key: cord-1035876-b4x2gxbq
authors: Liu-Helmersson, Jing; Ouma, Anne
title: Sámi traditional medicine: practices, usage, benefit, accessibility and relation to conventional medicine, a scoping review study
date: 2021-07-28
journal: International journal of circumpolar health
DOI: 10.1080/22423982.2021.1924993
sha: b051d08e566399cdd0025dd1a48b4f14e4d77dd7
doc_id: 1035876
cord_uid: b4x2gxbq

The Sámi Indigenous populations, who live in the arctic Sápmi area across four countries – Norway, Sweden, Finland and the Kola Peninsula of Russia – have practiced traditional medicine (TM) for millennia. However, today Sámi TM is unknown within the Swedish health care services (HCS). The aim of this study is to describe the nature and scope of research conducted on Sámi TM among the four Sápmi countries. This study covers peer-reviewed research published in the English language up to 8 April 2020. From 15 databases, 240 abstracts were identified, and 19 publications met the inclusion criteria for full review. Seventeen studies were conducted in Norway, one in Finland and one in Sweden, none in Russia. In northern Norway, Sámi TM is actively used by the local communities, and is claimed to be effective, but is not accessible within HCS. Holistic worldviews, including spirituality, prevail in Sámi TM from practitioners’ selection criteria to health care practices to illness responsibilities. An integration of Sámi TM into HCS is clearly the desire of local communities. Comparisons were made between Sámi TM and conventional medicine on worldviews, on perspectives towards each other, and on integration. More studies are needed in Sweden, Finland and Russia.

The Sámi Indigenous populations live across four countries in the Arctic Sápmi region: Norway, Sweden, Finland and the Kola Peninsula of Russia. The Sámi population is estimated to be around 80,000, with approximately 50,000 in Norway, 20,000 in Sweden, 8,000 in Finland and 2,000 in Russia [1] . Sámi traditional indigenous knowledge, such as traditional knowledge on health and wellbeing or traditional medicine (TM), has for millennia supported the survival and resilience of the Sámi Indigenous populations in the cold and harsh Arctic environment. However, today Sámi TM is often ignored and is not recognised within the conventional health care system [2, 3] . In some other countries, TM is recognised officially. For example, in China, India, Tanzania and South Africa, people are free to choose from either, or a combination of TM and conventional medicine [4] [5] [6] [7] . In some countries up to 80% of the population are dependent on traditional medicine as their primary health service [5] .

The term conventional medicine used in this study refers to the official medical practice in most countries of the world, especially in the Western world. It is based on scientific knowledge which is from the Western worldview. Some studies called it biomedically based medicine [7] . Other names have also been used in the literatures: allopathic, Western, conventional or modern medicine. In this review, we use the term Western conventional medicine (WCM) and conventional medicine interchangeably.

The term traditional medicine is often used interchangeably with "alternative medicine" and/or "complementary medicine". The World Health Organization (WHO) defines these terms in the following way:

in Sápmi. When both TM and complementary and alternative medicine (CAM) are practiced in a country/ region, the combination is often termed in literature as T&CM [5] , to distinguish it from TCM -traditional Chinese medicine.

Within the four countries where Sámi Indigenous populations live, this study found two centres for research on TM and/or CAM, one in Norway and one in Sweden. In Norway, the National Research Center in Complementary and Alternative Medicine (NAFKAM) has been an official research and information institution under the Norwegian Directorate of Health since 2000, located at UiT The Arctic University of Norway [8] . It is one of the two WHO Collaborating Centres for TM in the European region. Many research publications have been produced by this Centre, including a number on Sámi TM. The Swedish centre for integrative medicine 2005 -the Osher Center for Integrative Medicine (OCIM) [9] -has been established in the Karolinska Institutet since 2005. It is one of the seven academic centres in the world funded by The Bernard Osher Foundation to study, teach, and practice integrative medicine. On the basis of reading through the research projects and publications currently listed in OCIM, this study notes the absence of Sámi TM.

In Sweden, Johan Turi, the first Sámi author and a healer wrote two books giving a comprehensive description of practices of Sámi TM over one century ago [10, 11] . A PhD thesis (in Swedish) by Carola Skott [12] , a nurse and social anthropologist, gives a more updated summary of Sámi healing practices in Sápmi, including Sweden. However, our study has not found current research in Sweden in the English scientific literature on Sámi TM, nor on the practices of TM in the health care services (HCS) in northern Sweden where the Sámi people live. According to WHO: "Traditional medicine (TM) is an important and often underestimated part of health services. TM has a long history of use in health maintenance and in disease prevention and treatment, particularly for chronic disease." [5] (p11). Evidently, it is important to understand the status and the usage of Sámi TM and its relation to the conventional HCS in Sweden as well as the other countries in the Sápmi region.

