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Health Care Beliefs and Practices Among Native American Patients

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Health Care Beliefs and ... Also, translation of written material ... Not until 1934 and the passing of the Indian Reorganization Act by Congress were Indians ... – PowerPoint PPT presentation

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Title: Health Care Beliefs and Practices Among Native American Patients


1
Health Care Beliefs and Practices Among Native
American Patients
  • Presented by
  • Rick Haverkate, MPH
  • Director of Public Health
  • Michigan Inter-Tribal Council
  • Sault Sainte Marie, Michigan

2
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

3
(No Transcript)
4
  • Learning Objectives

5
  • 1. Describe the unique relationship between
    American Indian/Alaska Native and the United
    States government.

6
  • 2. Develop awareness of the importance of the
    historical context in the lives of todays
    American Indians and Alaska Natives.

7
  • 3. List the top five causes of death for American
    Indian/Alaska Natives, and how they might be
    affected by culturally appropriate prevention
    programs.

8
  • 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.

9
  • 5. Describe strategies for the development of
    culturally appropriate verbal and non-verbal
    communication skills with American Indian/Alaska
    Native and their families.

10
  • 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.

11
  • Introduction and Overview

12
  • 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.

13
  • There are at least 558 different federally
    recognized tribes/nations and 126 tribes/nations
    applying for recognition.

14
  • There are now more people who identify themselves
    as Indian in urban areas (62) than on
    reservations and other rural areas.

15
  • 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.

16
The Influence of Historical Experiences on
Todays Indian
  • The Boarding School Experience

17
  • The Nixon administration pushed through the
    Indian Self-Determination and Education Act of
    1975, with the ultimate goal of self-sufficiency.

18
  • 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.

19
  • 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.

20
  • The term medicine is often used to denote
    actions, traditions, ceremony, remedies, or other
    forms of prayer or honoring the sacred.

21
  • Healing is considered sacred work and in many
    Indian traditions cannot be effective without
    considering the spiritual aspect of the
    individual.

22
  • Many contemporary Indians use white mans
    medicine to treat white mans diseases.

And use Indian medicine to treat Indian
problems.
23
Terminology
  • Native American
  • American Indian
  • North American Native
  • Indigenous

24
  • 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.

25
  • The U.S. Census category includes anyone who
    self-identifies as Indian.

26
  • The term Indian country refers to all
    reservation lands (there are 278 federally
    recognized reservations).

27
  • Indian Country is also
  • considered a state of mind.

28
  • 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.

29
  • 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.

30
  • Patterns of Health Risk

31
  • The primary source for AI/AN health data is the
    Indian Health Service.

32
  • Collected only from eligible (tribally enrolled,
    living on-or-near reservation of federally
    recognized tribes) members, who actually utilize
    I.H.S. services.

33
  • 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.

34
  • 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.

35
  • Prevalence rates vary widely, especially in
    I.H.S. data, from service area to service area,
    and by tribal affiliation.

36
  • 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.

37
  • Excess deaths are reported among older American
    Indians for tuberculosis, diabetes, pneumonia,
    and cirrhosis.

38
  • Morbidity and Functional Status

39
  • Alcohol Abuse

40
  • 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.

41
  • Culturally Appropriate Care

42
  • Cultural values affect behavior, attitudes, and
    beliefs about health care and treatment, as well
    as expectations of health care providers.

43
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
44
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)
45
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
46
  • Culturally Appropriate Care

47
  • 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.

48
  • 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.

49
  • Questions should be adapted to age and
    acculturation level.
  • Important for the health care provider to slow
    down when communicating with an Indian.

50
  • Questions should be carefully framed to convey
    the message of caring, not indicate idle
    curiosity about the culture or cultural practices.

51
  • 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

52
  • 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

53
  • Language Assessment

54
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
55
  • Domains of assessment

56
  • Client background
  • World view, life experiences, current status
    affected by
  • - Geographic Location of Birth
  • - Boarding School
  • - Tribal Affiliation
  • - Level of Acculturation
  • - Military Service

57
  • 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

58
  • 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

59
  • 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.

60
  • Explanatory Models of Illness
  • The importance of exploring beliefs concerning
    the causes and treatment of illness with the
    individual cannot be overstated.

61
  • 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?

62
  • 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?

63
  • EXAMPLES OF AMERICAN INDIAN/ALASKA NATIVE
    EXPLANATORY MODELS FOR ILLNESS

64
  • 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.

65
  • Illness is caused by an imbalance in the
    patients spiritual, emotional, and social
    environment.

66
  • 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.

67
  • Illness is caused by the stress on Indians of
    trying to live in two worlds at one time.

68
  • Culturally Appropriate Care Prevention and
    Treatment

69
  • 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.

70
  • It is important to emphasize the importance of a
    detailed history.

71
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

72
  • Literacy level should be assessed

73
  • Cultural nuance can influence the meaning of
    words
  • Some Indian cultures do not speak of death,
    dying, or of negative outcomes

74
  • Ample time should be given for consideration of
    information given
  • Consultation with other persons in the AI
    community

75
  • 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

76
  • 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

77
  • 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
78
  • Many AI will take Indian medicine concurrently
    with Western pharmaceutical medicines
  • Indian medicine considers the individuals
    spiritual, emotional, mental, physical, and
    relationship state

79
  • 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
80
  • Coordinating Biomedical and Traditional Therapies

81
  • 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.

82
  • 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

83
  • 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

84
  • Acceptability
  • Culturally incongruent treatment
  • Cultural differences in modesty
  • Lack of Respect
  • Long clinic waits
  • No Desire of handouts

85
  • 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.

86
  • From the Native American perspective, medicine is
    more about healing the person than curing a
    disease.

87
  • 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.

88
  • Medical mistrust among Native Americans hinders
    the success of even the most well-planned health
    program.

89
  • 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.

90
  • There is a sentiment by Native Americans that
    providers are prejudiced against them.

91
  • Some key practices include one-to-one outreach,
    involvement of the provider and tribal community,
    and practicing cultural competency.

92
  • Healthcare navigator is familiar with tribal
    customs and can help encourage screening in a way
    that is culturally sensitive.

93
  • Increasing cultural competency among healthcare
    providers.

94
  • Cultural orientations on different topics
    creation of an environment for health care that
    reflects local culture in its architecture,
    galleries, gardens, and walking trails.

95
  • Cooperative medical teams of Western doctors and
    traditional healers.

96
  • Medical practitioners should work with tribes to
    develop and distribute culturally sensitive
    information about screening through tribally
    affiliated one-to-one healthcare navigator
    programs.

97
Megwitch
Contact Information Rick Haverkate,
MPH Director of Public Health Michigan
Inter-Tribal Council RickH_at_itcmi.org www.itcmi.org
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