Download Health Care Beliefs and Practices Among Native American Patients

Health Care Beliefs and Practices
Among
Native American Patients
Presented by:
Rick Haverkate, MPH
Director of Public Health Programs
National Indian Health Board
Washington, DC
Learning Objectives
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1. Describe the unique relationship between
American Indian/Alaska Native and the
United States government.
2. Develop awareness of the importance of the
historical context in the lives of today’s
today s
American Indians and Alaska Natives.
5. Describe strategies for the development of
culturally appropriate verbal and non-verbal
communication skills with American
Indian/Alaska Native and their families.
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6. Discuss the importance of eliciting
explanatory information regarding illness and
wellness from the American Indian/Alaska
Native and his family for collaborative
treatment planning.
Researchers believe that self-identification of
race by American Indian (AI) respondents in
Census counts since 1960 have dramatically
increased, but that the 1990 Census
contained a severe undercount of American
Indians estimated to be 12.2% in tribal areas.
There were 4.1 million people who identified as
AI/AN in the 2000 Census.
There are at least 558 different federally
recognized tribes/nations and 126
tribes/nations applying for recognition.
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There are now more people who identify
themselves as Indian in urban areas (62%)
than on reservations and other rural areas.
The lives of today’s Indians are likely to have
been influenced by the history of oppression,
repression intergenerational anger
repression,
anger, and
intergenerational grief, experienced since
North American was colonized by Europeans.
The Influence of
Historical
Experiences on
Today’s Indian
The Boarding School Experience
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The Indian Reorganization Act of June 18, 1934, secured certain
rights to American Indians and Alaska Natives. These include a
return to local self-government on a tribal basis. The Act also
restored to Native Americans the management of their assets
(being mainly land) and included provisions intended to create a
sound economic foundation for the inhabitants of Indian
reservations.
constitution However,
However if
• The act did not require tribes to adopt a constitution.
the tribe chose to do so, the constitution had to:
1. allow the tribal council to employ legal counsel;
2. prohibit the tribal council from engaging any land transitions without
majority approval of the tribe; and,
3. authorize the tribal council to negotiate with the Federal, State, and
local governments.
In 1954, the United States Department of Interior began
implementing the termination and relocation phases of the Act.
Among other effects, termination resulted in the legal
dismantling of 61 tribal nations within the United States.
• This The Indian Reorganization Act act was based upon the
thought that tribes should be in existence for an indefinite period
of time
The Nixon administration pushed through the
Indian Self-Determination and Education Act
of 1975, with the ultimate goal of selfsufficiency.
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The basic tenets of Christianity (love for God
and fellow man, honor, generosity and
sharing, compassion, forgiveness, and selfsacrifice for the good of the community) were
already institutionalized in the belief systems
of many indigenous cultures before the
missionization of North America.
Most Indian traditions teach that the
“interconnectedness” of all things
leads to a relationship between man,
Creator/God, fellow man, and nature.
In many Indian traditions, healing,
spiritual belief or power
power, and
community were not separated, and
often the entire community was
involved in a healing ceremony and in
maintaining the power of Indian
“medicine.”
The term “medicine” is often used to denote
actions, traditions, ceremony, remedies, or
other forms of prayer or honoring the sacred.
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Healing is considered sacred work and in many
Indian traditions cannot be effective without
considering the spiritual aspect of the
individual.
Many contemporary Indians use
“white man’s medicine” to treat
“white man’s diseases.”
And use “Indian
medicine” to treat
“Indian problems”.
Terminology
Native American
American Indian
North American Native
Indigenous
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There is no one legal definition for the term
“Indian”.
Courts have used a two-part definition for being
Indian, in the absence of definition by
Congress:
1. That the person must have some identifiable
Indian ancestry
2. That the Indian community must recognize this
person as an Indian.
The U.S. Census category includes anyone
who self-identifies as “Indian.”
The term “Indian country” refers to all
reservation lands (there are 278 federally
recognized reservations).
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“Indian Country” is also
considered “a state of mind.”
The American Indian (AI) experience is different
from other ethnic minority groups in that:
1) AI nations were colonized by Europeans and did
not immigrate from other places within the last 700
years
2) Health care, education, and social programs were
bought and paid for with ceded land by treaty.
The term tribal sovereignty refers to this unique
relationship by which Indian tribes/nations
maintain the right (by treaty) to negotiate
directly with the federal government as
independent nations.
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The primary source for AI/AN health data is the
Indian Health Service.
Collected only from eligible (tribally enrolled,
living on-or-near reservation of federally
recognized tribes) members, who actually
utilize I.H.S. services.
IHS data may reflect “availability of services”
rather than incidence and prevalence of
illness, and may not include most of the 62%
of AI/AN who live off-reservation.