This study aims to describe the nature and scope of research conducted on Sámi TM in Sápmi. Specifically, it aims to identify the available evidence on and the knowledge gap in Sámi TM regarding its practices, providers, worldviews, benefits, usage, accessibility, as well as its relation to official health care services. Our study tries to answer the following questions:

• How is Sámi TM practiced? • 

Study design A literature review study is used. Among the many different types of literature review methodologies, a scoping review is found to be suitable to identify the available evidence, key factors and the knowledge gap, in view of the relatively small body of literature on Sámi TM and the fact that no comprehensive review has been done before [13] . The procedures are described by the Joanna Briggs Institute Reviewers' Manual for scoping reviews [14] . The essential steps in a scoping review are illustrated schematically very clearly by Jong et al. [15] . Results of the scoping review are reported following the Preferred Reporting Items for Systematic review and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) [16] .

The inclusion and exclusion criteria are listed in Table 1 . It has been modified after testing on different databases with help from Umeå University librarians. In the beginning of the selection process, no limitation for language was set. Besides English, only the Norwegian language has many hits. Only one Finnish study was found, and it is remotely related to Sámi TM. After reviewing abstracts, we found that the Norwegian researchers who published studies in Norwegian published also in English. Thus, including Norwegianlanguage studies would not seem to add more new information, but would only consume more time. The search in PubMed for Russian language studies resulted in many hits, but these were found to be irrelevant after reading the abstracts. So, we limit our review to English peer-reviewed scientific literature, as has been done in other review studies [17] .

To identify search terms, we followed the guideline from Joanna Briggs Institute Reviewers' Manual for scoping review [14] All identified abstracts and titles were uploaded to EndNote X9®, a reference management software programme, where duplicates were removed. A two-step screening process were used to identify the eligible studies for full review: 1) screening titles and abstracts, 2) reading full study. If studies did not meet one or more inclusion criteria, they were removed. For example, studies focused on Sámi but not on health, Sámi health/traditional knowledge but not TM or Sámi TM but not peer reviewed, such as books or theses [18] . However, some of the excluded records were helpful in providing context and background information for this study.

Full texts of the accepted studies were read in detail and information were extracted based on predefined categories ( Table 2 ). The data extraction includes both general information about the study (Article information, study location, main outcomes and methodology) and specific information (worldviews, basic knowledge and practices of, and accessibility to Sámi TM, HCS's perspectives on Sámi TM, etc.), weaknesses/bias and quality, and any relevant references from the study that needs to be added in the screening list, that is, citation mapping. The analysis of the studies was [17, 19] .

Out of the 15 electronic databases searched, 240 records were found from 12 databases: PubMed = 39, Scopus = 26, Web of Science = 37 from its four databases (WS core collection 33, MEDLINE 20, Russian Science Citation Index 2, SciELO Citation Index 1, excluding books, conference proceedings, and abstracts. Duplications are removed); and EBSCO = 138 from its six databases (Academic Search Premier 69, MEDLINE 33, APA PsycInfo 21, SocINDEX 3, CINAHL with full text 11, ERIC 1). After exclusion of 98 duplicates, 142 unique records were identified for screening. A flowchart illustrates details of the selection process ( Figure 2 ).

Following the first step of reading the title and abstracts, 115 records were excluded for reasons listed in the box on the right of the flowchart. From the second step of reading the full texts of the remaining 27 records, 14 records were identified as meeting the inclusion criteria. In addition, 10 more records were identified as relevant from the citation mapping. The two screening steps were repeated again. By this repetition, four records were excluded from the screening of titles and abstracts (see the number in the parenthesis after the plus sign in the flowchart), and six records were chosen for full-text screening, of which one was excluded. So, in total, 19 studies were found to meet the inclusion criteria for full review.

The overview of the included studies is described in Table 3 . Majority (17) of the research on Sámi TM is from Norway [3, [20] [21] [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] [32] [33] [34] [35] , one from Finland [36] and one from Sweden [37] . No studies were found from Russia within the English scientific literature that met our inclusion criteria.

The subject area of information extracted ranges from the basic knowledge about Sámi TM (healers, their practices, and access to Sámi TM), to different views on Sámi TM, on HCS and on the need for integration. The methods and designs of the studies consist of quantitative surveys with questionnaires; qualitative studies including interviews, narratives and observation; and literature reviews. Five studies are quantitative; all use cross-sectional design, and all were carried out in Norway. Eleven qualitative studies range from short narrative interviews to ethnographic field work. Three literature reviews consist of one book and one narrative review, and one review that did not specify the type.

