Health Care Beliefs and Practices Among Native American Patients

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Health Care Beliefs and PracticesAmongNative
American Patients

• Presented by
• Rick Haverkate, MPH
• Director of Public Health
• Michigan Inter-Tribal Council
• Sault Sainte Marie, Michigan

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I honor the members, staff, and clients from our
Michigan tribes who allow us to work n their
communities and on their behalf

• Grand Traverse Band
• Keweenaw Bay Indian Community
• Hannahville Indian Community
• Lac Vieux Desert Band
• Bay Mills Indian Community
• Little Traverse Bay Bands
• Saginaw Chippewa Indian Tribe
• Match-E-Be-Nash-She-Wish
• Nottawaseppi Band of Huron Potawatomi
• Sault Ste. Marie Tribe of Chippewa Indians
• Pokagon Band of Potawatomi Indians
• Little River Band
• Detroit and Grand Rapids Urban Sites

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• Learning Objectives

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• 1. Describe the unique relationship between
  American Indian/Alaska Native and the United
  States government.

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• 2. Develop awareness of the importance of the
  historical context in the lives of todays
  American Indians and Alaska Natives.

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• 3. List the top five causes of death for American
  Indian/Alaska Natives, and how they might be
  affected by culturally appropriate prevention
  programs.

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• 4. Recognize indicators of conflicting
  expectations and responses to conflicting values
  of the American Indian/Alaska Native and the
  Euro-American value based health care system.

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• 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.

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• Introduction and Overview

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• 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.

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• 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.

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• The lives of todays Indians are likely to have
  been influenced by the history of oppression,
  repression, intergenerational anger, and
  intergenerational grief, experienced since North
  American was colonized by Europeans.

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The Influence of Historical Experiences on
Todays Indian

• The Boarding School Experience

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• The Nixon administration pushed through the
  Indian Self-Determination and Education Act of
  1975, with the ultimate goal of self-sufficiency.

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• The basic tenets of Christianity (love for God
  and fellow man, honor, generosity and sharing,
  compassion, forgiveness, and self-sacrifice for
  the good of the community) were already
  institutionalized in the belief systems of many
  indigenous cultures before the missionization of
  North America.

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• 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, and community were not
  separated, and often the entire community was
  involved in a healing ceremony and in maintaining
  the power of Indian medicine.

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• 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.

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• Many contemporary Indians use white mans
  medicine to treat white mans diseases.

And use Indian medicine to treat Indian
problems.
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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
• That the person must have some identifiable
  Indian ancestry
• That the Indian community must recognize this
  person as an Indian.

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• The U.S. Census category includes anyone who
  self-identifies as Indian.

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• 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.

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• 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.

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• 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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• Patterns of Health Risk

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• The primary source for AI/AN health data is the
  Indian Health Service.

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• Collected only from eligible (tribally enrolled,
  living on-or-near reservation of federally
  recognized tribes) members, who actually utilize
  I.H.S. services.

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• 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.

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• Prevalence rates vary widely, especially in
  I.H.S. data, from service area to service area,
  and by tribal affiliation.

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• These causes of death have implications for the
  health care providers and education.
• MOST ARE PREVENTABLE!
• It could be addressed by culturally congruent
  intervention programs.

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• Excess deaths are reported among older American
  Indians for tuberculosis, diabetes, pneumonia,
  and cirrhosis.

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• Morbidity and Functional Status

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• Alcohol Abuse

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• Contrary to stereotypes, AI/AN men reported lower
  levels of chronic drinking than non-Hispanic
  white men at older ages.
• AI/AN reported less current drinking but about
  the same amount of binge drinking as non-Hispanic
  whites by age and sex.

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• Culturally Appropriate Care

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• Cultural values affect behavior, attitudes, and
  beliefs about health care and treatment, as well
  as expectations of health care providers.