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Mortality for AI/AN may be underestimated by
50% due to errors of misidentification of the
race of the decedent, and/or misclassification
in the cause of death.
Prevalence rates vary widely, especially in
I H S data
I.H.S.
data, from service area to service area
area,
and by tribal affiliation.
Excess deaths are reported among older
American Indians for tuberculosis
tuberculosis, diabetes
diabetes,
pneumonia, and cirrhosis.
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Alcohol Abuse
Contrary to stereotypes, AI/AN men reported
lower levels of chronic drinking than nonHispanic white men at older ages.
AI/AN reported less current drinking but about
the same amount of binge drinking as nonHispanic whites by age and sex.
Culturally Appropriate Care
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Cultural values affect behavior, attitudes, and
beliefs about health care and treatment
treatment, as
well as expectations of health care providers.
AMERICAN INDIAN
EURO-AMERICAN
Cooperation
Competition
Group Harmony
Individual Achievement
Modesty and Humility
Physical Modesty
Not putting one’s self forward
Non-attention seeking behavior
(expect in sports)
Overt identification of
accomplishments
Physical exhibition
Non-Interference
Advice giving,
directiveness
“Counseling” and
“Educating”
Silence is valued
Ability to listen and wait
Points made by
aggressive verbal
behavior, expression of
opinion
AMERICAN INDIAN
EURO-AMERICAN
Emotional Control
Contemplation
Non-demonstration of anger or
other strong emotion
Action over inaction
Direct confrontation
Direct expression of anger
Indifference toward future planning
Saving for one’s own benefit not
accepted
Planning for future generations lost
with the land
The future, if there is one, “will take
care of itself”
Time orientation to the “present”
Saving for the future
(Insurance, retirement,
savings account)
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AMERICAN INDIAN
EURO-AMERICAN
Indian Time
Non-linear, relative to the activity at
hand, flexible
Eurocentric obsession
with time, “time is money”
Extended Family Orientation
Aunts and uncles considered as
mothers and fathers
Grandparents traditionally parented
Family members often “kept” by
other relatives with no disruption of
a family unit
Multi-generational and multigeographical “homes” with family
members
Nuclear Family Orientation
Natural parents are only
valid responsible parties
Measure of successful
rearing is for children to
“leave home”
AMERICAN INDIAN
EURO-AMERICAN
Avoidance of direct eye contact as
a sign of respect
Direct eye contact
considered sign of honesty
and sincerity
Handshake lightly; some women
touch only the finger tips
Firm handshake denotes
power
Personal information not forth
coming
Self-disclosure valued,
“open and honest”
communication style
Ideas and feelings conveyed
through behavior rather than
speech
h
Verbal expression of ideas
and feelings
Words are chosen carefully and
Verbosity and small talk is
deliberately, as the power of words appropriate social behavior
is understood
Withdrawal used as a form of
disapproval (“voting with your
feet”)
Direct expression of
disapproval
Request given through indirect
suggestion
Directiveness of requests
EXAMPLES OF AMERICAN
INDIAN/ALASKA NATIVE
EXPLANATORY MODELS FOR
ILLNESS
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• Each person is put on the earth for a short
time for a purpose.
• When that purpose is accomplished the
person is ready to leave this world.
• Death and illness are not caused by others,
and prolonged grieving prevents the spirit
from crossing over to the next world where
there is no pain, but peacefulness.
Illness is caused by an imbalance in the
patient’s
patient
s spiritual,
spiritual emotional
emotional, and social
environment.
Dementia is a condition in which the person’s
spirit has already crossed over into the next
world, but the body remains behind as it
prepares to leave.
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Illness is caused by the stress on Indians of
trying to live in two worlds at one time.
Many AI/AN exhibit a basic distrust of the
Western health care system based on
historical abuses and belief that this system is
based on “greed” rather than care for the
individual.
Cultural nuance can influence the meaning of
words
Some Indian cultures do not speak of death,
dying, or of negative outcomes
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From the Native American perspective,
medicine is more about healing the person
than curing a disease.
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Tribal Public Health Assessment Results
Rick Haverkate, MPH
Director of Public Health
Slide show produced by:
Blake Harper, MPH Candidate
The George Washington University
NIHB, Public Health Intern
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• Vision
– The National Indian Health Board (NIHB) advocates on behalf of all Tribal
Governments, American Indians and Alaska Natives (AI/AN) in their
efforts to provide quality health care for ALL Indian People!