The informants range from the general population, to patients with specific diseases (cancer, psychiatric and pain problems), to healers and health-care personnel. The comparison between different ethnic groups is limited to Sámi vs. Norwegian, since those studies were carried out in Norway. Some cross-sectional studies put Sámi and Kven (Finnish origin) together to increase sample size for statistical analysis. Some studies compare Sámi and non-Sámi which can be a mixture of Norwegian, Kven, Finnish and other nationalities in Norway [21] .

Further summary of the included studies is shown in Table 4 , where quantitative studies (Table 4a ) and qualitative/reviews (Table 4b ) studies are summarised in different tables. These tables include study design and time, data collection, sample size, age, ethnicity, and main outcomes.

The quantitative studies cover the time span 2003-2016. The data collection ranges from the general population in Tromsö, Norway (the 7 th -survey-Tromsö study), to the SAMINOR 1 (the Survey in regions with Sámi and Norwegian populations), to the psychiatric patients in Finnmark and Nord-Trom in nine mental health service clinics. The sample sizes range from 186 (psychiatric patients) to 21,083 (general population) in cross-sectional studies. The informants' ages range from 30 to 79 in those studies where age is mentioned. The main outcomes from all five quantitative studies were prevalence of visiting TM and its association with demographic and socioeconomic factors. Four studies focused on the use of Sámi TM and one on the desire for integration of Sámi TM and HCS. The time frame for use of Sámi TM varies from study to study -either over the past one year or over one's entire lifetime.

The Sámi informants are entirely limited to those living in Norway, mostly in northern Norway. Norway's lack of ethnic registry means that Sámi ethnicity needs to be identified indirectly from the survey questions answered, such as self-identification, or the languages spoken by the informant, or by his/her parents or grandparents. So the Sámi ethnic group was often divided into two: one of individuals who identified strongly as Sámi, having Sámi-speaking grandparents on both sides of the family, and the other of individuals associated with Sámi by self-defined cultural affiliation or by meeting only part of the criteria predefined as Sámi, the Sámi affiliation group. Thus, the Sámi sample sizes in the reviewed quantitative studies were identified from 43 to about 4000, or nearly 6000 if one includes the Sámi affiliation group.

The qualitative studies (Table 4b) include data collection from participant observations and different interviews: explorative, focus group, in-depth, and semistructured. Respondents include patients who used the outpatient mental-health-care clinics of northern Troms in Norway, HCS personnel, Sámi traditional healers, communities in northern Norway familiar with TM, and an entire village of Sámi adults in Finland (500 adults).

The sample sizes range from a few to 500 in qualitative interview and observational studies. The ages range from 22 to 80 in those studies that mentioned age. The main outcomes of qualitative studies include: the experiences, feelings and perceptions of Sámi patients towards TM [2, 32, 38] and HCS [31] , the change of one Sámi TM practice over time [36] , and perceptions and worldview(s) on health and wellbeing in process and practice [24, 27, 28, [30] [31] [32] 35] .

The studies unveil health and wellbeing-promoting effects by sociocultural networks [25] and yoik -the Sámi singing traditions [20] . In addition, they highlight 

Are there any differences between the four countries in Sápmi region regarding above questions?

Background information useful to give the context Weaknesses -what was not included? Quality of the paper (1-10) Any articles to be added from citation mapping?

the attitudes, knowledge and experiences of healers [26, 32, 35] , communities and HCS personnel in their clinical practice [23, 24, 28] . Transformation of Sámi TM over time in northern Norway is discussed [26, 28, 29, 36] . All the studies explain the practices of Sámi TM, but to different degrees. As shown in Table 5 Sámi TM, the materials used, as described by Turi one century ago, can be from animals, plants, minerals and chemicals. The methods can be herbal remedies to drink or to be burned in moxibustion, physical therapy, or magic rituals. They heal both acute ailments and chronic conditions.

In studies from Norway, reading a prayer and laying on of hands are the two most frequently mentioned methods used in Sámi TM practice. Reading can be done either face-to-face or at a distance from the patient [23] . Other modalities include blowing, curing, cupping, moxibustion, yoik, affirmations, movement and body therapy, drum journeying which can be done on an individual or a group. Materials/tools include both the invisible and the visible, such as words, prayers or singing, natural elements (plants, stones, water, wool and soil, etc.) and man-made objects (steel knives, scissors, prayer cloths, a piece of paper, or drums), or just healers' hands. Treatment can be performed in person or over a distance for various health issues: from acute problems (e.g. bleeding, toothache, and heart infarction) [28, 31, 36] , to chronicle diseases (e.g. multiple sclerosis, ulcerous colitis, pain, diabetes, and cancer) [21, 26, 28] , to mental problems (e.g., anxiety, depression, stress, nervous breakdown, sleeplessness, and "processing negative emotions and inducing positive ones") [20, 24, 28] , and to life's difficulties (e.g., out of work, quarrels between couples, lost or stolen articles) [11, 28, 29] 

