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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 1 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. 2 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. 3 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 4 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. 5 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. 6 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 7 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). 8 “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. 9 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. 10 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. 11 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 12 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) 13 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 14 • 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. 15 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 16 From the Native American perspective, medicine is more about healing the person than curing a disease. 17 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 1 • 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 2 3 1 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 4 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 5 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%) 6 2 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 7 Tribal Health Organization Characteristics Participants 8 Tribal Health Organization Characteristics Participants 9 3 Tribal Health Organization Characteristics Tribal Health Departments 10 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 11 Community Health Assessments and Planning ESSENTIAL SERVICES I: MONITOR HEALTH STATUS TO IDENTIFY COMMUNITY HEALTH PROMOTION 12 4 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 13 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. 14 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 15 5 Other Important Topics • Collaboration • Administration and Governance • Ensuring Safety and Regulation • Access • Workforce • Evaluation • Participation in Health Research 16 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 17 What’s Working in Tribal health Organizations 18 6 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 19 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 20 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 21 7