme, when explored considering Leininger’s Sunrise Enabler, can align with several of the concepts.
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Cultural Values, Beliefs, and Lifeways was most prominent. May, Julio, and
Augusto described growing up in Jamaica and being surrounded by people who used and believed in bush. Furthermore, May, Marcus, Sara, Julio, April, and Octavia gave strong statements about their belief in bush and/or what causes illnesses including diabetes.
Participants talked about multiple benefits of CT for diabetes such as conditions such as cancer, high blood pressure, and high cholesterol. were useful to treat other health.
Participants wanted to lessen the side effects of conventional medicine, a concept described by authors including: Alvarado-Guzmán et al. (2009); Davis (1997); Scott
(1974); and Zayas et al. (2011).
Perhaps Biological factors affect the response to CT. Participants disclose their uncertainties about the results. They talked about how different plants may have varying results based on the individual using them. Several participants did not see immediate change or sustained change in their blood sugar control but believed so strongly in the bush that they continue to use them.
Kinship and Social Factors was also obvious. I found that most participants obtained bush medicine from friends or relatives. This affirms what was revealed in the literature that in Caribbean people, CT and related services started in the home and then may extend outside depending on results that were achieved (Scott, 1974; & Davis,
1997).
I think Educational factors interplay here. The participants talked about their experience with bush medicine. Participants talk about experimenting with treatment types or doses. The folk care system is strong and friends and family, and in particular
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elderly people teach the younger generation about CT to perpetuate its use for future
generations.
Interestingly, the participants in this study had diverse ideas about what causes
diabetes. However, their ideas about the root of diabetes did not seem to influence their
use of CT. Use of CT to treat diabetes in this study population might be a function of
their Care Expressions, Patterns and Practices.
Theme 3: Jamaicans Use Traditional Folk Remedies for Managing Diabetes
Question three, what are the CT used by Jamaican people with diabetes who live
in South Florida, is answered by theme three seen above. Though many different plants
were used by Jamaicans with diabetes, some were more commonly used. The most
frequently named was cerasee (bitter melon). Other plants such as Aloe vera, moringa, and soursop were also mentioned a few times.
Considering the social structure factors of the Sunrise Enabler, I see a link with technological factors. I see bush medicine as a low technology option for treating
diabetes. Again, simple low-tech recipes were mainly used in preparing the plants. Using
single plants may not have required any technological savvy.
Bush medicine was described as natural medicine, the good old herbs,
homeopathic remedies, natural stuff, bush tea, and alternatives. Julienne described bush
medicine as plant chemicals. Tony, a general participant used terms such as alkaline, anti-
oxidants, and blood-builder to describe several plants. Though all participants did not use the same bush or think the same way about each bush, the way most of them described or
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named the plants led me to conclude that language is important to the way culture is
expressed in this group.
Ethnohistory may explain to some extent the use of CT for diabetes in this group
of people. Historical events and facts can influence lifecare about culture (Leininger, as
cited in McFarland, 2018). Several of the herbs that the Jamaican participants in this
study talked about were discussed in the literature over periods of time: aloe vera
(Delgoda, 2012; Lans, 2006; Mahabir & Gulliford, 1997; Picking et al., 2011; Smith,
2012; & van Andel & Westers, 2010); papaya (Clement et al., 2015; Giovannini et al.,
2016; & Lans, 2006); periwinkle (Clement et al., 2015; & Mahabir & Gulliford, 1997);
citrus (Mahabir & Gulliford, 1997; & Picking et al., 2011); and cerasee/caraili/bitter
melon (Caban & Walker, 2006; Giovannini et al., 2016; Lans, 2006; Mahabir &
Gulliford, 1997; Picking et al., 2011; Smith, 2012; & van Andel & Westers, 2010).
On exploration of the literature related to CT use in peoples of Jamaica or the
Caribbean, no reference was found that described bush medicine as chemical, antioxidant, or alkaline. Hence that is a new finding in this study. Based on the descriptions in the data the researcher believes again that Language might be a factor here.
Theme 4. Jamaicans are Willing to Try Folk Care in the Face of Uncertainty
How do Jamaican people who use CT describe how they know what CT are
appropriate? The short answer is, Jamaicans are willing to try folk care in the face of
uncertainty. Theme four sums up the responses of the participants.