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AMERICAN INDIAN EURO-AMERICAN
Cooperation Competition
Group Harmony Individual Achievement
Modesty and Humility Physical Modesty Not putting ones 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
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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 ones 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 multi-geographical homes with family members Nuclear Family Orientation Natural parents are only valid responsible parties Measure of successful rearing is for children to leave home
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• Culturally Appropriate Care

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• Listening is valued over talking by most older
  AI calmness and humility are valued over speed
  and self-assertion or directiveness.
• Avoiding the invisible patient syndrome, asking
  for the patients help in understanding the
  current situation.

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• Avoiding the invisible patient syndrome, and
  asking for the patients help in understanding
  the current situation and in planning the
  components of further care are important aspects
  of showing respect for the patients experience.

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• Questions should be adapted to age and
  acculturation level.
• Important for the health care provider to slow
  down when communicating with an Indian.

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• Questions should be carefully framed to convey
  the message of caring, not indicate idle
  curiosity about the culture or cultural practices.

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• Conversational pace.
• American Indian languages have some of the
  longest pause time
• Silence is valued, long periods of silence
  between speakers is common
• Interruption of the person who is speaking is
  considered extremely rude

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• Non verbal communication
• Physical distance several feet is usual comfort
  zone
• Eye Contact not direct or only briefly direct,
  gaze may be directed over the shoulder
• Emotional expressiveness may be controlled,
  except for humor
• Body movements minimal
• Touch not usually acceptable except a handshake

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• Language Assessment

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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 Verbal expression of ideas and feelings
Words are chosen carefully and deliberately, as the power of words is understood Verbosity and small talk is appropriate social behavior
Withdrawal used as a form of disapproval (voting with your feet) Direct expression of disapproval
Request given through indirect suggestion Directiveness of requests
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• Domains of assessment

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• Client background
• World view, life experiences, current status
  affected by
• - Geographic Location of Birth
• - Boarding School
• - Tribal Affiliation
• - Level of Acculturation
• - Military Service

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• Clinical Domains
• Health History
• Aggressive/dismissive approach may be damaging
• Reference to a problem that needs fixing by a
  health care provider, should be avoided

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• Physical Examination
• Modesty and privacy are valued
• Loudness and brusque manner are associated with
  aggression
• Permission should be obtained before examination
  of each area, and care taken to keep the body
  covered

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• Problem/Condition Specific Information
• A problem oriented format may be offensive and
  patronizing to many older American Indians as it
  implies a power differential between the health
  care provider (usually a member of the dominant
  society) an the person with the problem.

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• Explanatory Models of Illness
• The importance of exploring beliefs concerning
  the causes and treatment of illness with the
  individual cannot be overstated.

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• Example of questions to elicit the patients
  perspectives include
• What do you think caused your problem?
• Why do you think it started when it did?
• What do you call it?
• What do you think your sickness does to your
  body?
• How does it work?

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• Intervention specific data
• Adaptation of questions to age and cultural
  competence, e.g., How are you and your family
  treating this condition? What kinds of medicines,
  healings, have you tried.
• What type of treatment do you think you should
  receive from me?
• Culturally specific content for specific
  interventions (e.g., dietary/nutritional/food
  preferences, cultural basis for chronic pain
  management)
• Does anyone else need to be consulted?
• Is there any other information that might help us
  design a treatment plan?

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• 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.

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• Illness is caused by an imbalance in the
  patients spiritual, emotional, and social
  environment.

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• Dementia is a condition in which the persons
  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.

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• Culturally Appropriate Care Prevention and
  Treatment

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• 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.

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• It is important to emphasize the importance of a
  detailed history.

