|Year : 2022 | Volume
| Issue : 2 | Page : 214-222
Factors influencing the emergence of self-reliance in primary health care using traditional medicine: A scoping review
Shivanand Basappa Savatagi1, Prashanth Nuggehalli Srinivas2, Unnikrishnan Payyappallimana3
1 PhD. Scholar, The University of Trans-Disciplinary Health Sciences and Technology; Faculty and Assistant Director Research, Institute of Public Health, Bengaluru, Karnataka, India
2 Faculty and Assistant Director Research, Institute of Public Health, Bengaluru, Karnataka, India
3 Visiting Professor, The University of Trans-Disciplinary Health Sciences and Technology, Bengaluru, Karnataka, India
|Date of Submission||30-Sep-2021|
|Date of Decision||15-Feb-2022|
|Date of Acceptance||16-Feb-2022|
|Date of Web Publication||12-Jul-2022|
Shivanand Basappa Savatagi
The University of Trans-Disciplinary Health Sciences and Technology, 74/2, Post Attur via Yelahanka, Jarakabande Kaval, Bengaluru - 560 064, Karnataka; Institute of Public Health, 3009, II-A Main, 17th Cross, Krishna Rajendra Rd, Banashankari Stage II, Bengaluru - 560 070, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Self-reliance is the responsible behavior and the ability of an individual to take care of one's own health using local resources. A substantial proportion of the population use traditional medicine (TM) for primary health care (PHC) in low- and middle-income countries (LMIC). The underlying philosophy of the TM approach is self-reliance due to its emphasis on culture, traditions, customs, and local resources. Given the complexity and ambiguity of how self-reliance emerges, there is a need to have clarity in its understanding and the practice in relation to TM. Hence, we conducted this review to synthesize the factors determining the emergence of self-reliance in PHC using TM in resource-poor settings with a specific focus on LMICs. We searched PubMed, Google scholar, and the Social Science Research Network databases, and conducted reference tracking of selected articles. We included articles published between 2000 and 2020 May. Thematic analysis was done using QDA-miner Lite software version 2.1. We retained 29 papers for review and analysis. A conceptual framework was developed that located factors influencing the emergence of self-reliance. Self-reliance manifests through a socially constructed interaction between factors from the macro (policy and environment) to the micro context (community and household). Due to the lack of explanatory models, there is a substantial gap between understanding self-reliance and its application in health policy and practice. Achieving comprehensive PHC and universal health coverage requires policy provisions to create an enabling environment in health-care facilities, communities, and households that allows the emergence of self-reliance.
Keywords: Primary health care, scoping review, self-care, self-reliance, traditional medicine
|How to cite this article:|
Savatagi SB, Srinivas PN, Payyappallimana U. Factors influencing the emergence of self-reliance in primary health care using traditional medicine: A scoping review. Indian J Public Health 2022;66:214-22
|How to cite this URL:|
Savatagi SB, Srinivas PN, Payyappallimana U. Factors influencing the emergence of self-reliance in primary health care using traditional medicine: A scoping review. Indian J Public Health [serial online] 2022 [cited 2022 Aug 18];66:214-22. Available from: https://www.ijph.in/text.asp?2022/66/2/214/350667
| Introduction|| |
It is estimated that 65%–85% of all health care is provided by the individual or the family without professional assistance using either nonallopathic or allopathic health interventions. The illness process begins with personal awareness of a change in body feeling and that gets labeled as a disease by self or by family. The philosophy of “self” can be traced to ancient systems of medicine in India. Ayurveda's focus of health within the self is reflected in the Sanskrit word for health, “Svasthya” (”Sva,” the “self”); it means being established in oneself, a deep state of self-awareness. Thus, the philosophy of self in health is not a new approach rather a continuous approach that has been in practice by individuals, families, and communities irrespective of its recognition in the health system. However, within the concept of self, often, terms such as self-care, self-efficacy, self-reliance, and self-management [Supplementary File 3] are used interchangeably in literature reflecting ambiguity, diversity, and its wide application in different fields.,
In many low- and middle-income countries (LMICs), the practice of traditional medicine (TM) is an important source of primary health care for several individuals and households. For instance, in India, more than 70% and around 80% in African countries use TM for primary health care (PHC)., With its emphasis on local resources, culture, traditions, and beliefs, the TM interventions designed for PHC often link self-reliance in its approach. Hence, we considered TM interventions as an opportunity to conceptualize self-reliance in relation to TM.
