Native Americans

Culture and health

Ted Danger, Kyle Mamer, Allen Cogswell, Chad Paisley, Rachel

Stelzer
Personal identification

As of 2009, American Indians and Alaska Natives represent 4.1 million

individuals and 562 federally recognized tribes

· 27% of the 4.1 million individuals are under 18 years old

· From the 562 recognized tribes, the individuals identify as:

o 2.9 million as American Indian (AI)/Alaskan Natives (AN)

o 1.6 million as AI/AN in combination with 1 or more race

(Lettenberger-Klein, Fish, & Hecker, 2013)

Personal Identification

Figure 1. American Indians and Alaskan Natives (AIANs) by identification: 1890-2010.

Adapted from “Joining, leaving and staying in the American Indian Race Category,” by
C. Liebler, R. Bhaskar and S. Porter. 2016, Demography, 53(2), 507-512.
Personal Identification

According to Liebler, Bhaskar & Porter (2016) some of the causes for large
jump in personal identification as AIANs:

· Individuals moving into an area with a large population of American Indians

may make them identify more

· Qualifications can change based on the agency. Example, Census Bureau does
not require tribal enrollment, but some (e.g. The Indian Health Service) do.

· A person with a mestizo identity may be unsure as to what to mark and may
change it over time
Home life

As of 2006, 49% of the 4.1 million individuals lived within the

Western United States

● The largest tribes being the Cherokee and Navajo

Thirty years ago, most AI/AN individuals lived on or near reservations

(Lettenberger-Klein, Fish, & Hecker, 2013)

Family

Nuclear family consists of grandparents, uncles, aunts and cousins but

they use different labels

● The words “brother” and “sister” means siblings, but is also

used for cousins
● There is no distinction made between married and blood
relatives

Non-blood relatives are often considered family and involved in

raising children and passing along traditions
(Lettenberger-Klein, Fish, & Hecker, 2013)
Language and Communication

English or native language indigenous to their tribe (Broome,

B. & Broome, R., 2007)

Use metaphors to describe or explain a situation (Broome, B.

& Broome, R., 2007)

Folktales and stories are embedded in their culture and can be

used to teach as a creative and non-threatening way to relate
to problems (Lettenberger-Klein, Fish, & Hecker, 2013)
Language and Communication

Respect is shown by avoiding intense eye contact (Broome, B.

& Broome, R., 2007)

A loud tone of voice is associated with aggression (Broome, B.

& Broome, R., 2007)

Some Native Americans speak at a much slower pace than you

are used to (Satter, Veiga-Ermert, Burhansstipanov, Pena, &
Restivo, 2005)
Language and Communication

Native Americans choose their words carefully, and are

comfortable with long periods of silence (Flowers, 2005)

There may be a long pause from the time you end your
question and the time they answer it (Satter et al., 2005)
Gift Giving

Gift giving is a sign of respect and honor

The degree to which a person shares his or her wealth is

symbolic of the individual’s worth and not always the financial
value it represents

(Lettenberger-Klein, Fish, & Hecker, 2013)

Customs, Beliefs and Values

Four element that make up each person) (Hodge, Limb, & Cross, 2009)

Spiritual

Body

Mind

Context (Environment)
Four Elements

Spiritual; involves a relationship with the Creator, influenced

by good and bad forces (Hodge, Limb, & Cross, 2009)

Ex. Bad forces are called ghosts, evil spirits, bad

Luck

Body (physical): a combination of age, sleep, nutrition, fitness,

Substance use
Four Elements Continued

Mind (cognitive): memory, intellect, judgement, experience,

affect and personality

Environment/Context: directly shapes people in both

negative ways (trauma, substance abuse, crime) and
positive ways (family and tribal members)
Health and Beliefs

American Indians ascribe to the belief that these four elements are
inseparable (Cross, 2001).

The connected nature of the four elements means that a change in

one will result in a change in another. (Hodge, Limb, & Cross, 2009)
Health and well-being are the result of a combination of spirit, body,
cognitive and emotional state and environment.
Balance and Harmony

Two concepts of wellness:

1. Balance
-Balance in these four areas results in health.
-Balance does not mean fully healthy in all aspects, simply a
balance between good and bad.