From the qualitative analysis of the 19 included studies, Norway clearly leads the world in the study of Sámi TM, especially The Arctic University of Norway and University Hospital of North Norway Tromsö. Most of the Sámi Indigenous populations live in Norway (50,000). However, the proportion of research in Sweden (only one study) on Sámi TM is well under the proportion of Sámi population (20,000) within the four arctic countries of Sápmi.

Comparing the 19 included studies, we notice the following differences (Tables 3-4): 1) study design/methods used -qualitative interviews/observations, quantitative cross-sectional surveys, and literature reviews, 2) study focus • Quantitative studies: prevalence of visits to TM, and the need for integration, • Qualitative studies: culture, experiences, and worldviews on health/illness, accessibility to Sámi TM, patients' view on HCS, and awareness/view of HCS on Sámi TM, • Review studies: practices, methods, and worldview of Sámi TM.

Among the topics, what stand out most is the Sámi's Indigenous relational worldview, and the role of spirituality used in Sámi TM which affects practices ranging from the cost, range of diseases/problems that can be treated to the physical distances that the healers can cover (Table 5) . Qualitative studies focus more on cultural, experiential, and worldview aspects, while the quantitative studies focus more on patient visits to TM and the relation of TM to HCS. Compared to conventional medicine, Sámi TM seems quite simple in practice and in the materials/tools used. However, these studies demonstrate that Sámi TM covers a variety of areas and issues: physical, mental, emotional and life situations. The last are normally considered outside the areas of conventional medicine. However, public health studies increasingly attribute the causes of diseases to social determinants of health. As stated by WHO, social determinants of health cause premature mortality and health inequities [39, 40] . Scott-Samuel et al state, "There is persuasive evidence that the reduction of health inequalities can only be achieved by addressing their fundamental causes as Table 3 . Description of studies included in this review: topics, number of studies, relative percentage to the total, and references. The topics comprise location, subject area, design, methodology, informants, and ethnicity comparison. (TM -traditional medicine. HCS -health care services.) opposed to the diseases through which they are expressed, or the immediate precursors of those diseases." [41] . An awareness of this seems to exist within Sámi TM, whereby both the cause(s) and symptoms of diseases are addressed simultaneously in the practices. One question arises naturally: How effective is Sámi TM in treating these widely diverse health and life problems? Among the 19 studies, effectiveness was mentioned only in qualitative interview studies with positive comments by informants: "If they (readers) are good, it always helps." [31] (p145). "They are also commonly referred to as 'miracle doctors' or 'wonder doctors' " [35] (p41). Several studies similarly state: "I see the doctor to find out what is wrong with me, and then I see a healer to get well." [32] (p64) [26, 31] . This may imply that patients in northern Norway who used both types of medicine perceive Sámi TM to be more effective than conventional medicine in treating their mental and general health problems.

Given the above-mentioned claims, we reflect on how using simple practices like reading and laying on of hands and/or using simple materials work to treat such a complex variety of health and life problems. Careful reading and detailed analysis revealed that prayer and faith in God's healing power seems to be the cornerstone of Norwegian Sámi healing traditions. A healer is able to practice TM in person or at a distance, which explains the large number of consultations that one Sámi healer had over a 4-week period: 473 patients (419 telephone consultation plus 54 personal consultations) [28] ; another, 80 per day and 8000 annually, a third 25 per day over a 35 year career [35] (p41, 46) . This is a number that few medical doctors can match, neither a primary health care physician in the USA, nor physicians in Sweden, since Sweden is the country having the longest consultation time among 67 countries, based on a recent systematic review [42] .

Prayer and faith may explain why the simple materials/tools used in TM have achieved the better results claimed than medical drugs among those patients interviewed. However, one may also question if these positive results are from the healing treatment or from a placebo effect. As one informant stated "the healer must really believe in what he/she is doing, otherwise the technique will be without effect" [36] (p324). However, another study suggests that faith is not needed, through examples of how a healer was effective in healing the sickness of a cow and of one nonbeliever, but failed to heal a religious man [35] (p49). Secrecy seems important in Sámi TM: "There is a firm belief that a reader will lose his power if he is too public about his abilities or skills" [31, 32] . If Sámi TM truly works as well as conventional medicine, why the secrecy approach?

