Indigenous Health Services Research Articles

Unmasking population undercounts, health inequities, and health service access barriers across Indigenous populations in urban Ontario.

Our Health Counts (OHC) methods are designed to address gaps in urban-based Indigenous health information. In partnership with local Indigenous health service providers, we have successfully implemented OHC in six Ontario cities. The aim of this study is to summarize findings regarding Indigenous population undercount, health inequities, and health service access barriers across study sites. We estimated Indigenous population size using OHC census participation survey responses and a multiplier approach. Health inequities between Indigenous populations and overall populations in each city were examined using respondent-driven sampling (RDS), adjusted OHC survey results, and existing public data. Measures included health status outcomes; determinants of health; barriers to health service access, including discrimination by health service providers; and unmet health needs. Indigenous social networks were strong and extensive, and the urban populations demonstrate resilience and cultural continuity across multiple measures. Self-reported rates of census participation for Indigenous populations were markedly lower than those for the general population in each city, and OHC Indigenous population size estimates were consistently 2‒4 times higher than reported in the census. Indigenous to general population health inequities cut across measures of chronic disease, determinants of health, and unmet health needs. Indigenous populations experienced multiple barriers to health services access, including racial discrimination by health service providers. The Canadian census appears to markedly underestimate Indigenous population size in urban areas. Indigenous health inequities and service access barriers are striking and cross-cutting. Timely adaptation of health policies, services, and funding allocations in response to these findings is recommended.

Health Care Utilization and Perceived Quality of Care in a Colombian Indigenous Health Organization.

Indigenous governance of health care has increasingly been advocated among Indigenous peoples in many countries. However, there is limited research that has empirically examined its benefits. In 2020/21, we conducted a survey of 2113 Indigenous Wayuu individuals in Colombia who received services from the Indigenous Wayuu led health care insurance organization Anas Wayuu and its network of service providers, and Wayuu individuals who received services from non-Indigenous health insurance organizations. We compared their health care utilization and perception of quality of care. A main finding of the study was that Anas Wayuu enrollees were more than twice as likely to access health care than enrollees from non-Indigenous health insurance organizations, even when controlling for the demographic and health characteristics. The study provided compelling evidence suggesting that Anas Wayuu, being an Indigenous led health organization improves access to, and quality of care, among Indigenous health service recipients.

Measuring Mental Health Service Accessibility for Indigenous Populations: a Systematic Review.

Indigenous populations have experienced inequality of accessing mental health services compared with their non-Indigenous counterparts, although the way of measuring mental health service accessibility for Indigenous populations is unclear. This systematic review examines measures of mental health service accessibility for Indigenous people, including the diversity of mental health services that are available to them and the barriers to accessing mental healthcare. Using a systematic search procedure, we identified 27 studies that explored Indigenous populations' mental health service access. Our review shows that 18 studies used interview-based methods to explore how Indigenous people use mental health services, and only nine studies used quantitative methods to measure the uptake of mental health services. While advanced methods for quantifying geographical access to healthcare services are widely available, these methods have not been applied in the current literature to explore the potential access to mental health services by Indigenous populations. This is partially due to limited understanding of how Indigenous populations seek mental healthcare, barriers that prevent Indigenous people from accessing diverse types of mental health services, and scarcity of data that are available to researchers. Future research could focus on developing methods to support spatially explicit measuring of accessibility to mental health services for Indigenous populations.

Descoordenação a serviço do racismo institucional: considerações sobre o acesso de indígenas à política de saúde

Abstract The Brazilian policy for indigenous health has its efficacy conditioned by the promotion of intergovernmental coordination between the Special Secretariat for Indigenous Health (SESAI), municipal, and regional health services. This coordination should be done both in the policy formulation and in its implementation-which should occur between medium and street-level bureaucrats. Based on the literature that discusses federalism and intergovernmental coordination mechanisms, this article investigates the mechanisms and difficulties of cooperation in the frontline of health services offered to Indigenous peoples. A total of six semi-structured interviews were carried out with professionals of the SESAI in the Mato Grosso do Sul DSEI. It was identified that the difficulties are related mainly to institutional racism, the overload of the Brazilian National Health System (SUS), the unaccountability of municipal services, and the weak communication between SESAI and hospitals. The cooperation mechanisms are personal relations, situated agency of SESAI professionals, and a monetary incentive. In conclusion, there is a need for more intergovernmental collaboration mechanisms that consider these difficulties in integrating the implementation of these services.