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Jamaicans commented that they learned about CT though people they trust. Most
were older folks. This was one way they described how they know the CT they were
using was an appropriate selection. The related concept from Leininger’s Sunrise Enabler
that supports what the data conveys is Kinship and social factors. This was an important
commonality found in the data. Bush medicine was generationally imparted from the
grandmothers and older people in the communities.
Participants also declared that the characteristics of the plants they used were an
indication of their appropriateness in diabetes management. One of the characteristics
that stood out was bitterness because it was said by several participants. The bitter plant
most often named was the cerasee (bitter melon). Cerasee was used by Jamaicans and
other Caribbean peoples as stated by the following authors: Caban & Walker (2006);
Giovannini et al. (2016); Lans (2006); Mahabir & Gulliford (1997); Picking et al. (2011);
Smith, 2012; and van Andel & Westers (2010).
Jamaicans acknowledged that the results may not be the same among individuals
and that they experiment to determine the appropriateness of CT they opt to use in diabetes management. I could not see a connection with the Sunrise Enabler. There was also no link to the literature.
Theme 5. Jamaicans Use Self-management Strategies Trusting the Wisdom of the
Elderly.
Jamaicans who use bush medicine in diabetes management trust the wisdom of the elderly. This theme answers the research question, how do Jamaican people describe or report evidence that the CT they use for DM work to reduce or improve their symptoms of the disease. Ethnohistory and Kinship and Social Factors of the Sunrise 122
Enabler can relate. Participants denoted that these therapies have been around a long time and they were passed down from old people. They trusted their source of information, and so valued the CT.
Aside from the trust they placed in their kinfolk they monitored their blood sugar and A1C levels. Self-monitoring habits were practiced by most participants who used bush medicine; whether they used the bush concurrently or alternated it with the conventional medicine. Therefore, I would say, Technological factors and Professional
Care-Cure Practices were used. There was no mention in the literature that Jamaican or any other Caribbean group monitored their sugar or A1C levels while using CT.
Implications for Nursing
Nursing Research
Nurse researchers have an ethical obligation to maintain privacy and protect their participants’ data. Still it can create a dilemma for nurse researchers whose obligation to caring for people leave them with concerns about how to ensure people who use bush are safe. Therefore, findings from this and similar studies should be translated and disseminated through channels that lay people can access. Emphasis on translated so that people do not use the information inappropriately because of their personal interpretation.
The nurse researcher will want to conduct systematic reviews to discover more about effective herbs, how herb interact, and how herbs and drugs act upon each other.
Complementary therapies that can be verified as effective and safe are gaining acceptance by the WHO and US government. Nurses should partner with other disciplines in conducting clinical research to verify the safety and efficacy of bush.
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Findings from this study cannot be generalized, however nurses can conduct
similar studies with other culture sharing groups to explore if similarities exist within the
findings. This study consisted of a relatively small population. It would be interesting to
see how the findings would compare with a larger sample size, or with a similar
population in different settings. Retrospective studies can be done including Jamaican
people who used popular or personal recipes while monitoring their sugar to see what
kinds of effects these recipes had on their diabetes.
Nursing researchers should create instruments that allow accurate documentation of the participants’ ethnicity and/or how they identify themselves. Mixed methods research would add dimensions to the responses of participants and could incorporate the instrument mentioned above.
Nursing Practice
For 17 years nurses have consistently maintained the position of “most trusted professionals” (GALE, 2019, p 1.). Nurses are in the perfect position to serve as cultural brokers to stem the divide between conventional medical providers and the culture-
sharing group. Nurses are constantly educating clients and should use every opportunity
to discover the cultural orientation of their clients, so they can provide the most
appropriate care in a safe caring environment.
It is important that the values and beliefs of all are honored while employing
means to minimize or eliminate harm. Leininger’s theory of culture care diversity and
universality can be used as a guide. Leininger’s action modes can be used when it is
determined that the client/s is/are oriented toward using complementary therapies. The
nurse will assess and collaborate with the individual or group using these forms of
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therapy. For example: Some herbs have proven efficacy for lowering blood sugar. The
nurse may accommodate and/or negotiate with clients with diabetes to include herbs that have proven efficacy and are not contraindicated because of compounding issues (other health conditions, side effects, etcetera). There would be ongoing exchange between the nurse/cultural broker and the individual or cultural group so they would be aware of the likely outcomes including beneficial care, disability, or death as consequences of the therapy selected. The individual may suffer ill-consequences if the treatment selected is not appropriate for him/her. Implementing culturally congruent care may also aid in satisfying the aims of the National Institutes of Health (NIH, 2015), which includes ensuring that all people have access to the best care possible without any form of discrimination.