One may wonder who and how many use TM. Is it mostly certain groups of the population who have noncurable diseases and are desperate to try anything? Among the recent studies (2016), we find that Sámi TM was still actively used by the population in northern Norway, by both Sámi and non-Sámi: among cancer patients (6.4% of 404 during past year or 33% of 252 over 5 years) and among the general population (13.8% of 16,544 over lifetime) [21, 23, 24, 43] . The prevalence of individuals using Sámi TM is higher among the following: Sámi, religious groups from the Laestadian church, those living in certain locations such as inner Finnmark, those having self-rated poor health, lower income, or more severe health complaints, those who are older, women, and those practicing medical pluralism [21, 28] . Education and marriage do not influence TM usage. This shows that prevalence of TM usage is not an insignificant matter that can be ignored. Then, one wonders why do people choose to use TM, including those who have higher education and have general health problems? We find a few factors that contribute to the choice of using TM. First, historically some remote parts of northern Norway have had an acute lack of conventional medical doctors until recent decades, so that TM was the only primary HCS, and this generated a tradition that continues today [26] . Second, Sámi TM is affordable to all since it is mainly provided for free [21] [22] [23] [24] 29, 31, 32] . This is important for the lowincome group(s) of the population, which is similarly the case in countries such as South Africa, Tanzania, and Brazil [5] . Third, users of Sámi TM have cultural affinity. To some, Sámi TM is trustworthy, less stigmatising, and in line with the Sámi culture, particularly with regard to psychological problems [20] [21] [22] [23] [24] [25] 29] . To others, TM satisfies the need to deal with sickness holistically -including life's events, relations with nature, social circles and spirits, especially facing crises such as cancer [3, 24, 30] .

Sámi TM shows different beliefs and worldview from those of Western conventional medicine (WCM), especially with respect to spirituality and the view of the nature of health/diseases. Spirituality emerges from most (13 out of 19) of the studies. Sámi culture views the world as including both visible and invisible parts [30] [31] [32] , while WCM accepts and acknowledges only the visible part of the world and human life. WCM focuses on disease/infirmity and its risk factors, sees disease as associated mainly with the physical body and pathogens. Pathogenesis, a framework pioneered and developed by Williamson and Pearse [44] , is based on scientific and mechanical understanding of diseasesbiomedical approach.

In contrast, we find that Sámi TM takes a holistic approach, of seeing disease as inseparable from its social, natural and supernatural/spiritual environment. TM is based on the belief that humans have body, mind and soul. Humans, nature and supernatural beings are all alive and strongly connected. "Health and healing were thus closely connected to religion and world view, affirming a holistic view in which health was a relation between the individual and the community." [32] (p56); "the illness is related to events and values which are central to the patient's life." [35] (p61). To achieve health, one needs to be "in balance and harmony in human relations and the natural and spiritual world" [22, 24, 27, 30] . This holistic view shares great similarity with Salutogenesis [45] , which focuses on health and health-causing factors [46] . Table 6 displays the comparison of Sámi TM and WCM. This difference in worldview takes the form of contested encounters between Sámi patients, Traditional healers and the HCS, as demonstrated from the interview of a Sámi psychiatric patient [31] . This patient who was struggling after her father's death shared descriptions of seeing her deceased father in both dreams and in a waking state and received a comforting response from her Sámi Healer. However, she did not tell her therapist in the psychiatric clinic for fear of being diagnosed as "lunatic" and "using heavy drugs that you don't really need." The difference in worldview results in many Sámi patients not trusting their health providers in mental health clinics. This is an important motivation for Sámi patients to choose Sámi TM over HCS or in combination, while access to Sámi TM is shrouded in secrecy, as discussed extensively by Haetta [33] (p33).

In addition, we find that spirituality affects how medical practitioners were selected or trained. In WCM, everyone who is able to go to a medical school and complete the formal medical education and training can become a medical practitioner, for example, doctor, nurse, or psychologist. In Sámi TM, not everyone can be taught to be a healer. He or she must have a gift, a calling to be a healer. The older healers select the youth based on specific attributes and characteristics that can enable the acquisition of the knowledge and profession; it usually runs in the family line [21, 30, 32] . However, "To be a traditional healer is to receive both an inheritance from parents or another close relative, and the gift from God." [32] (p62). This is because the healer is "only a tool or a channel for some force outside of themselves" [29] (p581); "healing takes place with the help from a higher power" [26] (p3); "I have received my gifts from Heaven" [28] (p47); "what was freely given to me, I freely give" [31] . This explains why healers from Sámi TM generally do not accept payment for their services. Similar cases are found in research on TM from other countries [6] (p198). The destiny of the healer is perceived to serve the common good and heal people in need. This kind of demand is not for everyone since it requires willingness to be a "tool", "mentally strong", "have high moral standards", "inner desire to help others" in order to serve without payment. In addition, one needs to have the ability to keep the knowledge secret [26] : "one must be a reliable person with respect to both holding the knowledge esoteric and using the knowledge properly" [33] (p32). "I know of no Table 5 . Methods, materials and practices that include some treatment and healers' capacity in Sámi TM. The colours are used to label different categories: Red = method, Blue = materials, Green = illness, Pink = healers' capacity.