Systematic review of Indigenous cultural safety training interventions for healthcare professionals in Australia, Canada, New Zealand and the United States

ObjectiveTo synthesise and appraise the design and impact of peer-reviewed evaluations of Indigenous cultural safety training programmes and workshops for healthcare workers in Australia, Canada, New Zealand and/or the United...

Mental health and use of Medicare Benefits Schedule follow-up mental health services by Indigenous people in Australia during the COVID-19 pandemic.

Mental health care has declined during the COVID-19 pandemic as has attendance for preventive mental health health services. This study aimed to investigate trends in all types of mental health service claims identified in an Indigenous-specific health assessment for Indigenous people before and during COVID-19. We conducted an analysis of Medicare Benefits Scheme (MBS) mental health service items (Items 81,325 and 81,355), to investigate the trends in all types of mental health service claims specifically intended for Indigenous people of Australia. Data were analysed using descriptive statistics, including the total annual numbers of Indigenous peoples' mental health service claims cross-tabulated by age groups and gender, between the calendar years 2017-2021. Multivariable Poisson regression modelling was used to determine associations that were statistically significant. Our results indicate an overall rise in MBS claims for mental health follow-up services during 2019-2020 followed by a decline in 2020-2021. In addition, there was an overall decline in claims for follow-up psychology services across the time period 2019-2021. We found a significant decline in MBS items specific to follow-up mental health services (MBS Items 81,325 and 81,355) for Indigenous people in Australia suggesting a decline in attendance for mental health service follow-up which in turn may indicate a deficit in mental health care during the COVID-19 pandemic, an issue that may lead to poorer mental health outcomes in the future. Further research is needed to understand whether these changes were due to the impact of the COVID-19 pandemic or other factors.

Closing the gap in Indigenous Australian cancer care: Initiatives to foster cultural safety and improve access to radiation therapy

IntroductionAboriginal and Torres Strait Islander peoples receive a poorer cancer prognosis compared to non-Indigenous Australians. Indigenous access to cancer care is limited by several factors, including differences in cultural understanding surrounding cancer and distrust of mainstream health institutions. It is believed that radiation therapy is being under-utilised by the Indigenous community. In response, several strategies were implemented to increase presentation and attendance by Indigenous Australians at a rural, private radiation therapy practice. MethodsA local Indigenous health service, Traditional Owners and Elders and the clinic's Reconciliation Action Plan Working Group were consulted to implement initiatives to reduce barriers to engaging in healthcare. One of these initiatives involved community consultation to select a culturally safe, Indigenous word to name one of the clinic's linear accelerators. Indigenous patient referrals into the clinic were tracked using an oncology information system. It is expected that by implementing several culturally safe strategies, there would be an increase in utilisation of the radiation therapy service and therefore, a decrease in Indigenous cancer burden across the local region. If strategies were yielding positive outcomes, there would be scope to implement these at other sites across a broader monitored network. ResultsCurrently, service utilisation is being monitored to determine whether initiatives have been successful. Initial data evaluation has been conducted and results are showing increased service utilisation by the Indigenous community. ConclusionWork has been undertaken to implement strategies to improve cultural safety and improve access to radiation therapy for Indigenous cancer patients. Preliminary results show an increase in the number of presentations to the clinic for radiation therapy treatment.

'By identifying myself as Métis, I didn't feel safe…': Experiences of navigating racism and discrimination among Métis women, Two-Spirit and gender diverse community members in Victoria, Canada.

Racism acts as a major barrier to accessing health services for Indigenous communities in Canada, often leading to delayed, avoided or lack of treatment altogether. The Métis population is uniquely positioned in urban settings, as they experience discrimination from both Indigenous and mainstream health and social services due to Canada's long colonial history that is ongoing. Yet, Métis are often left out of discussions regarding racism and health service access. This study explores the experiences of racism and health service access among Métis peoples in Victoria, British Columbia. We allied a conversational interview method to explore and understand experiences of self-identifying Métis women, Two-Spirit and gender diverse people (n = 24) who access health and social services in Victoria. Data analysis followed Flicker and Nixon's six-stage DEPICT model. In this paper, we share the experiences of racism and discrimination of those who accessed health and social services in Victoria, British Columbia Such experiences include passing as White, experiencing racism following Métis identity disclosure and witnessing racism. Passing as White was viewed as a protective factor against discrimination as well as harming participants' sense of identity. Experiences of racism took the form of discriminatory comments, harassment and mistreatment, which influenced the willingness of disclosing Métis identity. Witnessing racism occurred in participants, personal and professional lives, negatively impacting them in indirect ways. Each experience of racism had a negative influence on participants' wellbeing and shaped their experience of accessing health and social services. Métis people confront racism and discrimination when attempting to access health and social services through first-hand experiences, witnessing and/or avoidance. While this study contributes to the all too often unacknowledged voices of Métis in Canada, there is a continued need for Métis-specific research to accurately inform policy and practice.

