Integrating conventional science and aboriginal perspectives on diabetes using fuzzy cognitive maps

Abstract

There is concern among Aboriginal communities in Canada that conventional approaches to the treatment of diabetes are ineffective in part because they fail to recognize the local Aboriginal perspective on the causal determinants of diabetes. While this shortcoming has been recognized, there have been no explicit attempts to practically define these perspectives and prescribe how conventional health management might be altered to incorporate them. In part, this may be due to difficulties in communicating Aboriginal perspectives in a manner which permits incorporation into conventional science-based frameworks. Here we use fuzzy cognitive mapping (FCM) as a technique to represent and compare Canadian Aboriginal and conventional science perspectives on the determinants of diabetes as contained in published articles drawn from a search of Medline and PubMed (1966–2005). The FCM allows for a detailed description of the complex system of culture, spirituality and balance at the root of the Aboriginal view. It also highlights how, for these less tangible factors, it is possible to identify more concrete stressors and outcomes which are amenable to management and monitoring. This preliminary comparison of conventional and Aboriginal views also demonstrates the potential for FCM as a technique to extract, compare and integrate perspectives of different knowledge systems into health management and policy development.

Introduction

The health of Aboriginal communities in Canada is generally lower than that of comparable non-Aboriginal communities. In particular, non-insulin-dependent diabetes mellitus (Type 2) (NIDDM) rates are significantly higher among Aboriginals compared to the general Canadian population (Bruce, 2000; Young, Reading, Elias, & O’Neil, 2000;) especially for Aboriginal women (Green, Blanchard, Young, & Griffith, 2003; Kelly & Booth, 2004) and children (Dean, 1998; Harris, Perkins, & Whalen-Brough, 1996). Diabetes prevalence in Aboriginal communities continues to increase, despite being a priority concern for health agencies (Health Canada, 2000).

Diabetes is seen as a new disease within Aboriginal communities, predominately linked to the move away from traditional hunter-gather to a more western lifestyle (Gracey (1995), Gracey (2000); O’Dea, 1991; Zimmet, 1979; Zimmet, McCarty, & de Courten, 1997). The conventional scientific view is that adoption of a western lifestyle has led to decreased physical activity, increased prevalence of obesity, and major shifts in diet. These factors, potentially overlaying a genetic susceptibility, have resulted in the observed increases in diabetes incidence (Ben-Haroush, Yogev, & Hod, 2004; Daniel, Rowley, McDermott, & O’Dea, 2002; McDermott, O’Dea, Rowley, Knight, & Burgess, 1998; Rowley & O’Dea, 2001; Young et al., 2000).

For many Aboriginals, however, conventional science fails to recognize the true root causes of diabetes: a life out of balance due to the loss of traditional lifestyles, community, culture and spirituality (Garro, 1995; Iwasaki, Bartlett, & O’Neil, 2005; London & Guthridge, 1998; Thompson & Gifford, 2000). There is, furthermore, evidence that within Aboriginal communities there is a belief that the determinants of diabetes are beyond individual control (Gregory et al., 1999; Potvin, Cargo, McComber, Delormier, & Macaulay, 2003); this contrasts sharply with the conventional view that emphasizes individual lifestyle choices such as diet and physical activity.

These perceived differences between Aboriginal and conventional scientific perspectives on health reduce the likelihood of success of diabetes prevention programs based solely on the science perspective. The perceived lack of control over diabetes, for example, has been identified as a barrier to treatment and prevention aimed at individual lifestyle changes (Bisset, Cargo, Delormier, Macaulay, & Potvin, 2004; Daniel et al., 1999; Daniel & Messer, 2002; Garro, 1995; Gregory et al., 1999).

The integration of traditional Aboriginal and conventional scientific knowledge (SK) in diabetes management faces several hurdles. Particularly problematic is the way in which knowledge is stored and transmitted. Traditional knowledge (TK) is generally seen as being held collectively in a largely qualitative form (Gervais, 2003). In comparison, conventional SK is predominately based on quantitative evidence, and often restricted to a small group of experts. The difficulties associated with measuring or manipulating the socio-cultural and spiritual determinants of diabetes also limits their contribution to conventional science-based treatment and prevention programs (Wilson & Rosenberg, 2002).

The Mohawk Council of Akwesasne (MCA) and the Institute of the Environment, University of Ottawa have undertaken a project to incorporate the local Aboriginal perspective of diabetes into health policy. The first step was to articulate the views held by the Akwesasne community and compare them to those held by members of the conventional scientific community. In what follows, we refer to the former as TK, the latter conventional SK, even though it is clear that TK may include strongly scientific elements (i.e., systematic observation, hypothesis formulation and prediction). Here fuzzy cognitive mapping is used to represent and compare TK and SK with respect to the causal determinants of diabetes and demonstrate how FCM may be used to explore the impacts of different management scenarios, given the articulated causal relationships in a given knowledge domain.