2. Harmony: requires work to achieve; a pursuit of positive balance

through discipline, cultural, spiritual and mental practices.
-People in harmony achieve wellness and thrive. Balance adds
and integrates the four elements to understand and promote
wellness (Cross, 2001).
Healing
Interventions for a loss of health and
balance:

Spirit: ceremonies, rituals, dreams, prayer

Body: nutrition, sleep, exercise, recreation

Mind: storytelling, reminiscing, memorials,

remembering

Context: family, elders, culture, traditions

(Hodge, Limb, & Cross, 2009)

Delivery of Health Services

Native Americans have different views of healthcare and

delivery

Traditional vs. Western Medicine

There is more of an integration between the two now than

there was in the past
Traditional Medicine

Native Americans traditionally

use Medicine People or Healers
to diagnose and treat ailments.

Methods used are focused on treating

the mind, body and spirit, as
opposed to just symptoms.
Blessings from the Medicine Man, Howard Terpning
Many techniques used to treat
sickness
Treatment of Disease

Healers have many different ways to treat diseases

“The most common methods include prayer, chanting, music,

smudging - purification with the smoke of sacred herbs -
herbalism, laying on of hands, counseling, and ceremony”
(Cohen, 1998)
Delivery of Health Services - Western Medicine

There have been many laws and reform to health services for Native
Americans

● Synder Act of 1921

● Indian Health Care Improvement Act (IHCIA)
● Affordable Care Act (Ross, et al., 2015)

These acts were pertinent to allocating government funds to Native

American well being and health care
Western Medicine Cont.

Indian Health Services (IHS) is an organization that oversees

the delivery of health services through the IHS, tribally
operated, and urban health clinics (NCAI, 2017).

The IHS covers a vast majority of programs and services

(behavioral health, diabetes management, inpatient and
prenatal health, etc.) (IHS, 2017).
Cultural Considerations in
Assessment
● Respect is shown by avoiding intense eye contact (Broome, B. & Broome,
R., 2007).
○ Avoid direct eye contact, or keep it brief

● A loud tone of voice is associated with aggression (Broome, B. & Broome,

R., 2007) and some Native Americans speak at a much slower pace than
you are used to (Satter, Veiga-Ermert, Burhansstipanov, Pena, & Restivo,
2005).
○ Speak slowly and with less volume than normal

● Native Americans choose their words carefully, and are comfortable with
long periods of silence (Flowers, 2005).
○ Allow them time to express themselves. Wait out their
conversation pauses while they are trying to choose their words.
Cultural Considerations in
Assessment Continued
● They require more personal space, and touch is sometimes unacceptable
unless they know the person well (Flowers, 2005).
○ Give them plenty of personal space.
○ Explain what you are going to do, why you need to do it, and get
permission before making any physical contact.

● They are often very stoic about expressing pain (Flowers, 2005)
○ Watch for nonverbal communication to detect pain, such as
grimacing or holding painful area.
Health Disparities
● Insufficient federal funding
○ Increases in population and medical inflation rates
● Limited access to IHS facilities
○ Availability
■ Travel to distant facilities & delay in treatment as only options
● Geographic isolation
● >538,000 Native Americans living on reservations
○ Accessibility
■ Eligibility requirements for IHS services
● Establishment of economic needs not required
● Concern based on who is “Indian”

(Office of the General Counsel U.S. Commission on Civil Rights, 2004)

 Health Disparities Continued
● Quality of care issues
○ Acceptability
■ Services provided and received are acceptable to recipient
○ Need for “Culturally competent” services
○ Shortages in competent health care staff
■ Vacancy rates 8-23% with high turnover
○ Aging facilities
■ Financial constraints
● Poor access to health insurance
○ Affordability
○ 27% utilize public insurance programs; 25% with no insurance
○ Incomplete CMS regulations
○ Difficult enrollment process

(Office of the General Counsel U.S. Commission on Civil Rights, 2004)