Indigenous maternal health and health services within Canada: a scoping review

BackgroundGlobally, there are disparities in access to maternal health care services and equity in maternal health outcomes between Indigenous and non-Indigenous populations. While the literature is growing, it has not been systematically synthesized. This review addresses this gap by synthesizing the existing literature on the organizational structure of maternity care, accessibility and delivery of services, and clinical disparities impacting Indigenous maternal health within Canada. It also identifies current knowledge gaps in research on these topics.MethodsA scoping review was completed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines and the extension for scoping reviews. The search for relevant papers was performed in PubMed, CINAHL, and SCOPUS electronic databases and included any empirical literature written in English and published during 2006 – 2021. The research team inductively coded 5 articles to develop a coding scheme, which was then applied to the remaining articles.ResultsA total of 89 articles were included in the review, of which 32 were qualitative papers, 40 quantitative, 8 were mixed-methods publications, and 9 were review papers. The analysis of the articles resulted in identifying a range of overarching themes pertaining to the maternal health of Indigenous women within Canada including provision of services, clinical issues, education, health disparities, organization, spatial context, and impact of informal support. The results suggest that physical, psychological, organizational, and systemic barriers inhibit the quality-of-care pregnant Indigenous women receive, and that maternal health services are not consistently provided in a culturally safe manner. Results also suggest that, compared to non-Indigenous pregnant women, Indigenous women are more likely to develop clinical complications during pregnancy, reflecting the structural impacts of colonization that continue to negatively influence Indigenous maternal health and well-being.ConclusionsThere are many complex barriers that prevent Indigenous women from receiving high quality and culturally appropriate maternal care. Possible areas that could address the service gaps illuminated through this review include the implementation of cultural considerations across health care jurisdictions within Canada.

Exploring the perspectives of caregivers of urban Inuit children on child health knowledge mobilisation

ABSTRACT Our study sought to explore the experiences of caregivers of urban Inuit childrenwith respect to child health knowledge acquisition to developcommunity-specific best practices for health promotion initiatives. A needs assessment wasconducted to understand how caregivers access child health knowledge andservices; what child health issues require improved knowledge mobilisation; andhow caregivers would like to access this knowledge. Four focus groups were heldwith twenty-four parents and caregivers of Inuit children. Child healthknowledge acquisition was influenced by dynamics of trust and discrimination,making caregivers’ social networks and Indigenous health services highly valuedsources. Health topics identified as requiring improved knowledge mobilisationwere those in which caregivers faced tensions between Indigenous andnon-Indigenous ways of knowing. Such topics included parenting and development,adolescent mental and sexual health, common childhood illnesses, infant care,and nutrition. Caregivers preferred a multi-modal approach to health promotion, highlightingimportance of in-person gatherings while also valuing accessible multi-media components. Thepresence of Elders as facilitators was especially important for childdevelopment, parenting, and nutrition. For health promotion to beeffective, it must consider community-specific health knowledge sharingprocesses; tensions between Indigenous and non-Indigenous ways of knowing;and community ownership in health promotion endeavors.

Impact of an Aboriginal and Torres Strait Islander brief intervention training program on health staff participants' own health behaviours: Smoking, nutrition and physical activity.