Jamaicans follow individualized and diverse folk care patterns while using CT describes how the participants use CT for managing diabetes. Several of Leininger’s culture and social dimensions seem to be applicable to how the group operated. Nurses can use these findings to create integrative environments of care where culture care can be preserved or maintained.
Jamaicans believe CT are affordable folk care that they can trust. The nurse should be willing to learn from the client. When the nurse learns the lifeways of the people she/he will know what is truly important to the client and can provide the best care. She/he will be able to encourage disclosure about use of bush and concerns about bush medicine. Nurses who examine their personal perspective and acknowledge any biases they hold with regards to CT use might find it easier to establish a collaborative
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client-provider relationship with persons who use CT. That might be an important step on the continuum toward cultural congruence in care.
Jamaicans use traditional folk remedies for managing diabetes, for the most part thinking they are pure and natural. They had history with these things. Nurses can create history with their clients by showing interest in their personal histories and language. In doing so the nurse will be able to negotiate with the client if there are concerns about the overall health effects of folk care.
Jamaicans are willing to try folk care in the face of uncertainty. That is profound.
The Jamaicans who include bush medicine for diabetes management were demonstrating self-care tactics to improve their condition and lifeways. Kinship seemed to be important.
Nurses should establish a trusting working relationship with clients, so they will feel supported and cared for. The client will likely be more open to culture care repatterning and/or restructuring in case of an inappropriate selection of CT.
Jamaicans use self-management strategies trusting the wisdom of the elderly. The people they trust are those they likely felt were supportive, enabling, and who assisted them to improve their diabetes. In other words, these are likely the people they felt cared for them. Nurses of different cultures can reach the Jamaican/Caribbean client by establishing that trusting relationship they seek, again, by creating history and building kinship with the client.
Nursing Education
Jamaican adults with diabetes who use bush/complementary therapies (CT) in management of their diabetes rely on people they trust to advise and direct them where to obtain and how to use CT. The Jamaican adults who participated in this study describe
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their relationship with caring others; the trusted old folks who educated them about bush medicines and who served as role models by their longevity and healthy lifestyle. The study participants relied on role models in their communities. Therefore, nurse educators should implement teaching strategies that allow nurses to teach their patients by example.
Nursing curricula should include simulation sessions geared toward modeling culturally congruent care.
People who use low-tech methods also appreciate high-tech solutions. Therefore, nursing educators can impart to their students how to use media such as YouTube and
Facebook to educate people who bush medicine about ways they can protect their health.
Nursing informatics (NI) is interwoven throughout nursing curricula. NI programs should teach students effective use of social media as teaching tools.
A few participants in this study admitted that they had questions about the outcome of using bush. The nurse should also have available resources such as charts and tables from reputable sources that describe drug-herb and/or herb-herb interaction to help guide the health choices made by people. Charts such as Table 4 should be included in nursing text books and or online teaching resources.
Nursing Policy
The nurse in the policy settings will be active in the healthcare reformation process, promoting culturally congruent care. Nurses can use the results of high-quality research studies to guide policy creation that will benefit adults with diabetes or other chronic diseases who use CT. However, since there may be people with different persuasions within any culture-sharing group policies implementation should be flexible.
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Nurses can align themselves with lobbying groups that are committed to advancing and sustaining inclusion of cultural diversity in care. One thing that can be done is to encourage inclusion of people in the culture sharing group to be present and be a part of the policy formation. For example, at least one Jamaican adult with diabetes mellitus who incorporates CT in their diabetes care should be on a panel to discuss what are some of the things they think can be done to improve their access to culturally appropriate care.
Participants were hesitant to disclose their use of CT. If there were written policies in place to protect the rights of patients who opt to use CT, then perhaps they would be forthcoming with the conventional medical providers. Therefore, a bill could be instituted, or it could be written in the patient’s bill of rights that they should have the right to treatment options, monitoring, diagnostics and referral services without prejudice if they opt to use CT.
Study Limitations
The focused ethnography is an excellent way to obtain thick description in a
limited timeframe. However, the limited time also presented challenges. It was a
challenging feat building trust in the field in the relatively short time in which the
participants were recruited and the interviews conducted.