The scope of self-reliance is viewed in a wider context of sustainable development, localization, indigenous participation, and PHC. Hence, various community development programs and global health initiatives emphasized community participation with the main aim of enabling self-reliance. For instance, the 1978 Alma Ata Declaration and the first National Health Policy (NHP) of India in 1983 stated that the success of PHC depends on community participation and individual self-reliance. The period of 1990s witnessed an avalanche of self-reliance projects in response to the impact created by structural adjustment program policies. Self-reliance as a concept continues to attract the attention of policymakers and implementers even during the postneoliberal period as an effort toward achieving health as a larger social goal to reduce inequalities and inequities.
In the context of the health system, self-reliance is about the decisions made at the individual level. These decisions are influenced by various social, economic, political, and human agency factors. However, historical perspectives of self-reliance revealed that it is predominantly viewed from a resource availability perspective which reflects a narrow understanding and application of a complex social construct. Hence, there is a need to expand our analytical understanding of the systemic underpinning of self-reliance in health policy and systems practice.
The early 21st century witnessed developments in community health, TM, people-centred approaches, and sustainable initiatives in a more systematic way with the focus of enabling self-reliance. For instance, TM strategy 2002–2005 and 2014–2023 mentions the integration of TM and self-health care., In India, NHP 2002 and 2017 also resonate well with this., Hence, we included literature from the year 2000 to 2020 May to look at the recent developments about self-reliance.
This review is part of a research agenda for developing a self-reliance framework for PHC consisting of TM interventions. Scoping review is a type of knowledge synthesis used for topics that are interdisciplinary and underexplored., Hence, we considered scoping review as the best fit to synthesize the understanding of self-reliance.
| Objective and Review Question|| |
This study was to synthesize the understanding of self-reliance in PHC using TM in resource-poor settings.
What are the factors that enabled the emergence of self-reliance in PHC using TM in resource-poor settings?
| Methods|| |
We adopted the 2018 PRISMA scoping review guidelines and followed the steps as described under these guidelines.
Protocol and registration
The scoping review protocol was registered at Open Science Framework (OSF) https://osf.io/ycn2p for its scientific transparency and audit.
The ethical review of this study was not required because it solely used the data published in the literature.
| Identification of Relevant Studies|| |
Articles were searched systematically using keywords along with Boolean operators [Table 1]. Different databases were used based on their scope of coverage of articles. Only articles available through open access were included. Relevant articles from gray literature were also added using (1) Google and (2) websites of the institutions (nongovernmental organizations, private, and public) that worked on TM, PHC, local health traditions, and community development. The reference list of selected articles was scanned to identify relevant studies. The entire search process led to the selection of 401 articles [Table 1].
| Study Selection|| |
Inclusion and exclusion criteria
The inclusion criteria followed were that the articles should (1) describe the practice of self-care and self-reliance, community participation, PHC, and local health traditions, (2) be published between the year 2000 and 2020 May, (3) be peer-reviewed papers or book chapters, conference proceedings, and reports, (4) policy documents, and (5) be from LMICs. Articles published before the year 2000 and explained self-care and self-reliance as a concept alone but not including a practice element were excluded.
The screening process
The first author organized the articles and shared them with other authors for finalizing the selection. If disagreement, the consensus was sought on inclusion/exclusion. Steps are illustrated in [Figure 1].
| Quality Appraisal of Selected Articles|| |
Qualitative studies were assessed using Pope and Mays criteria. The main parameters assessed were clear explanation of sampling and study design, use of triangulation, respondents' validation, generalization, and relevance of the study. For quantitative studies, tools from Effective Public Health Practice were used, and parameters such as study design, clear explanation of methodology (sampling, study setting, control of possible biases, analysis, and the relevance of the study were assessed. For systematic reviews, Joanna Briggs Institute checklist was adopted and parameters assessed were clarity of the review question, clear explanation of search strategy, inclusion criteria, future directives for researchers, and relevance of the study. In respective tools, each of the parameters was assigned a score of “1” and the total score was 5. Articles with a score range 1–2 indicated poor, 3 – indicated average, and score with more than 3 indicated high quality [Supplementary file 2].
In the papers that used mixed method study design, major components (quantitative or qualitative) were assessed for quality as used previously by James et al. Policy documents were obtained from government official websites to ensure their authenticity.
Charting the data
Data captured were (a) year of publication, (b) author, (c) number of citations, (d) study design, (f) study setting, (g) levels of enabling self-reliance, and (h) factors influencing the emergence of self-reliance. The data were organized systematically in a spreadsheet and was discussed among all authors periodically.