Little research has been conducted on the impact of Aboriginal and Torres Strait Islander brief intervention training programs on health staff participants' own health behaviours. Through the Queensland B.strong program (2017-2020), brief intervention training in smoking cessation, nutrition and physical activity was provided to the Aboriginal and Torres Strait Islander health workforce and other health and community professionals. This study examined the program's impact on participants' own health behaviours. Data were collected through four surveys (pre- and post-training workshop, and 3-month and 6-month follow-up) of the 1131 participants in B.strong training workshops from June 2017 to August 2019. Surveys included items on participants' own health behaviours. Pre- and post-workshop surveys were paper-based, and follow-up surveys were completed online. For the analysis of data reported in this paper, paired-samples t tests were used to assess changes between pre-workshop and 3-month follow-up. Statistically significant improvements were found between pre-workshop and 3-month follow-up in the number of serves of vegetables or legumes/beans eaten per day, the number of serves of fruit eaten per day, and in time spent in physical activity. However, there was: no statistically significant change in smoking status, with baseline rates being relatively low; a statistically significant increase in consumption of sugary drinks, and of takeaway foods; a nonsignificant increase in consumption of snack foods; and no significant change in sedentary behaviour of participants. While some positive changes in participants' own health behaviours in nutrition and physical activity were associated with the B.strong program, there was no change in their smoking behaviour. SO WHAT?: This study found that some improvements in participants' own health behaviours were associated with the B.strong program. This research may inform future Indigenous brief intervention training programs and health services on how to promote healthy behaviours for health staff themselves.

Traditional healing and medicine in dementia care for indigenous populations in North America, Australia, and New Zealand: A scoping review protocol

AbstractObjectiveIn this scoping review we aim to explore approaches to the integration of traditional healing and medicine in dementia care for Indigenous communities in North America, Australia, and New Zealand. We aim to understand the roles and experiences of traditional healers, strategies and their evaluation, and the barriers and opportunities for integration of Indigenous and western dementia care approaches. Introduction: Access to culturally safe geriatric care and dementia assessment, diagnosis, and care in Indigenous populations worldwide is an emerging challenge. The World Health Organization recognizes traditional healers as stakeholders in dementia care. Traditional healers can provide dementia assessment and care in unique ways and play a catalytic role in the process of dementia care planning. This scoping review will inform Indigenous health service providers about the potential integration of traditional healing and medicine into dementia care and support systems. Inclusion criteria: This review will include all types of study designs, that examine the integration of Indigenous approaches and traditional healers in dementia care in Indigenous communities in North America (Canada and U.S.), Australia and New Zealand.MethodsIn close collaboration with Indigenous community advisors, we will search for OVID MEDLINE, PsycINFO, CINAHL and EMBASE include English literature from 1990 to 2020. After two independent screens of title and abstract, and then full text, we will extract the study population, participants, intervention type, aims, methods, key findings, and knowledge gaps. The results will be summarized and presented to Indigenous community advisors for contextual interpretation and validation prior to being finalized.ResultsOur initial search of CINAHL, Embase, Medline and PsycINFO identified 516 records published between 2000 and 2020 that met our search criteria. After 164 duplicates were removed, we screened 352 titles and abstracts and excluded 209 that did not meet inclusion criteria. Our second stage review of 143 full text studies resulted in the further exclusion of 113 studies. Of these, 84 studies did not include traditional medicine and 13 did not involve Indigenous populations or meet our study design criteria. Results were extracted from the 30 eligible and relevant studies that were included in the final scoping review.

Screening for diabetic retinopathy and reduced vision among Indigenous Australians in Top End primary care health services: a TEAMSnet sub-study.

Diabetic retinopathy (DR) prevalence is higher in Indigenous Australians than in other Australians and is a major cause of vision loss. Consequently, timely screening and treatment is paramount, and annual eye screening is recommended for Indigenous Australians. To assess the prevalence of DR, reduced vision and DR treatment coverage among Indigenous Australian adults with diabetes attending Top End indigenous primary care health services. A cross-sectional DR screening study conducted from November 2013 to December 2015 in two very remote Northern Territory Aboriginal primary healthcare services. In 287 subjects, the prevalence of non-proliferative DR, proliferative DR and clinically significant diabetic macular oedema was 37.3%, 5.4% and 9.0% respectively. Treatment coverage for PDR was 60% (of 10 patients) and for CSMO was 17% (of 23 patients). Vision data were available from 122 participants at one site. The proportion with normal vision, reduced vision, impaired vision and blindness was 31.1%, 52.5%, 15.6% and 0.8% respectively. Overall, ungradable monocular image sets (46%) were associated with poorer quality images and missing protocol images (both P < 0.001). Ungradable images for DR were associated with presence of small pupils/media opacities (P < 0.001). Ungradable images for diabetic macular oedema were associated with poorer image quality (P < 0.001), cataracts (P < 0.001) and small pupils (P = 0.04). A high prevalence of DR, CSMO and impaired vision was noted in Indigenous Australians with diabetes. Screening in primary care is feasible, but more effective screening methods are needed.