Turi's remedies consist of zootherapeutics (31%), physical acts (massage, moxibustion, or manipulation, 22%), ethnobotanical cures (17%), mineral and chemical cures (12%), and magic rituals (including incantations and ritual acts) that could be used alone (17%) or in conjunction with other types of healing (38%). They heal both acute ailments (65%) and chronic conditions (35%).

"the most common methods... in the Marka villages today are reading, the laying of hands, and blood stopping. A guvhllar …reading heals by reading prayers or formulas." other methods include massage, bloodletting, tinder burning and cupping. Materials: Herbs, plants, wool, ash, bone, urine, alcohol, tobacco, blood, feces, hair & other parts of animals. Curing infections, blood poisoning, toothache, pain. "finding lost things or persons; or make thieves immobile…make them bring back what they have stolen. ... 'cleaning' houses… & situations that represent social & relational problems -indirectly physical and mental well-being".

Haetta (2015) "Yoik may be considered a tool to express and process negative emotions, as well as expressing and inducing positive emotions" p5

Hämäläinen et al. 2017 "Yoik presents a means for a direct and noncognitive expression of emotions . It is thus different from talking about or discussing feelings" p4 Hämäläinen et al. 2018 Reading through speaking Biblical words with the intention to heal. "When performing reading, the reader often uses tools that have natural elements, such as water, stones, soil, a knife, and paper." p137 Kiil 2015 "The healing rituals may include prayer and the use of tools such as moss, water, stones, wool and soil. Examples of TM modalities offered in Northern Norway is cupping, blood-stemming, laying on of hands, healing prayers (called reading), and rituals." p2 "the TM providers gave the patients prayer cloths (pieces of fabric with printed prayers) to wear when they were seriously ill…" p8

Kristoffersen et al. 2019a

"…'reading' where the healer read a prayer over the illness [15, 16] . This 'reading' is used alone or together with elements from the nature such as rocks or water, or other remedies like steel or wool. When steel is applied, a knife is often used [17, 18] . Cupping therapy is also a part of the TM in Northern Norway [19] as well as use of medical plants [20, 21] and tare [18] . One of the specialties of the traditional healers in Northern Norway is to stop bleedings. This is used when people injure themselves or when they are in hospitals suffering from bleedings after childbirth or operations [17, 18] . The 'reading' can be received as distant healing or by visiting a traditional healer who is mostly non-professional and a non-commercial." p2 Kristoffersen et al. 2019b "Curing" is a concept in traditional healing that comprises both "reading a prayer" and applying "tools" during the healing ritual. Steel is a material which is often used, in the form of knives or scissors" p7

Langås-Larsen et al. 2017

"The network offers help with practical tasks and supports the closest relatives & they contact the healers. In cases of minor illness, only a few local healers are contacted. However, in cases of severe illness, local and more distant healers are contacted, phenomenon is called collective reading." p6

Langås-Larsen et al. 2018a

"Reading is a ritual where the healer reads a prayer based on the Bible to relieve symptoms and complaints [15] .

Blowing is a ritual where the healer blows three times after having read the healing prayer." p2. "We use Bible texts, and the word of God, The Lord's Prayer, and the Trinity. ... This is a kind of secret that I must preserve (Martin)." p7. Materials used can be natural elements: earth, fire, water, moss, stone, wool and potatoes, as well as man-made element: steel knife.

Langås-Larsen et al. 2018b

"They are also commonly referred to as 'miracle doctors' or 'wonder doctors' " (p41). "Brateng's career as a faith healer really started in his forties. The sick were treated with prayer and the laying on of hands. Brateng never made use of medicines of any kind. Within a short time, he became one of the best known folk healers in the area. He was sought out by people from' nearly every part of Northern Norway, as well as by people from Northern Sweden." (p42). He treated both humans and animals with touch or prayers, in person or over distance. Mathisen 1989 "Healer may heal all kinds of ailments and diseases. It is most common to heal pain and inflammation, and also stop blood and blood poisoning ... mental disorders such as anxiety. A healer is able to send away ghosts if someone is bothered by them. The healer can also heal a person's general life, for example by giving protection or sending away affliction or plagues. ... Today it is common to contact a traditional healer before giving birth or taking an exam. ... to 'ease' forthcoming hardships" p60