This study used a non-probability sampling strategy. Therefore, the persons
who could participate were limited to those who met the inclusion criteria. The
quality and quantity of the data may have been limited based on the participants who
were willing to share their narratives. The study took place in a relatively small urban
area in South Florida, possibly limiting the quality and quantity of the responses. 128
Other limitations were presented by the location. South Florida is closer to
Jamaica than many other states. Therefore, the researcher might find more individuals
in this location that are using Jamaican bush. South Florida has a subtropical climate
that may also make it more likely for participants to grow or have access to similar
herbs/bush/plant that they could obtain in Jamaica. In addition, it might have been
easier for South Florida residents to obtain plants from Jamaica. Participants who live
in another climate, a different urban setting or in a rural area, or with vastly different
soil topology might not have similar experiences with bush. Therefore, their
responses to the questions might have been different.
An interesting limitation found in this study is the language. English is the
official language of Jamaica and was spoken by all the participants. However,
anecdotally when Jamaicans get comfortable with other Jamaicans then the Jamaican
dialect ─Patois─ is spoken freely among them. The participants in this study would
start out speaking standard English then would break into episodes of Patois as they
got comfortable with the researcher. Though the researcher speaks Patois she used
Cassidy and Le Page (2002) Dictionary of Jamaican English for consistency in
spelling the words.
Recommendations for Future Research and Culture Care
The participants valued community and self-management was very much a part of their therapy as they practiced cultural traditions. Therefore, the use of community based participatory research (CBPR) in future research efforts is recommended. The study population will be partners in the research process and will likely feel more appreciated.
The results will also lead to direct benefits as the participants will make
129
recommendations and be a part of the implementation process regarding how to meet their cultural needs because of their involvement in the whole process.
Translational research is designed to improve health outcome. Based on what is already known from past studies and what was uncovered in this research, researchers may design translational research to fill identified gaps in knowledge. Community based participatory research can also include a translational component.
This study focused on Jamaicans living in South Florida. Future research can be done on a larger sample encompassing Jamaicans in diverse places various countries. The larger sample will allow the researcher to see how similar or different are the cultural practices of these people. Future studies can also compare the practices of Jamaicans living in Jamaica with those living in various parts of the US. An international internet survey of Jamaicans could also be done. Possible research questions are included below.
1. Use of voice journaling to explore diabetes symptom management in
Jamaican adults with diabetes mellitus who use bush medicine
2. Pilot testing of an instrument to assess resiliency in Jamaicans adults with
diabetes mellitus who use bush medicine
3. An examination of the self-monitoring habits/activities of Jamaican adults
with diabetes who use bush medicine
4. Exploring perceptions about the ability of bush medicine to prevent
diabetes complications in Jamaican adults
5. How does social determinants of health impact use of bush medicine in
Jamaican adults across America?
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6. Analyzing trends in A1C and stability in diabetes symptom control over
time in Jamaican adults who use bush medicine routinely.
Summary
Thirteen persons contributed to the important data collected in this dissertation.
The best effort was made to interpret the data to explain the participants inside view. The researcher then had to be aware of personal biases and avoid becoming native in the research; a feat that was not easy because the researcher is Jamaican and has been exposed to CT. However, as an ethical trusted professional it was imperative to the integrity of the research to maintain that stance.
The narratives provided by the participants were rich and infused with enthusiasm
for the way they practiced self-care. The interpretation of the data added depth to the
ethnographic report by using Leininger’s Sunrise Enabler to the Discover Culture Care.
This study contributed to the researcher’s discovery of self through the reflexive journal.
The researcher was able to uncover some of her personal biases that could hinder culture
appropriate care.
Despite the current existence of conventional medicine, traditional medicine is
very much a part of the practices that are valued by Jamaicans living in South Florida. A
few of these Jamaicans have concerns about the effects of bush on their health. However,
despite their concerns, Jamaicans persist in their use of bush medicine within their
diabetes care. Use of complementary therapy by Jamaican people may satisfy their
holistic viewpoint, while preserving their belief about the efficacy of the same.
The researcher uncovered that the relationship between the participant and the
conventional medical provider was not one that fostered trust and caring. Meanwhile,
131
trust, self-care, and social interactions were appreciated by the Jamaican adults represented. These constructs tell that the participants yearn for and cherish communion, communication, and community engagement as they manage their condition. They want healthcare providers that share their enthusiasm for bush medicine and understand their fears and inhibition about taking synthetic medications. None of the participants in this study spoke about contacting a traditional healer to obtain herbs.