Addressing the need for indigenous and decolonized quantitative research methods in Canada

Though qualitative methods are often an appropriate Indigenous methodology and have dominated the literature on Indigenous research methods, they are not the only methods available for health research. There is a need for decolonizing and Indigenizing quantitative research methods, particularly in the discipline of epidemiology, to better address the public health needs of Indigenous populations who continue to face health inequities because of colonial systems, as well as inaccurate and incomplete data collection about themselves. For the last two decades, researchers in colonized countries have been calling for a specifically Indigenous approach to epidemiology that recognizes the limits of Western epidemiological methods, incorporates more Indigenous research methodologies and community-based participatory research methods, builds capacity by training more Indigenous epidemiologists, and supports Indigenous self-determination. Indigenous epidemiology can include a variety of approaches, including: shifting standards, such as age standardization, according to Indigenous populations to give appropriate weight to their experiences; carefully setting recruitment targets and using appropriate recruitment methods to fulfill statistical standards for stratification; acting as a bridge between Indigenous and Western technoscientific perspectives; developing culturally appropriate data collection tools; and developing distinct epidemiological methods based on Indigenous knowledge systems. This paper explores how decolonization and Indigenization of epidemiology has been operationalized in recent Canadian studies and projects, including the First Nations Regional Longitudinal Health Survey and how this decolonization and Indigenization might be augmented with the capacity-building of the future Our Health Counts Applied Indigenous Epidemiology, Health Information, and Health Services and Program Evaluation Training and Mentorship Program in Canada.

The use and impact of digital technologies for and on the mental health and wellbeing of Indigenous people: A systematic review of empirical studies

Mental health issues in Indigenous communities have been increasingly documented by media, research, and government reports. High rates of suicide, depression, and substance abuse are prevalent among Indigenous people, especially youth. Research has reported that many Indigenous communities have adopted and are keen to adopt digital technologies, which have shown potential to provide e-mental health (eMH) resources for Indigenous people. By conducting a systematic literature review, this article examines the impact of Indigenous people's interactions with digital media on their mental health and wellbeing.The twenty-seven empirical studies included in this review were conducted with Indigenous participants primarily across four countries. We analyzed the studies' research objectives and respective instruments to measure the impact of an array of digital technologies adopted by Indigenous people for their mental health needs or used in Indigenous-specific eMH programs. This paper reports on themes found in the peer-reviewed literature, including Indigenous people and other stakeholders' perspectives on eMH and the viability of its implementation. The findings suggest that digital technologies can be effective in aiding the provision and improvement of Indigenous mental health services, particularly when applying decolonizing, culturally appropriate approaches. This review provides insights for researchers, health professionals, and educators to develop and implement innovative eMH resources for Indigenous communities.

Two-eyed seeing as a philosophy to facilitate communication between indigenous counselors and psychiatry about mind and mental health

IntroductionThe term “two-eyed seeing” is spreading across North America as a concept for explanatory pluralism. The concept was brought into academic science by Albert Marshall, a M’iqmaq from Nova, Scotia, Canada. It speaks to the idea that indigenous knowledge is an equally valid way of conceptualizing a phenomenon as is contemporary science. Marshall’s famous example compares a traditional M’iqmaq story about the origins of the large tides in the Bay of Fundy with contemporary oceanographic geology findings and simulations.ObjectivesWe wanted to explore how this two-eyed seeing model could be applied to mental health to facilitate a dialogue between psychiatry and traditional cultural healers.MethodsWe reviewed the existing literature on two-eyed seeing within mental health care using PubMed, IndexMedicus, OneSearch, and Google Scholar. We presented a course on two-eyed seeing for indigenous mental health services and two-eyed seeing for addressing trauma in indigenous communities and surveyed the participants about the two-eyed seeing concept. We offered this course primarily to providers within indigenous communities and also for other interested counsellors.ResultsParticipants in our trainings were enthusiastic about the role of two-eyed seeing for improving communication among indigenous providers and patients and non-indigenous providers. Most indigenous counselors had not heard of two-eyed seeing and were quite enthusiastic about its affirming nature and how it gave them a basis for dialogue with non-indigenous practitioners.ConclusionsTwo-eyed seeing allows a rich dialogue between European-derived practitioners and indigenous people that enabls each to appreciate the other’s perspectives, leading to greater cooperation and collaborative treatment.DisclosureNo significant relationships.

