The Importance of Culture Based Intervention as a Critical Element of Evidence Based Medical Care One Sky Center 20 th Annual AAIP Cross Cultural Medicine Workshop R Dale Walker, MD Patricia Silk Walker, Ph. D Michelle Singer April 27, 2012 Santa Fe, New Mexico
The News You've All Been Waiting to Hear. . . AAIP 41 st Annual Meeting Anchorage: July 31 – August 5, 2012 Let the Party Begin! 2
Education, Mentorship, Retention Opportunity, Research, Recruit One Sky Center Training, Consultation, Technical Assistance Excellence Tribal Leadership 3
Goals for Today • • Review An Environmental Scan for Natives Discuss Fragmentation and Integration Present Some Behavioral Health Care Issues Present Examples of Cultural Based Treatment and Prevention • Define Social Determinants of Health • Summarize Critical Issues for Native Peoples • Native Mentorship 4
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 5
INDIGENOUS PEOPLE WORLD MAP - 370 million indigenous peoples living in more than 70 countries 6
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American Indian/Alaskan Native As a Percentage of the total population 9
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Native Healthcare Resource Disparities 12
Agencies Involved in B. H. Delivery 1. Indian Health Service (IHS) A. Mental Health B. Primary Health C. Alcoholism / Substance Abuse 2. Bureau of Indian Affairs (BIA) A. Education B. Vocational C. Social Services D. Police 3. Tribal Health 4. Urban Indian Health 5. State and Local Agencies 6. Federal Agencies: SAMHSA, VAMC, Justice 13
Different goals Resource silos One size fits all Activitydriven How are we functioning? (Carl Bell and Dale Walker 7/03) 14
Outcome Culturally Driven Specific Integratin Best g Practice Resource s We need Synergy and an Integrated System 15
Recession Worsens Racial Wealth Gap
Who Rules America? Wealth, Income, and Power. Net Worth Financial Wealth
Behavioral Health Care Issues 18
Native Health Issues 1. 2. 3. 4. 5. 6. 7. 8. Alcoholism 6 X Tuberculosis 6 X Diabetes 3. 5 X Accidents 3 X Poverty 3 x Depression 3 x Suicide 2 x Violence? 1. Same disorders as general population 2. Greater prevalence 3. Greater severity 4. Much less access to Tx 5. Cultural relevance more challenging 6. Social context disintegrated 19
Adult Serious Mental Illness By Race/Ethnicity: 2001 SAMHSA Office of Applied Studies, 2001 20
Suicide Among ages 15 -17, 2001 Death rate per 100, 000 2010 Target 0 Total an ic k ric n ian an e ia s lac p s B Am Ind A Hi W te hi Females. Males Source: National Vital Statistics System - Mortality, NCHS, CDC. 21
Mental Illness: A Multi-factorial Event Psychiatric Illness & Stigma Edu. , Econ. , Rec. Cultural Distress Impulsiveness Substance Use/Abuse Family Disruption/ Domestic Violence Individual Negative Boarding School Historical Trauma Hopelessness Family History Psychodynamics/ Psychological Vulnerability Suicidal Behavior 22
Models of Care 23
The IOM Quality Report: Selected Quotes • “The current care systems cannot do the job. ” • “Trying harder will not work. ” • “Changing care systems will. ” 24
Chronic Care Model Community Resources and Policies Self. Management Support Informed, Activated Patient Health System Health Care Organization Delivery System Design Productive Interactions Decision Support Clinical Information Systems Prepared, Proactive Practice Team Functional and Clinical Outcomes
A Broader Picture of Health Ø Ø Ø Personal Health Family Health Community Health Public Health Population Health Transparency of Data Patient community Sharing information: demographics, environment, population data, and health conditions
Practice (Service) Best Practice Science & Scholarship 3/19/2018 Culture Values ØPhilosophies ØBelief about causes of problems and solutions ØLocal innovation, trial and error ØMedicinal use of wild plants and minerals ØHealing procedures ØOral transmission of knowledge ØCommunity evaluation and acceptance Using the OPRE Review 27
Community Based Logic Model 1. Causes 8. Long term (Impact) 7. Medium term Goals 2. 6. Short term Outcomes Target Population 5. Operations Manual 4. Theory of Change 3. Strategy 3/19/2018 Intervention Using the OPRE Review 28
Domains Influencing Behavioral Health: A Native Ecological Model Risk Individual Protection Peers/Family Community/Tribe Society/Cultural 29
Individual Intervention • Identify risk and protective factors counseling skill building improve coping support groups • Increase community awareness • Access to hotlines other help resources 30
Effective Interventions for Adults • • • Cognitive/Behavioral Approaches Motivational Interventions Psychopharmacological Interventions Modified Therapeutic Communities Assertive Community Treatment Vocational Services Dual Recovery/Self-Help Programs Consumer Involvement Therapeutic Relationships 31
Culture-Based Interventions • • • Story telling Sweat Lodge Talking circle Vision quest Wiping of tears Drumming Smudging Traditional Healers Herbal remedies Traditional activities 32
What are some promising strategies? 33
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 34
. Socio-cultural Socioeconomic Biological Science & Technology Aging Behavioral Health Education Gender Environmental Human Rights Social Justice
The Social Determinants of Health • The conditions in which people are born, grow, live, work and age. • Shaped by the distribution of money, power and resources at global, national and local levels. • Are mostly responsible for health inequities the unfair and avoidable differences in health status seen within and between countries. 36 WHO Commission on Social Determinants of Health | August 28 2008
Conceptual Framework of Health Determinants 37
Critical Elements for Native Peoples • • • Self determination Ecology and environment Economic prosperity, fairness and equity Leadership and capacity strengthening Racism / dominance / imperialism Healing, services, systems, structures Cultural sustainability, protection, stewardship Land Human rights 38
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 39
ACHIEVING A BRIGHTER FUTURE FOR TRIBAL NATIONS 2011 White House Tribal Nations Conference 1. Creating Jobs and Growing Tribal Economies 2. Promoting Safe and Strong Tribal Communities 3. Protecting Natural Resources and Respect for Cultural Rights 4. Improving Access to Healthcare, Education, Housing, Infrastructure and Other Federal Services 5. Strengthening the Government-to-Government Relationship http: //www. whitehouse. gov/sites/default/files/2011 whtnc_report. pdf 40
An Ideal Intervention • Broadly based: Includes individual, family, community, tribe, and society • Comprehensive: Prevention: Universal, Selective, Indicated Treatment Maintenance • Addresses opportunity, empowerment, security, dignity 41
Native Partnered Collaboration State/Federal Grassroots Groups Community-Based Organizations Education-Treatment-Research OHSU 42
Six Key Principles Evidence-based predictors of change • • • Leadership Mobilization Community driven Public health approach Strength based Culturally informed Proactive 43
The Wharerātā 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 44
Areas for Action Health Equity in all Policies Good Governance Fair Financing Responsibility Early child development and education Healthy Places Fair Employment Social Protection Universal Health Care Political empowerment – inclusion and voice Gender Equity
NIDA Native Mentorship Mentors: 17 Mentees: 21
Contact us at 503 -494 -3703 E-mail Dale Walker, MD onesky@ohsu. edu Or visit our website: www. oneskycenter. org 47
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