Health Disparities Continued

● Socioeconomic status linked with health

○ Based on income, unemployment rates, enrollment rates for public
benefits
○ Highest poverty rate among all racial groups
■ >25%
■ 5x more likely to have unmet health need
● Education level linked with health
○ Educational attainment levels lower than national average
○ Higher dropout rates
○ Less educated-->more risk factors-->chronic diseases

(Office of the General Counsel U.S. Commission on Civil Rights, 2004)

Question 1

Which of these acts were instrumental to providing federal funding to Native Americans for health
wellness? (Select all that apply)

a. Affordable Care Act

b. American’s with Disabilities Act
c. Synder Act of 1921
d. Indian Health Care Improvement Act
e. Freedom of Information Act
Question 2

Access to health care is based on what major factors? (Select all that apply)

a. Affordability
b. Accessability
c. Acceptability
d. Availability
e. All of the above
Question 3

Native Americans' concept of health model includes four elements: Spirit, Mind, Body and ________.
Select the last element.

a. Beliefs
b. Family
c. Environment
d. Success
Question 4

Which of these is not a way Native Americans communicate?

a. Using metaphors
b. Speaking loudly
c. Avoiding eye contact
d. English or tribal language
Question 5

What is one thing that should be done when performing an assessment on Native Americans?

a. Speak louder than normal

b. Keep physical contact to a minimum
c. Maintain good eye contact while speaking with them
d. Quickly repeat the question if they don’t answer right away
 References
Broome, B., & Broome, R. (2007). Native Americans: Traditional healing. Urologic Nursing, 27(2),
161-163

Cohen, K. (1998, November). Native american medicine. Alternative

Therapies in Health and Medicine, 4(6), 45-57. Retrieved from
http://search.proquest.com.ezproxy.usd.edu/docview/204813987/fulltextPDF/4C63C4B98B4D40
CEPQ/1?accountid=14750

Cross, T. (2001). Spirituality and mental health: a native american perspective. Focal Point,
15(2), 37-38.

Flowers, D. L. (2005). "Culturally-competent nursing care for American Indian clients in a critical
care setting." Crit Care Nurse 25(1): 45-50.
 References

Hodge, D., Limb, G., & Cross, T. (2009, July). Moving from colonization toward balance and
harmony; a native american perspective on wellness. Social Work, 54(3), 211-219.

Indian Health Service. (2017). https://www.ihs.gov/forpatients/healthcare/

Lettenberger-Klein, C. G., Fish, J. N., & Hecker, L. L. (2013). Cultural competence when working
with American Indian populations: A couple and family therapist perspective. The American Journal
of Family Therapy, 41, 148-159. https://doi.org/10.1080/01926187.2012.665273

Liebler, C., Bhaskar, R., & Porter (nee Rastogi), S. (2016). Joining, leaving and staying in the
American Indian/Alaska native race category between 2000 and 2010. Demography, 53(2),
507-540. doi: http://dx.doi.org.ezproxy.usd.edu/10.1007/s13524-016-0461-2

National Congress of American Indians. (2017).

http://www.ncai.org/policy-issues/education-health-human-services/health-care
 References

Office of the General Counsel U.S. Commission on Civil Rights. (2004). Native American Health
Care Disparities Briefing [Executive Summary]. Retrieved from
https://www.law.umaryland.edu/marshall/usccr/documents/nativeamerianhealthcaredis.pdf

Ross, R., Garfield, L., Brown, D., & Raghavan, R. (2015, November). The affordable care act and
implications for health care services for american indian and alaska native individuals. Journal
of Health Care for the Poor and Underserved, 26(4), 1081-1088.
http://dx.doi.org/10.1353/hpu.2015.0129

Satter, D. E., Veiga-Ermert, A., Burhansstipanov, L., Pena, L., & Restivo, T. (2005).
"Communicating respectfully with American Indian and Alaska natives: lessons from the California
Health Interview Survey." J Cancer Educ 20(1): 49-51.

Terpning, H. (n.d.). Blessing from the Medicine Man [Digital Image]. Retrieved from
http://www.greenwichworkshop.com/details/default.asp?p=1720&t=4