Point-of-care testing of HbA1c, renal function and lipids in remote or disadvantaged regions.

For optimal diabetes management HbA1c, lipid and renal function measurements are key. Suitable point-of-care systems can provide such data in remote areas, diabetes camps, disaster relief, small community hospitals and in community screening days in disadvantaged regions. Some systems are currently used in Australian rural, remote and indigenous health services.

Opportunities and challenges for physical rehabilitation with indigenous populations.

Indigenous peoples in colonised countries internationally experience a disproportionately high burden of disease and disability. The impact of many of these conditions, such as musculoskeletal pain, can be ameliorated by participating in physical rehabilitation. However, access by Indigenous peoples to physical rehabilitation is low. Overcoming barriers for Indigenous peoples to access high-quality, effective, culturally secure physical rehabilitation should be a priority. Physical rehabilitation outcomes for Indigenous peoples can be enhanced by addressing health system, health service, and individual clinician-level considerations. System-level changes include a greater commitment to cultural security, improving the funding of physical rehabilitation to Indigenous communities, building the Indigenous physical rehabilitation workforce, and developing and using Indigenous-identified indicators in quality improvement. At the health service level, physical rehabilitation should be based within Indigenous health services, Indigenous people should be employed as physical rehabilitation professionals or in allied roles, and cultural training and support provided to the existing physical rehabilitation workforce. For clinicians, a focus on cultural development and the quality of communication is needed. Indigenous ill-health is complex and includes societal and social influences. These recommendations offer practical guidance toward fair, reasonable, and equitable physical rehabilitation outcomes for Indigenous peoples.

Indigenous health organizations, Indigenous community resurgence, and the reclamation of place in urban areas

Research around the world has been nearly unanimous about the positive impacts of Indigenous‐led health organizations on Indigenous peoples' qualitative experiences in health care, in the face of often negative experiences in non‐Indigenous‐led health care settings. Urban environments, including health care environments, are areas of increasing attention with regard to Indigenous peoples' health in Canada. In this study, which took place in the northern city of Prince George, British Columbia, 65 Indigenous community members and health services workers participated in interviews and focus groups, describing their experiences with urban Indigenous‐led health organizations—defined in this study as non‐governmental organizations that prioritize the values and practices of local Indigenous communities. Employing perspectives on place and relationships drawn from Indigenous critical theory and Indigenous community resurgence to analyze the findings of this qualitative study leads to a focus on how relationships impact and can even constitute places, enabling new understandings of the roles of Indigenous‐led health organizations in urban Indigenous community resurgence.

Minister Terawan encourages Usadha Bali development under Traditional Balinese Medicine branding

In Bali, Study of traditional herbal medicine is known under term Usadha, derived from Sanskrit word Ausadhi means healing plants. The ancient wisdom of botanical medicine texts has been compiled on Lontar (Dried-Borassus leaf) under name Lontar Usadha. Traditional Balinese Usadha treatment is carried out by a shaman called Balian; whether Balian Ketakson or Balian Usadha. Usadha practice on the island of Bali is strongly related to herbal plants' existence. Herbal medication has been proven in Bali as a primary treatment for the patient since ancient times. However, due to current medication service, people no longer prefer a botanical-based therapy as the first option. As a result, the number of herbal plants on the island of Bali has been plummeting over the years. Although on some occasions, the central government and provincial government had suggested cultivating herbaceous plant as a decorative plant on a household level, yet the program did not make any significant impact. In December 2019, Governor of Bali, Wayan Koster expressed his deep interest on indigenous health service industry to be provided by hospitals, both state and private. On occasion, Indonesia minister of Health, Terawan Agus Putranto, showed his support for the development of health tourism, travelling medicine, and complementary traditional services with local genius. They both agreed that the service would be promoted under 'Traditional Balinese Medicine (TBM) service' branding. In future, it is expected that TBM would be available as an alternative service on Bali hospitals. The facility would promote herbal industry development as well as herbal plant preservation through the availability of local herb farms to be established in ​​Bangli, Karangasem, and Tabanan areas.