The stored data were transferred to QDA-miner lite software (Provalis Research, Montreal, Canada) to code and create themes. Obtained themes were used to develop a conceptual framework [Figure 2].
| Results|| |
Descriptive characteristics of selected articles
The main characteristics of the 29 articles are presented in [Table 2]. Six (20%) were qualitative studies, five (16.67%) were review articles, four (13.3%) used a cross-sectional design, and three (10.01%) used a mixed method of study design. The majority of articles (11, 37.93%) were from the Asian region and 8 (27.59%) were from the African region, one review article captured perspectives on self-care practice from LMIC context, and two review articles captured perspectives on self-care practice from both high-income and LMICs.
|Table 2: Descriptive characteristics of selected articles [Supplementary file 1]|
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Different levels of enabling self-reliance
This review revealed that the interventions that targeted enabling self-reliance were implemented at the individual (personal and family), community, and at institutional levels. The interventions that targeted enabling self-reliance at the individual level were most represented (six papers) and the most underrepresentation was at the institutional level (one paper). This may be due to the complexity of institutional arrangements in implementing programs or interventions to enable the self-reliance of individuals or communities. The papers we reviewed described these levels in a combination of one or two levels, i.e., 10 papers described both individual and community levels and four papers described all three levels.
Factors influencing the emergence of self-reliance in primary health care
We adopted the Anderson model for health-care utilization to navigate the emergence of self-reliance. The model describes different factors (environment, predisposing, and enabling factors) that are involved in the health behavior while utilizing health-care services. Since self-reliance is also related to health behavior, we used this model as a guide to categorize different factors involved in the emergence of self-reliance. Structural and agency factors are the additional components included in our framework [Figure 2].
We further categorized environmental factors into health system factors and geographical factors.
Health system factors
The challenges of the conventional health system that focused on an institutional-based approach acted as push factors for adopting practices to enable self-reliance. Long distances to health facilities and long waiting times influenced opting for self-care. Having accessibility to medicine acted as a pull factor and led to self-medication using herbal medicine for acute and minor conditions.,
Health policies facilitate the practice of self-care and self-reliance by giving due consideration in their design. For instance, Indian NHP 2002 emphasized local self-government institutions for health interventions; Indian NHP 2017 mentions documentation of local knowledge, farming herbal gardens, and building the credibility of the alternative systems of medicine through evidence-based research., The Behvarz program in Iran is another policy approach for enhancing self-care through community participation and utilizing local resources.
At the global level, a conceptual framework for self-care interventions was developed by the World Health Organization (WHO). Global policy roadmap for self-care by Bayer and White ribbon alliance in the year 2018 recommended integrating self-care with health policy, encouraged evidence-based self-care practice, and strong public–private collaboration. WHO Package for Essential Noncommunicable Disease Interventions for primary care in low-resource countries recommends early detection, community engagement, and self-care practice by the people. WHO TM strategy 2014–2023 emphasized developing tools for educating and disseminating information about self-care. Thus, policies play a vital role in pushing states and institutions toward creating an enabling environment for the practice of self-care that further enables self-reliance, but studies that examined how these policies impacted practice were unavailable.
Geographical factors referred to the availability of TM in specific contexts or settings. Being near forests facilitated the practice of TM, particularly medicines based on medicinal herbs., To make easy accessibility of medicinal plants, many countries have implemented household and community-based interventions. For instance, successful integration models in countries such as Vietnam, the Lao people's Democratic Republic, and Thailand have established community herbal gardens to aid the practice of TM.
The majority of health practices including self-care vary depending on the age, gender, and stage of life of the individual. Elders appeared to be using TM more than other age groups., Age and gender factors were reported in two studies., There appears to be a lack of consensus on the influence of education on the practice of self-care.,, Occupational factors such as long or busy work hours and daily wage work hindered access to institutional health services which possibly were driving a choice for home-based interventions for acute and minor conditions.,
Traditional knowledge influenced the use of local resources.,,,,,, Such knowledge is sourced from within families (especially mothers and elders), community members, and also trained community health workers in settings where TM has been integrated into health service delivery. Apart from traditional knowledge, health literacy, i.e., information about the availability of health services,,,,,, lifestyle factors, and economic circumstances influenced the practice of self-care. The use of TM was observed mainly among families belonging to low socioeconomic status.,,, The interventions targeted at the household mainly incorporated lifestyle messages including the use of home remedies,,,,,, to enable self-reliance, for instance, family medicine box project by Nippon Foundation in Mongolia and home herbal garden approach by the Foundation for Revitalization of Local Health Traditions in India.