Myrvoll 2015

"Empowerment of the patient or client by focusing on inherent strengths, including both internal and external resources, rather than problems to be overcome". p217

Rountree & Smith 2016 "Healer A: 'I heal by the words of the Lord. I must press at the site of the pain, my hand pulls out the pain, and the patient can feel it happen. If I heal many patients suffering from pain per day, I turn very weak myself.' Healer B: 'There are three stages of the healing. When I put my hand on the patient he will become hot and sweaty, then cold. Then the patient feels drowsy, and some of them fall asleep. Finally, the patient wakes up, feeling fine. The disease leaves the body along with the drowsiness.' Healer C: 'I am able to stop bleeding without being present, and I can heal by phone if I am told where the person is and where the disease is located. Still people come to me, because it is difficult to heal by phone. Therefore I do that only in cases of emergency.'"p44. "The female healer ... cured people who were insane and had visual hallucinations -that is, saw ghosts and headless people...' I heal by the words of God and by advice; I put advising thoughts into the prayer, without saying it out loud...'." p45.

"Moxibustion, 'toullmos', burning of the fungus growth from a birch gnarl close to a diseased organ or at points where pain was felt." Seitamo 1991 "There are many ways a helper can work-through conversation, the laying-on of hands or the use of plantsthey are commonly contacted by phone and help or heal over a distance." p581. "He uses a variety of techniques, including the laying-on of hands, prayer, affirmations, voice, movement and body therapy, and as drum journeying for individuals and groups" p584.

Laying on of hands, herbal remedies, reciting of special verses from bible, reading, distance healing or prayer.

Sexton & Sørlie 2008 laying on of hands, distance healing or "reading" where special verses from sacred texts are "read" for the patient, Intuitive forms of knowledge and clairvoyance.

one who has become haughty or arrogant in their role as a traditional healer. If so, people will not use you anymore. It is in a way self-regulating." [32] (p67). The Sámi worldview on health and disease reflects on how people perceive and act when facing illness or crisis. In WCM, illness is the problem of the patient or patient's family alone and treating illness is the responsibility of medical professionals. Patients' family and social circles are usually not involved directly. This is closely related to the WCM's worldview on illnesses as physical problems. In Sámi TM and culture, illness is collectively "owned" by a large social circle, the extended family called Siida [25] . Siida´s approach involves visiting and supporting the individual who is ill and his/her family while contacting multiple healers to provide multiple readings, for example, from clairvoyance to see where the problem is and from a healer or healers as to what prayers(s) to use for treatment. This collective responsibility is consistent with their holistic worldview. Mutual respect and support by family and community in times of illness are perceived as paramount and as the core values of Siida. Fabrega [47] calls this approach to illness a social not just a personal concern. Swantz et al. [48] and Polanyi [49] discuss Traditional healers as having a profession defined in terms of a gift economy in which reciprocity and mutuality are paramount within a holistic worldview. This holistic or systemic worldview enables Sámi TM providers to treat life's difficult situation(s), since all areas are connected in a human's life -human relations, the natural and spiritual worlds. This supports the notion that "Healing -'recovery' may be culturally determined." [32] (p64)

The Sámi Indigenous Peoples´ worldview(s) including spirituality in addressing illness, share similarities found within African, Oriental, Australasian and Indigenous American cultures, as discussed by Oguamanam (2006) . A wealth of theoretical writings exists on comparative features of indigenous and western health systems [27, 50] . Scholars argue that many individuals consult TM due to the widely held belief that good health, disease, success or misfortune are not chance occurrences but rather are due to the actions of individuals or ancestral spirits [51, 52] . Agrawal uses a "systems knowledge" framework to present characteristics of indigenous knowledge [53] : 1) It is systematically embedded in a community; 2) it is contextually bound; 3) it involves non-belief in individualist values; 4) it does not create a subject/object dichotomy.

If Sámi TM is as effective as it is claimed by statements found in this study, the benefit of integration into the HCS could be enormous. Since Sámi TM claims to be able to carry out consultations and treatment through telephone and over distance, TM can reach an unlimited physical distance. Since a healer can consult many patients in a week and charges no money or expects only a small gift, this means that sustainability of the universal health care [5] is no longer an issue, even if the government pays the healer's salary like that of a regular medical doctor. Even if Sámi TM covers only some health areas, integration could solve many urgent problems currently facing the health care system, from budgets, to shortage of medical personnel, to rural coverage of HCS.

