MICHIGAN INTER-TRIBAL COUNCIL Health Care Beliefs and Practices Among Native American Patients Presented by: Rick Haverkate, MPH Director of Public Health

MICHIGAN INTER-TRIBAL COUNCIL

Health Care Beliefs and PracticesAmong

Native American Patients

Presented by:Rick Haverkate, MPH

Director of Public HealthMichigan Inter-Tribal CouncilSault Sainte Marie, Michigan


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 CommunityHannahville Indian Community

Lac Vieux Desert BandBay Mills Indian CommunityLittle Traverse Bay Bands

Saginaw Chippewa Indian TribeMatch-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


Learning Objectives


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 American Indians and Alaska Natives.


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


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.


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


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.


• Introduction and Overview


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.


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, and intergenerational grief, experienced since North American was colonized by Europeans.


The Boarding School Experience


The Influence of Historical Experiences on Today’s

Indian

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


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.


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.”


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


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 AmericanAmerican IndianNorth American NativeIndigenous


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 ancestry2. 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).


“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.


Patterns of Health Risk


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.


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, from service area to service area, and by tribal affiliation.


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.


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


Morbidity and Functional Status


Alcohol Abuse


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.


Culturally Appropriate Care


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


AMERICAN INDIAN EURO-AMERICAN

Cooperation Competition

Group Harmony Individual Achievement

Modesty and HumilityPhysical ModestyNot putting one’s self forwardNon-attention seeking behavior (expect in sports)

Overt identification of accomplishments Physical exhibition

Non-Interference Advice giving, directiveness“Counseling” and “Educating”

Silence is valuedAbility to listen and wait

Points made by aggressive verbal behavior, expression of opinion



Emotional ControlContemplationNon-demonstration of anger or other strong emotion

Action over inactionDirect confrontationDirect expression of anger

Indifference toward future planningSaving for one’s own benefit not acceptedPlanning for future generations lost with the landThe future, if there is one, “will take care of itself”Time orientation to the “present”

Saving for the future(Insurance, retirement, savings account)



Indian TimeNon-linear, relative to the activity at hand, flexible

Eurocentric obsession with time, “time is money”

Extended Family OrientationAunts and uncles considered as mothers and fathersGrandparents traditionally parentedFamily members often “kept” by other relatives with no disruption of a family unitMulti-generational and multi-geographical “homes” with family members

Nuclear Family OrientationNatural parents are only valid responsible partiesMeasure of successful rearing is for children to “leave home”


Culturally Appropriate Care


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 patient’s help in understanding the current situation.


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


Questions should be adapted to age and acculturation level.

Important for the health care provider to slow down when communicating with an Indian.


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


Conversational pace.American Indian languages have some of

the longest pause timeSilence is valued, long periods of silence

between speakers is commonInterruption of the person who is speaking

is considered extremely rude


Non verbal communicationa)Physical distance: several feet is usual

comfort zoneb)Eye Contact: not direct or only briefly direct,

gaze may be directed over the shoulderc) Emotional expressiveness: may be

controlled, except for humord)Body movements: minimale)Touch: not usually acceptable except a

handshake


Language Assessment



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


Domains of assessment


Client background

World view, life experiences, current status affected by:

- Geographic Location of Birth- Boarding School- Tribal Affiliation- Level of Acculturation- Military Service


Clinical Domains

Health HistoryAggressive/dismissive approach may

be damaging

Reference to “a problem” that needs fixing by a health care provider, should be avoided


Physical ExaminationModesty and privacy are valuedLoudness and brusque manner are

associated with aggressionPermission should be obtained before

examination of each area, and care taken to keep the body covered


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”.


Explanatory Models of IllnessThe importance of exploring beliefs

concerning the causes and treatment of illness with the individual cannot be overstated.


Example of questions to elicit the patient’s 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?


• Intervention specific dataa)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.

b)What type of treatment do you think you should receive from me?

c) Culturally specific content for specific interventions (e.g., dietary/nutritional/food preferences, cultural basis for chronic pain management)

d)Does anyone else need to be consulted?e) Is there any other information that might

help us design a treatment plan?


EXAMPLES OF AMERICAN INDIAN/ALASKA NATIVE

EXPLANATORY MODELS FOR ILLNESS


• 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 spiritual, 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.


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


Culturally Appropriate Care: Prevention and Treatment


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.


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


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


Health Education

Literacy level should be assessed


Cultural nuance can influence the meaning of words

Some Indian cultures do not speak of death, dying, or of negative outcomes


Ample time should be given for consideration of information given

Consultation with other persons in the AI community


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


• Indian tribal beliefs affects the provider’s 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


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

Many AI will take Indian “medicine” concurrently with Western pharmaceutical medicines

Indian medicine considers the individual’s spiritual, emotional, mental, physical, and relationship state


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

Coordinating Biomedical and Traditional Therapies


• 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.


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


• 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


Acceptability

Culturally incongruent treatmentCultural differences in modestyLack of RespectLong clinic waitsNo Desire of “handouts”


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.


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


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.


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


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.


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


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


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


Increasing cultural competency among healthcare providers.


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


Cooperative medical teams of Western doctors and traditional healers.


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


Megwitch

Contact Information:

Rick Haverkate, MPHDirector of Public Health

Michigan Inter-Tribal [email protected]

www.itcmi.org


Documents

MICHIGAN INTER-TRIBAL COUNCIL Health Care Beliefs and Practices Among Native American Patients Presented by: Rick Haverkate, MPH Director of Public Health