Community-directed interventions are considered the gold standard method for enhancing local participation through the involvement of people. Seven (24.1%) papers mentioned community participation as an enabler for the practice of self-care. Having a community health worker and self-help groups in the community were also identified as enablers. Seven (24.10%) articles identified the presence of local health workers as an important enabler for the self-reliance of the community.,,,,,, Community health programs such as ASHA program under NRHM in India, village midwife program in Indonesia, community midwives program in Sri Lanka and female community health volunteer in Nepal, Behvarz community health program in Iran, and traditional knowledge and conservation of local biodiversity project by Globinmed organization in Malaysia are few examples that facilitated the participation of people and promoted the use of local resources.
Household and community factors cannot be seen in silos since they influence each other. For instance, households with traditional knowledge contributed to community health through shared learning, and also, the presence of community health workers helped in building the capacities of families in taking care of their health.
| Structural Factors and Agents|| |
The response to an illness stems from how an individual perceives and experiences it. This understanding of illness or disease is driven by culture, traditions, and social norms., They influence behavior, decisions, and actions related to health. For example, theism and mantra recitation, restrictions to certain foods, avoiding sexual intercourse during menstruation, and taking bath after attending a funeral were considered as part of self-care. Six articles (20.07%) mentioned culture and traditions as an influencing factor for self-care. Beyond structural factors, several attributes at the individual level (personal skills and abilities, self-efficacy, and moral values) which are in constant interaction with structural factors influenced decisions and actions. For instance, better health was always associated with good moral values,,, and these moral values were attributed by the societal consensus and adopted at the individual level. In this respect, people are not autonomous actors, nor is their behavior influenced completely by structural factors, rather it is an interplay between structural and agency factors. Thus, there are macro- and micro-level dynamic interactions including contextual factors that influenced the emergence of self-reliance. Our conceptual framework describes the interaction of different factors that are involved in the emergence of self-reliance in PHC using TM.
| Discussion|| |
Terms used interchangeably with self-reliance were self-care, self-management, and self-efficacy. We included all these possible terms in our search to tease out the differences between them. According to Fonchingong and Fonjong, self-reliance is defined as “A state of mind that regards to one's own mental and material resources as the primary stock to draw on in the pursuit of one's objectives, and finds emotional fulfilment not only in achieving the objectives but of having achieved them primarily by using one's own resources.” WHO defines self-care as “the ability of individuals, families, and communities to promote health, prevent disease, maintain health and cope with illness and disability with or without the support of healthcare provider.” Critical analysis of these two definitions shows that the use of local resources and seeking a balance between dependency and independency are commonalities between them. Self-care is an attitudinal component wherein major focus lies with an individual believing in his/her ability. Self-efficacy is confidence through which skills are manifested. The ability to manage physical and psychological consequences in the event of achieving self-care ability is called self-management. When an individual has achieved a stage of self-management, there is a state of mind of an individual who trusts his/her own skills, which is termed self-reliance. Hence, self-reliance is a broader concept and all other terms are precursors to it., Self-reliance incorporates three attributes, i.e., being responsible, disciplined, and confident. Factors described concerning the practice of self-reliance in our review resonate with other studies conducted in China and sub-Saharan Africa.,
Significance of different factors in the emergence of self-reliance
We identified that the distribution of traditional knowledge varied across age groups.,, The ability to use TM comes from both intellectual and experiential knowledge. Since knowledge of TM passes through intergeneration and word of mouth in the community, the level of education of an individual seems to be having less influence in the acquisition of this knowledge. Occupational factors identified in this review influenced the adoption of self-care practice, but these factors also highlight the failure of the health system to meet the needs of the working people.
Health system factors described in this review could act both as push and pull factors of self-reliance. While push factors such as unaffordability, nonavailability, and nonaccessibility could facilitate the practice of self-care, they also reflect systemic gaps which may not necessarily have chosen if there was a more equitable health system. On the other hand, if the practice of self-care is influenced by pull factors (easy accessibility, aligning with culture, values, traditions), they need to be strengthened for addressing issues of equity and equality. Hence, there is a need to take a close assessment of these factors while facilitating self-reliance. The articles included in the review described self-reliance as a resource-intensive strategy. However, mere making accessibility and availability of resources (health services, information, financial resource, medicines, etc.) may not result in self-reliance since there are structural and agency factors influencing its emergence. These factors are underrepresented in literature or explained in silos without proper linkage of macro- and micro-level contexts.