We note that currently no Sámi TM is provided within HCS, though patients access it through informal networks [22] . The awareness of Sámi TM among the conventional medical personnel is minimal to nonexistent [22] [23] [24] 30] . This could be due to the earlier discussed secrecy which surrounds Sámi TM in general and the communication between patient and HCS [28, 31] . However, two studies on elderly, severely ill cancer patients' visits and use of Sámi TM show positive attitudes and open-mindedness by health care providers in northern Norway, where HCS personnel, if requested, delivered TM [24, 28] . This evolving change illustrates signs of an awareness shift within psychiatric, elderly and cancer care in northern Norway in some of the study areas. Regarding the health seeking pattern-(s), the study reveals that it seems common in northern Norway for Sámi patients to use both types of medicine by obtaining a diagnosis from the conventional medicine and accessing treatment from Sámi TM [31, 32] . From the qualitative studies, we therefore see the belief by Sámi patients that Sámi TM is more effective than the HCS in treating their health problems and/or has fewer side effects than WCM.

The health-seeking pattern(s) of Sámi patients in northern Norway also indicates the need for medical pluralism and integration. Although only one quantitative study has addressed this issue directly, the desire for integration of Sámi TM and conventional medicine is clearly voiced by the psychiatric patients in this study among the majority of the Sámi (81%) and even some Norwegians (31%) [3] . Sámi patients' health-seeking behaviours and healers' medical practices indicate that both types of medicine are already used informally. Table 7 shows the comparison of mutual perspectives towards each other and the desire for integration between Sámi TM and WCM. A few studies emphasise the ethical principles of patient-centred care, and how integration could provide mutual benefit(s) between HCS and Sámi TM [22, 23] . One Traditional healer cited the TM way of self-protection from accumulating negative energy as an example that could benefit health professionals in HCS [29] . We interpret this as a call to embrace a pluralistic way of addressing and working with health, illness and wellbeing in which it is possible to accommodate both WCM and Sámi TM rather than seeing them as antagonistic.

The WHO TM strategy [5] embraces a pluralistic theory of health that accommodates the western and nonwestern approaches to health and disease. WHO and extensive research describe contemporary increased international emphasis on rethinking health services in light of local (sometimes indigenous) practices, worldviews and understandings [54] , with particular emphasis on mental health services [29, 55] . WHO strongly recommends mutual respect and cooperation between traditional and conventional health practitioners in an era where there is a growing focus on "whole person care" and patient-centred health care [5] .

This study has its limitation in three areas: the study selection process (same searching formular for all different databases), the screening process (authors' bias), and the criteria used that excluded non-peer reviewed and non-English literatures. The last one may affect the study results about Sámi TM from Sweden, Finland and Russia more than Norway. 

This study finds that spirituality and a holistic or systemic worldview of health, wellbeing and life dominate the Sámi TM. They permeate all aspects of the Sámi TM, from how a health provider is selected, including what qualities he/she should have, to how health care is practiced, to who takes responsibility for an illness. Differences in health care practice between Sámi TM and Western conventional medicine are quite large. They range from tools and materials used, to the physical distance(s) over which a consultation and treatment can take place, to the healthcare areas and issues covered, to the number of patients that a health provider can consult and treat in a given week, to the cost.

Although the number of studies on Sámi TM so far is still too limited to make a generalised conclusion, the differences in how health providers work within the two types of medicine may still lead us to reflect on how much the belief systems and worldviews have contributed to patient-centred care. In light of the huge medical care costs in Sweden and in the world, especially since the start of the COVID-19 pandemic, an integration of traditional medicine and conventional medicine maybe timely and beneficial to not just the Sámi Indigenous population but the whole society. Regarding research on Sámi TM, our results show that Norway is well ahead of the other three countries in the Sápmi area -Sweden, Finland, and Russia. There were more qualitative than quantitative studies. All the quantitative studies focused on prevalence of usage of Sámi TM or the desire for integration, while not addressing effectiveness. More studies, both qualitative and quantitative, are needed to understand the Sámi TM situation in Sweden, Finland, and Russia.

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This work is supported by Várdduo -Centre for Sami Research at Umeå University. The author (JLH) is grateful to Dr. Lena Maria Nilsson, the assistant director of Várdduo, for the suggestion of this study and the initial discussion, and to Dr. Krister Stoor, the director of Várdduo, for support to conduct this research. We are grateful to Lawrence Lerner, Professor Emeritus at California State University Long Beach, USA, for language proofreading of this manuscript; to Lars Jacobsson, Professor Emeritus at Umeå University, Sweden, for discussion on response to reviewers' comments.

The authors have not received any funding or benefits from industry or elsewhere to conduct this study.

Jing Liu-Helmersson http://orcid.org/0000-0001-9647-1015