Indigenous Diabetic Foot-Related Lower Extremity Amputations: Integrating Traditional Indigenous and Western Health Models for Improved Outcomes

Many Indigenous peoples worldwide face health inequities, poor healthcare access, and culturally discontinuous health services.1 This legacy stems from colonialism and racism, including the systematic suppression of traditional Indigenous health knowledge and healing practices.2 In 2015, the Truth and Reconciliation Commission of Canada3 detailed the urgent need for full healthcare rights for Canadian Indigenous Peoples (CIP) encompassing the elimination of disparities; removing racist processes from the health sector; and integrating traditional knowledge, therapies, and healing practices. Age- and sex-adjusted prevalence studies demonstrate strikingly disproportionate rates of diabetes mellitus and diabetic morbidities among Indigenous populations internationally (including CIP).4–6 This includes a high incidence of diabetes-related major lower extremity amputations (LEAs).4–8 Risk factors include peripheral vascular disease, neuropathy, end-stage renal disease, and foot and ankle deformities. Those CIP living on reserves also have a higher incidence of foot ulcers and shorter times to major LEA.7–10 The LEAs among CIP may be up to 16 times more frequent than in the general population.6 Diabetic foot complications create numerous burdens on healthcare systems, such as frequent outpatient visits, hospitalizations, ED visits, and medical transport for patients requiring specialty care. Unmet needs include limited access to primary health and specialist care; inadequate home care; incomplete resource infrastructure, such as the lack of clean running water in homes;5 and language, and knowledge, and transportation barriers. Serious calls to action include adequate funding for interprofessional programs focusing on improved preventive care and proactive practices to reduce morbidity and cost of care.5–7 Key program elements are patient education, improved glycemic control, healthy nutrition, and access to foot care and screening. The delivery models could include nursing-led education and on-site or traveling preventive foot screenings.7,8 Access to vascular assessment and revascularization must be integrated into regional amputation prevention efforts for all individuals with diabetes, especially within the Indigenous population.11 Despite available solutions, the siloed approaches to prevention and management often taken in mainstream and Westernized health models risk continued poor outcomes among CIP, who have historically perceived and addressed health in their own traditional ways. A predominantly biomedical approach to health fails to address the myriad needs in an integrated and holistic matter.12 There is a need for Indigenous and general health model coinclusion, with Indigenous engagement and empowerment reflecting realities of what is now clearly understood as a complex and dynamic interplay of social, political, historical, cultural, environmental, economic, and other forces. Ultimately, health indicators must be Indigenous-specific and community-driven for health planning and action and must account for Indigenous peoples’ holistic worldviews, histories, and resources. Traditional health, viewed in a balanced and holistic way, not only connects physical, mental, and psychosocial dimensions, but also emphasizes spiritual aspects and interconnectedness. Healing specialists, Knowledge Keepers, and Elders who understand Indigenous cultural worldviews and determinants of health are increasingly needed in medical partnerships, decision-making processes, and wound-related patient care. Disjointed approaches13 and limited access to care14–16 remain in many regions of North America, with the largest burdens present in northern and remote Canadian Indigenous communities. Approaches to reduce amputations and address diabetic morbidities need to be tailored to regional circumstances.17 Novel approaches include the microcredential courses at Sault Ste Marie College, Ontario, Canada. These interactive, interprofessional educational sessions include both the Indigenous community and healthcare stakeholders. The content is focused on skin and wound care in persons with diabetes and the need to service remote and northern populations. This project may serve as a launch point for future focus groups and education linked to improved interprofessional support for diabetic foot care and reduced amputations in Canada. There is a need to equitably save the limbs and lives of Indigenous persons with diabetes worldwide. References are available as supplemental digital content at https://links.lww.com/NSW/A#. Rachel Asiniwasis, MD, MS(HS), FRCPC, FAADA. Blair Stonechild, PhD, Professor and Knowledge Keeper ElderDouglas Queen, PhD, MBAR. Gary Sibbald, MD, MEd, FRCPC, FAAD, JM

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