Need for differentiating different levels in the emergence of self-reliance
In this review, studies that described the specific pathways through which interventions enabled self-reliance at various levels (individuals [personal and family], community, or institutional) neither identified reasonable endpoints for determining the emergence of self-reliance nor identified how these could be sustained. Hence, we contend that there is a need for having a critical lens to categorize these levels considering overlapping and interaction of different factors within these levels.
Need for social science research methods
To understand practice-based evidence and the application of self-reliance, there is a need to relook at the conventional epidemiological methods that are used to investigate a complex phenomenon like self-reliance., The articles that we chose in this review mainly adopted a qualitative, cross-sectional, and mixed-method approach to explain self-reliance which we feel is insufficient. Experimental approaches and different scales were also used to generate evidence regarding self-care and self-reliance. However, due to its psychosocial construction and complexity as well as the context specificity, a social science research approach capturing lived experiences of people, their history, and social embeddedness could help to explain the interaction of various factors of self-reliance.
| Strengths and Limitations of the Study|| |
The main strength of this review is the conceptual framework which provided an understanding of self-reliance in PHC using TM. Limiting our scope to LMICs, PHC, and TM settings and the inclusion of select gray literature are our limitations. Self-reliance is socially constructed and the academic term self-reliance is a catch-all term for a variety of individual and community perceptions and practices, especially concerning TM. Hence, a more comprehensive effort at collating keywords that integrate the breadth of community practices concerning TM might have yielded a greater number of articles that better reflect the practice. The scope of self-reliance could also cover chronic conditions and mental health which has not been covered in our study.
| Conclusion|| |
If TM practice has to be promoted as an enabler of self-reliance, there is a need to recognize the best practice of TM based on both evidence-based practice and practice-based evidence to integrate into health policy. Due to the influence of various factors, the emergence of self-reliance differs widely across different contexts and goes beyond the individual level since it is socially constructed. In the era of growing interest in pluralistic health-care approaches, health decisions made at the individual level impacts one's health status. To better inform these decisions, understanding self-reliance is crucial. Self-reliance ought to manifest within capacitated households as their own choice rather than as a forced choice for addressing the health systems' gaps by filling the substantial gap between the policy and the practice of self-reliance. The lack of psychosocial and contextual exploration of self-reliance opens an opportunity to investigate it through social science research approaches, and our proposed conceptual framework could guide such empirical studies to strengthen its practice.
We express our deep gratitude to Friends of Hope Trust – UK, the University of Trans-Disciplinary Health Sciences and Technology – Bengaluru, Institute of Public Health – Bengaluru, and Indian Council of Medical Research, for their financial support. We thank Dr. Sarin for language editing help.
Financial support and sponsorship
This work was supported by a PhD fellowship awarded to Shivanand B. Savatagi by the Friends of Hope Trust – the UK through the University of Trans-Disciplinary Health Sciences and Technology – Bengaluru, and Indian Council of Medical Research – India, and supplemented by a PhD grant from the Institute of Public Health – Bengaluru.
Conflicts of interest
There are no conflicts of interest.
Supplementary File 3: Glossary of terms
Local: It denotes a particular geographical context or setting. It might be a community, village, or ethnic group.
Resources: Denotes financial resources, social networks, local health services, health institutions, and natural resources (medicinal plants) within a community or geographical context.
Resource-poor settings: Are those settings where there are limited health-care delivery services and limited financial resources.
Primary health care: It is a whole-of-society approach to health that aims at ensuring the highest possible level of health and well-being and their equitable distribution by focusing on people's needs and as early as possible along the continuum from health promotion and disease prevention to treatment, rehabilitation, and palliative care, and as close as feasible to people's everyday environment.
Self-care: According to WHO, self-care is “the ability of individuals, families, and communities to promote health, prevent disease, maintain health, and cope with illness and disability with or without the support of healthcare provider.”
Self-efficacy: Self-efficacy is confidence through which actions are carried out.
Self-management: The ability to manage physical and psychological consequences in the event of achieving self-care ability is called self-management.
Self-reliance: Self-reliance is defined as “A state of mind that regards to one's own mental and material resources as the primary stock to draw on in the pursuit of one's objectives, and finds emotional fulfilment not only in achieving the objectives but of having achieved them primarily by using one's own resources.”
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[Figure 1], [Figure 2]
[Table 1], [Table 2]