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Health Education

• Frequent causes of death for AI/AN are at least
  partially preventable and could be addressed by
  development of culturally congruent education
  programs
• One-on one education with a trained provider,
  rather than written printed materials
• Doing rather than Talking has been a
  traditional way of teaching for many Indians

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• Literacy level should be assessed

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• 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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• Ample time should be given for consideration of
  information given
• Consultation with other persons in the AI
  community

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• After slow and deliberate consideration of
  treatment options, an AI/AN may choose not to
  accept the procedure or treatment
• Use of a cultural guide, or spiritual leader, may
  be helpful

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• Indian tribal beliefs affects the providers
  ability to speak directly about negative outcomes
• Discuss with the family or spokesperson
  situations requiring decisions that have happened
  to others
• Other AI tribal communities have no difficulty
  speaking directly about death or dying.
• They tend to look at death as a natural part of
  the circle of life, not to be feared

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• Sharing of medicines is common within clan groups
  and extended families
• Pharmaceuticals may be stopped by the AI when
  s/he feels better
• Saved to self-medicate if the problem recurs

Medications
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• Many AI will take Indian medicine concurrently
  with Western pharmaceutical medicines
• Indian medicine considers the individuals
  spiritual, emotional, mental, physical, and
  relationship state

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• Many traditional AI/AN were taught to withstand
  pain as a skill for survival
• Older AI/AN may be less likely to ask for pain
  medication and more likely to use internal
  resources to manage pain
• AI/AN are also generally undertreated for chronic
  and acute pain

Chronic Pain Management
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• Coordinating Biomedical and Traditional Therapies

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• Surveyed 150 patients at an urban Indian Health
  Service clinic in Milwaukee, Wisconsin
• 38 were utilizing the services of a healer
• Greater than 1/3 of the patients received
  differing advice from the healer and the
  physician
• More inclined to follow the advice of the healer
• Only 14.8 of this population shared this
  information with their physician.

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• In many urban areas there are no Native American
  healers
• Medicine persons travel long distances when
  called to these areas
• Co-therapy with traditional healers and medicine
  persons or diagnosticians should be encouraged

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• Have the traditional healer participate as a
  member of the interdisciplinary team
• Arrangements may be made for ritual or ceremony
  at the bedside
• Smudging with sage or sweet grass smoke
• Medicine pouches, bundles, or other specific
  items of sacredness and healing, that should not
  be disturbed or touched by health care personnel
  or hospital staff

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• Acceptability
• Culturally incongruent treatment
• Cultural differences in modesty
• Lack of Respect
• Long clinic waits
• No Desire of handouts

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• Native American healing is a broad term that
  includes healing beliefs and practices of
  hundreds of indigenous tribes of North America.
• It combines religion, spirituality, herbal
  medicine, and rituals that are used to treat
  people with medical and emotional conditions.

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• From the Native American perspective, medicine is
  more about healing the person than curing a
  disease.

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• By promoting cultural competency, community
  involvement, and one-on-one outreach to patients,
  medical mistrust in urban Native American
  populations can be reduced and rates of
  colorectal cancer screening can be improved.

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• Medical mistrust among Native Americans hinders
  the success of even the most well-planned health
  program.

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• Most Indian Health Services (HIS) resources are
  directed towards rural, reservation-bound Native
  Americans, but urban Native Americans are largely
  left without access to preventive healthcare
  coverage.

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• There is a sentiment by Native Americans that
  providers are prejudiced against them.

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• Some key practices include one-to-one outreach,
  involvement of the provider and tribal community,
  and practicing cultural competency.

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• Healthcare navigator is familiar with tribal
  customs and can help encourage screening in a way
  that is culturally sensitive.

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• Increasing cultural competency among healthcare
  providers.

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• Cultural orientations on different topics
  creation of an environment for health care that
  reflects local culture in its architecture,
  galleries, gardens, and walking trails.

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• Cooperative medical teams of Western doctors and
  traditional healers.

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• Medical practitioners should work with tribes to
  develop and distribute culturally sensitive
  information about screening through tribally
  affiliated one-to-one healthcare navigator
  programs.

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Megwitch
Contact Information Rick Haverkate,
MPH Director of Public Health Michigan
Inter-Tribal Council RickH_at_itcmi.org www.itcmi.org