Taking Care of Home: Evidence-Informed Culture-Based Interventions and Best Behavioral Health Practices in Native Communities

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Taking Care of Home Evidence-Informed
Culture-Based Interventions and Best Behavioral
Health Practices in Native Communities

• One Sky Center
• R Dale Walker, MD, Anne Helene Skinstad, PhD, and
  Patricia Silk Walker, PhD
• Oklahoma Department of Mental Health Substance
  Abuse Services
• and National Health Conference
• Nov 6, 2014 Oklahoma City, Oklahoma

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Native Communities
Advisory Council / Steering Committee
Opportunity, Research, Recruit
Education,
Mentorship, Retention
One Sky Center
Training, Consultation, Technical
Assistance
Excellence
Tribal Leadership
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Indigenous Knowledge
Definition

• Local knowledge unique to a given culture or
  society it has its own theory, philosophy,
  scientific and logical validity, used as a basis
  for decision-making for all of lifes needs.

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Traditional Medicine
Definitions

• The sum total of health knowledge, skills and
  practices based upon theories, beliefs and
  experiences indigenous to different culturesused
  in the maintenance of health.
• WHO 2002

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Goals for Today

• Review Native Health Circumstances
• Explain Culture Based Interventions
• Explore Social Determinants of Health
• Discuss Human Development Index
• A Little Surprise
• Review Native Mentorship Opportunities
• Advocacy Getting the Job Done

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Who are indigenous peoples?

• Indigenous peoples remain on the margins of
  society they are poorer, less educated, die at a
  younger age, are much more likely to commit
  suicide, and are generally in worse health than
  the rest of the population."
• (Source The Indigenous World 2006,
  International Working Group on Indigenous Affairs
  (IWGIA) WHO

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INDIGENOUS PEOPLE WORLD
MAP - 370 million indigenous peoples living in
more than 70 countries
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• Geography Where we live, how we live
• Identity How we define who we are
• Stereotypes How we have been defined by others
  through the years
• Disparity, Morbidity, Mortality

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Early Human Migrations
1st Migration, 38,000-1800 BCE 2nd Migration, c.
10,000-4,000 BCE 3rd Migration, c. 8,000-3,000 BCE
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CULTURE AREAS OF NATIVE AMERICANS
1491
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American Indian/Alaskan Native
As a Percentage of the total population
GEOGRAPHY Population Growth and Resettlement
Means that in Addition to the Federal Government,
We Now Must Work With States, Counties, and
Cities to get Our Health and Education Needs Met
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Projective Negative Stereotyping
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Native Healthcare Appropriations Compared to
Other Federal Health Expenditures, 2006
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Native Health Morbidity Disparity

• Alcoholism 6X
• Tuberculosis 6X
• Diabetes 3.5 X
• Accidents 3X
• Poverty 3x
• Depression 3x
• Suicide 2x
• Violence?

• Same disorders as general population
• Greater prevalence
• Greater severity
• Much less access to Tx
• Cultural relevance more challenging
• Social context disintegrated

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American Indian/Alaska Native Admissions, by
Gender, Primary Substance, and Age 2009
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Mortality Rates Disparity

• AI/AN ALL
  Ratio
• ALL CAUSES 953.7 776.5 1.2
• Alcohol induced 45.0 6.9 6.5
• Diabetes 65.6 23.3
  2.8
• Homicide (assault) 11.0 6.0
  1.8
• Infant Deaths
  7.3 6.7 1.1
• Maternal Deaths 20.2 13.3 1.5
• Pneumonia/Influenza 24.3 17.8
  1.4
• Suicide 19.0 10.9
  1.7
• Uninten. Injuries 94.8 39.8
  2.4

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Death Rates Attributed to Alcoholic Liver Disease
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Major AI/AN Health Disparities

• Chronic Diseases
• Infant Mortality
• Sexually Transmitted Diseases (STDs)
• Injuries
• Obesity
• Mental Health
• Substance Abuse

Source OMHD CDC http//www.cdc.gov/omhd/Brochures
/PDFs/1PAIAN.pdf
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Rates of Suicide by Race 2010
17.3
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6.3
5.3
5.3
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Suicide Among ages 15-17, 2001
Death rate per 100,000
2010 Target
Females
Males
Total
American Indian
White
Black
Hispanic
Asian
Source National Vital Statistics System -
Mortality, NCHS, CDC.
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Prescribing Psychotropic Meds
Mark T, et al. Psych Mark T, et al. Psychotropic
drug prescriptions by medical specialty.
Psychiatric Services (2009). Vol 60. No 9. p. 1167
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Survey.

