Taking Care of Home: EvidenceInformed 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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Education,
Mentorship,
Retention
Opportunity,
Research,
Recruit
One Sky
Center
Training,
Consultation,
Technical
Assistance
Excellence
Tribal
Leadership
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Definition:
Indigenous
Knowledge
• 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 life’s needs.
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Definitions:
Traditional Medicine
• The sum total of health knowledge,
skills and practices based upon
theories, beliefs and experiences
indigenous to different cultures…used in
the maintenance of health.
WHO 2002
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Goals for Today
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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
1491
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
1.
2.
3.
4.
5.
6.
7.
8.
Alcoholism 6X
Tuberculosis 6X
Diabetes 3.5 X
Accidents 3X
Poverty 3x
Depression 3x
Suicide 2x
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
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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
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•
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ALL CAUSES
953.7
Alcohol induced
45.0
Diabetes
65.6
Homicide (assault)
11.0
Infant Deaths
7.3
Maternal Deaths
20.2
Pneumonia/Influenza 24.3
Suicide
19.0
Uninten. Injuries*
94.8
776.5
6.9
23.3
6.0
6.7
13.3
17.8
10.9
39.8
Ratio
1.2
6.5
2.8
1.8
1.1
1.5
1.4
1.7
2.4
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Death Rates Attributed to
Alcoholic Liver Disease
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Major AI/AN Health Disparities
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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
16
5.3
5.3
6.3
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Suicide Among ages 15-17, 2001
Death rate per 100,000
16
14
12
10
8
6
4
2010
Target
2
00
Total
Females Males
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
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-cultural
Socioeconomic
Biological
Science
&
Technology
Aging
Health
Behavioral
Education
Gender
Environmental
Human
Rights
Social
Justice
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Role of Inequities in Healthcare
Simulation :Estimated % Contribution to Health Disparity
other
5%
genes
3%
poverty
25%
racism
15%
Adapted from V. Hogan
health care
10%
behaviors
20%
culture
10%
environment
15%
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Childhood Mortality Versus Wealth
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Poverty Rate
Percentage of Persons in Poverty: Race
U.S. Census 2006
SAT Scores by Income
Family Income
Median Score
More than $100,000
$80,000 to $100,000
1129
1085
$70,000 to $80,000
$60,000 to $70,000
$50,000 to $60,000
$40,000 to $50,000
$30,000 to $40,000
1064
1049
1034
1016
992
$20,000 to $30,000
$10,000 to $20,000
Less than $10,000
964
920
873
Source: (ETS) Mantsios; N=898,596
DETERMINANTS OF HEALTH:
RACE AND ETHNICITY
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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
A. Give every child the best start in life
B. Enable all children, young people and adults to
maximize their capabilities and have control over
their lives
C. Create fair employment and good work for all
D. Ensure healthy standard of living for all
E. Create and develop healthy and sustainable places
and communities
F. Strengthen the role and impact of ill health
prevention
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
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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
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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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Practice
(Service)
Best
Practice
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
Science &
Scholarship
4/13/2015
Using the OPRE Review
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Community Based Logic Model
1. Causes
8. Long term
(Impact)
Goals
7. Medium term
2.
6. Short term
Outcomes
Target
Population
5. Operations Manual
4. Theory of Change
3. Strategy
4/13/2015
Intervention
Using the OPRE Review
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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 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
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Six Key Principles
Evidence-based Predictors of Change
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Leadership
Mobilization Community driven
Public health approach
Strength based
Culturally informed
Proactive
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Let’s
Make a
Difference!
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Contact us at
503-970-7895
E-mail
Dale Walker, MD
walkerrd@ohsu.edu
Or visit our website:
www.oneskycenter.org
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