The participants who continue to use bush despite uncertainties about effects are willing to face the consequences of their actions, knowing that as one key participant stated, they are doing it at their own risk. In developing her theory of Culture Care
Diversity and Universality, perhaps Leininger recognized the risks people were willing to take for the sake of maintaining cultural norms. Hence, her inclusion of “face disability or death” in her culture care decision modes.
The data show that this small sample of Jamaican adults have combined traditional medicine with conventional medicines to try to combat the effects of diabetes.
Their practice follows patterns that they learn through socialization and reinforce through practice. The revelation of their thoughts about what complementary therapies do for diabetes mellitus conjures images that Caribbean people operate from a holistic point of view.
The major themes resulting from the data are: Jamaicans follow individualized and diverse folk care patterns while using CT; Jamaicans believe CT are affordable folk care promoted by people they can trust; Jamaicans use traditional folk remedies for managing diabetes; Jamaicans are willing to try folk care in the face of uncertainty;
Jamaicans use self-management strategies trusting the wisdom of the elderly. The themes
132
while separate are not detached from each other. The researcher thinks that these themes address the study objectives and answers the research questions.
That no equivalent to most of the themes developed were found in the literature is not surprising since this research seeks to add new knowledge. As a reminder the central question was, how do Jamaican adults with diabetes mellitus who live in South Florida select and use complementary therapies for managing their diabetes.
Nurses should therefore aim to partner with their clients while continuously learning about cultural lifeways; actively participating in policy decisions for advancing culturally congruent care; educating others about known CT that can be safely implemented in care of clients with diabetes; and creating safe practice environments to meet client’s needs. The findings will contribute to healthcare providers’ abilities to educate themselves, mentor prospective cultural brokers, plan and execute relevant policies, design future research, and apply practice approaches for safe culture care of
Jamaican adults who use CT in their diabetes management.
133
APPENDICES
134
Appendix A. Adult Consent Form
135
Appendix B. Recruitment Flyer
136
Appendix C. Script for Verbal Advertisement
137
Appendix D. Sociodemographic Questionnaire
Date: ID #: Site ID:
1. Age (Date of birth MM/DD/YYYY) 2. Sex/Gender 1) Female 2) Male 3. Country of birth 4. Years in the USA 5. Years of education 1) Less than 7th grade 2) 7th grade - 9th grade 3) 10th grade – 11th grade 4) 12th grade 5) Partial college or specialized training 6) College or university graduation 7) Graduate college 6. Insurance type 1) Public 2) Private 3) None 7. Employment status 1) Employed 2) Out of work 3) Unable to work 4) Retired 5) Other (please specify) 8. Household Annual Income 1) ≤ $ 15,000 2) $15,001 ~ $25,000 3) $25,001 ~ $35,000 4) $35,001 ~ $50,000 5) ≥ $50,001 6) Prefer not to answer 9. Marital status 1) Never married 2) Married 3) Divorced 4) Separated 5) Widowed 6) Common-law 7) Others 10. Primary religious belief 1) None 2) Catholic 3) Protestant 4) Jewish 5) Muslim 6) Buddhism
138
7) Other (please specify) 11. Self-identity 1) Jamaican 2) American 3) Other (please specify)
139
Appendix E. Letters of Cooperation
140
141
Appendix F. Florida Atlantic University IRB Approval
142
143
Appendix G. Sample Interview Guide
12. When were you first diagnosed with diabetes?
13. How did you feel when your doctor first told you that you have diabetes?
14. What was your initial reaction when your doctor said you have diabetes?
15. Did your doctor immediately prescribe medications to treat your diabetes? If no,
what was the original plan. If yes, what medication/s were prescribed?
16. Did you fill your prescription or take the medication immediately? If not, why
not?
17. Did you try any home remedies or other treatment?
18. Where did you get information to try this?
19. Who suggested it/them?
20. What did they tell you?
21. What did you use first?
22. Do you use, or did you use that along with what the doctor prescribed?
23. How frequently did you use it/them?
24. How did you use it/them?
25. What do you use for your diabetes that is not prescribed by your doctor?
26. Why did you think of using … in addition to what was prescribed?
27. When did you start using …?
28. Do you use anything else? What other things do you use
29. When did you start using?
30. Why did you choose …?
31. How do you know that it/they are helping with your diabetes?
144
32. What would/will you do if it/they do not help?
33. Did you always use…?
34. What led you to continue or discontinue?
35. What did you use before?
36. Why did you change?
37. Why do you use these things together?
38. How did you know what to use?
145
Appendix H. Permission to Use Leininger’s Sunrise Enabler
146
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