• Have you ever directly asked someone if he/she
  was thinking about ending his/her life?
• Yes
• No

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Causes of Health Disparities

• 1. Limited Access
• IHS Eligibility
• Direct/Tribal/Urban
• Direct Delivery
• Tribal Health
• Urban Indian Health
• Contract Health Services Program
• 2. Poor Access to Health Insurance
• Social and Cultural Factors
• Procedural Factors
• Collection Factors

• 3. Insufficient Federal Funding
• 4. Quality of Care Issues
• Ability to Recruit and Retain Health Providers
• Accreditation Status
• Importance of .Culturally Competent. Health
  Services
• Problem of Aging Facilities
• 5. Disproportionate Poverty
• and Poor Education

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Social Determinates of Health Whitehall Studies

• Within a hierarchical society, there is a social
  gradient for morbidity and mortality. (Poverty,
  sanitation, nutrition, and shelter are
  controlled.)
• Higher status folks live longer and healthier.
• Health Care Improvement Needs More Than Money
• Opportunity, Empowerment, Security, Control, and
  Dignity.

www.thelancet.com Dec 9, 2006. Marmot Amartya
Sen 1998 Nicholas Stern 2004
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• .

Socio- economic
Socio-cultural
Science Technology
Health
Biological
Aging
Education
Behavioral
Gender
Environmental
Social Justice
Human Rights
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Role of Inequities in Healthcare
Adapted from V. Hogan
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Childhood Mortality Versus Wealth
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Percentage of Persons in Poverty Race
Poverty Rate
U.S. Census 2006
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SAT Scores by Income
Family Income Median Score
More than 100,000 1129
80,000 to 100,000 1085
70,000 to 80,000 1064
60,000 to 70,000 1049
50,000 to 60,000 1034
40,000 to 50,000 1016
30,000 to 40,000 992
20,000 to 30,000 964
10,000 to 20,000 920
Less than 10,000 873
Source (ETS) Mantsios N898,596
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DETERMINANTS OF HEALTH RACE AND ETHNICITY

• Economic
• Political
• Social
• Educational
• Employment
• Income
• Access to health care

• Environment
• Law Enforcement / Justice
• Home
• Colonialism as a Broader Social Determinant of
  Health

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Fair Society Healthy Lives Six Policy
Objectives

• Give every child the best start in life
• Enable all children, young people and adults to
  maximize their capabilities and have control over
  their lives
• Create fair employment and good work for all
• Ensure healthy standard of living for all
• Create and develop healthy and sustainable places
  and communities
• Strengthen the role and impact of ill health
  prevention

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Human Development Index
NOTICE The 2014 Human Development Report
'Sustaining Human Progress Reducing
Vulnerabilities and Enhancing Resilience' will be
launched on 24 July in Tokyo at 2 PM Tokyo (GMT
9)
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Measures of Well Being by Race
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Selected International Human Development Index
Scores 2001

• 1 Norway .944
• 2 Iceland .942
• 3 Sweden .941
• 4 Australia .939
• 5 Netherlands .938
• 6 Belgium .937
• 7 United States .937
• 8 Canada .937

• 20 New Zealand .917
• 23 Portugal .896
• 30 South Korea .879
• 31 U.S. American Indian and Alaska Native .877
• 32 Czech Republic .861
• 33 Canadian Aboriginal

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What are some promising strategies?
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• Culture Values
• Philosophies
• Belief about causes of problems and solutions
• Local innovation, trial and error
• Medicinal use of wild plants and minerals
• Healing procedures
• Oral transmission of knowledge
• Community evaluation and acceptance

Practice (Service)
Best Practice
Science Scholarship
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Community Based Logic Model
8. Long term (Impact)
7. Medium term
6. Short term
5. Operations Manual
4. Theory of Change
3. Strategy
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Key Activities in a Technology Needs Assessment

• Community input, tribal history early and
  recent. Their theory of cause and solutions. Not
  there to stop problem but help them. Establish
  Cultural Alignment.
• Work in partnership with community
  towards assessment. Build team across community
  systems School, Legal, Health.
• Identify best fit of technology with
  community. Indianize or use a traditional
  approach
• Deliver continued contact with
  involvement of community leaders. Ceremony as a
  part of success. Build the story
• Continuously develop outreach and build
  knowledge. Tribe begins to own new theories of
  causes and
• solutions.
• Disseminate to other tribes and
  communities. Center of opportunity becomes a
  center of excellence.

Hay, 2003
Walker, 2013
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The Wharerata Declaration

• 1. Indigeneity
• 2. Best / Wise Practice
• 3. Best / Wise Evidence
• 4. Indigenous Leadership
• a. Informed d. Connected
• b. Creditable e. Sustainable
• c. Strategic
• 5. Indigenous Leadership Influence

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Six Key PrinciplesEvidence-based Predictors of
Change

• Leadership
• Mobilization Community driven
• Public health approach
• Strength based
• Culturally informed
• Proactive

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Lets Make a Difference!
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Contact us at 503-970-7895 E-mail Dale Walker,
MD walkerrd_at_ohsu.edu Or visit our
website www.oneskycenter.org
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