• About NIHB
–
–
–
–
Health Care advocacy services
Tribal budget consultation
Research, policy analysis, program assessment and development
National and regional meeting planning, training, technical assistance for
program, and project management
– Monitoring, reporting on and responding to federal legislation and
regulations
– Conduit for the advancement of AI/AN health care issues
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Presentation Overview
Funding
Design
Benefits
Tribal Health Organization
Characteristics
Community Health Assessments
and Planning
Public Health Activities and
Services
Other Important Topics
What’s Working in Tribal Health
Organizations
Future Directions
Acknowledgements
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Funding
Provided by the W.K. Kellogg Foundation
• National Indian Health Board awarded grant to
complete the Tribal Public Health Profile on
b h lf of:
behalf
f
– Tribal Representatives
– Stakeholders
– Partner Organizations
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Design
2010 Tribal Public Health Profile
• Modeled after existing public health performance assessment
instruments
• Organized around the Three Core Functions of Public Health
and the Ten Essential Public Health Services
• Adapted to be specific to tribal public health
Questionnaire
• Web-based
• Sent via email to 376 directors and administrators
• 346 successfully delivered
• 145 responses received (42%)
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Benefits
Designed to describe tribal public health capacity using
national standards for measuring performance
Benefits include:
•Baseline to measure growth and change
•Prioritize areas for development and resources
•Advocate for resources and policy development
•Assess readiness for accreditation
•Identify technical assistance and QI needs
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Tribal Health Organization
Characteristics
Participants
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Tribal Health Organization
Characteristics
Participants
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Tribal Health Organization
Characteristics
Tribal Health Departments
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Community Health Assessments and
Planning
ESSENTIAL SERVICES I: MONITOR HEALTH STATUS TO IDENTIFY COMMUNITY HEALTH PROMOTION
• 44% of Tribal Health Organization
have conducted a community
health assessment in the past 3
years
• 3 barriers to conducting
community health assessments
– Lack of staff
– Lack of resources
– Need for training
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Community Health Assessments and
Planning
ESSENTIAL SERVICES I: MONITOR HEALTH STATUS TO IDENTIFY COMMUNITY HEALTH PROMOTION
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Public Health Activities and Services
ESSENTIAL SERVICES II: DIAGNOSE AND INVESTIGATE HEALTH PROBLEMS
• Tribal Health Organizations
vary in their knowledge about
the delivery of public health
services in their communities
• Tribal Health Departments
report that local health
departments provide more
public health activities in their
communities than state health
departments
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Public Health Services and Activities
ESSENTIAL SERVICES III: INFORM, EDUCATE, AND EMPOWER PEOPLE ABOUT HEALTH ISSUES
Highlights
• The most common primary prevention activities for Tribal
Health Departments is in the area of chronic disease and
tobacco
• The highest percentage of health screenings provided by
Tribal health Departments is for high blood pressure and
diabetes
• In Urban Indian health Centers, the most common
surveillance activity is chronic disease, followed by
communicable disease and behavioral risk factors.
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Public Health Services and Activities
ESSENTIAL SERVICES III: INFORM, EDUCATE, AND EMPOWER PEOPLE ABOUT HEALTH ISSUES
Prevention
• Prevention activities included in the profile:
–
–
–
–
–
Immunizations
Screening
MCH
General health care (Oral health, Behavioral Health, Substance Abuse)
Primary Prevention (Injury, Chronic Disease, Tobacco, Asthma)
• Tribal Health Departments reported that local health departments
conduct prevention activities in tribal communities more frequently
than do state health departments
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Other Important Topics
• Collaboration
• Administration and Governance
• Ensuring Safety and Regulation
• Access
• Workforce
• Evaluation
• Participation in Health Research
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What’s Working in Tribal Health
Organizations
• Partnerships
– Intergovernmental agreements
– Support from leadership
– Advisory committees or other groups
• Targeted Services
– Partnerships create positive impact
– Cross training provides great understanding
• Quality Improvement
– Plan-Do-Study-Act
– Strategic planning
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What’s Working in Tribal health
Organizations
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Future Directions
Development and resource allocation
•Opportunities to collaborate
•Workforce development
•Defining delivery of public health services
Advocate for resources and policy on behalf of Tribes
•Partnerships with state/local health departments
•Direct funding to tribes
•Access to care
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Future Directions
Assess readiness for tribal public health accreditation
•Self-assessments are an important first step
•Promote local data development/utilization for local health planning
•Tribal Health Orgs. engaging in QI to increase accreditation readiness
Identify technical assistance and quality improvement needs
•Tribal Health Orgs. realizing importance of data use and interpretation
•More resources needed for comm. health assessment/comm. planning
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Tribal Public Health Assessment Results
Contact Information:
Rick Haverkate, MPH
Director of Public Health
[email protected]
Tel (202) 507-4074
Tel.
507 4074
NIHB Website
www.nihb.org
2010 Profile Online
http://www.nihb.org/docs/07012010/NIHB_HealthProfile%202010.pdf
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