The Importance of Culture
Based Intervention as a Critical
Element of Evidence Based
Medical Care
One Sky Center
20th Annual AAIP Cross Cultural Medicine Workshop
R Dale Walker, MD Patricia Silk Walker, PhD Michelle Singer
April 27, 2012
Santa Fe, New Mexico
The News You've All Been Waiting to
Hear...........AAIP 41st Annual Meeting
Anchorage: July 31 – August 5, 2012
Let the Party Begin!
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Education,
Mentorship,
Retention
Opportunity,
Research,
Recruit
One Sky
Center
Training,
Consultation,
Technical
Assistance
Excellence
Tribal
Leadership
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Goals for Today
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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
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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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American Indian/Alaskan Native
As a Percentage of the total population
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Native Healthcare Resource
Disparities
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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
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Different goals
Resource silos
One size fits all
Activity-driven
How are we functioning?
(Carl Bell and Dale Walker 7/03)
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Culturally
Specific
Best
Practice
Outcome
Driven
Integrating
Resources
We need Synergy and an Integrated System
(Carl Bell and Dale Walker 7/03)
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Recession Worsens Racial Wealth Gap
Who Rules America? Wealth,
Income, and Power.
Net Worth
Financial Wealth
Behavioral Health Care Issues
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Native Health Issues
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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Adult Serious Mental Illness
By Race/Ethnicity: 2001
SAMHSA Office of Applied Studies, 2001
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Suicide Among ages 15-17, 2001
Death rate per 100,000
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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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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
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Models of Care
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The IOM Quality Report:
Selected Quotes
• “The current care systems cannot do
the job.”
• “Trying harder will not work.”
• “Changing care systems will.”
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Chronic Care Model
Community
Resources and Policies
SelfManagement
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
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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
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
4/9/2015
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
4/9/2015
Intervention
Using the OPRE Review
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Domains Influencing Behavioral Health:
A Native Ecological Model
Risk
Individual
Protection
Peers/Family Community/Tribe
Society/Cultural
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Individual Intervention
• Identify risk and protective factors
counseling
skill building
improve coping
support groups
• Increase community awareness
• Access to hotlines other help resources
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Effective Interventions for Adults
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Cognitive/Behavioral Approaches
Motivational Interventions
Psychopharmacological Interventions
Modified Therapeutic Communities
Assertive Community Treatment
Vocational Services
Dual Recovery/Self-Help Programs
Consumer Involvement
Therapeutic Relationships
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Culture-Based Interventions
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Story telling
Sweat Lodge
Talking circle
Vision quest
Wiping of tears
Drumming
Smudging
Traditional Healers
Herbal remedies
Traditional activities
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What are some promising strategies?
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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
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.
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WHO Commission on Social Determinants of Health | August 28 2008
Conceptual Framework of Health
Determinants
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Critical Elements for Native Peoples
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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
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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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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/2011whtnc_report.pdf
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An Ideal Intervention
• Broadly based:
Includes individual, family,
community, tribe, and society
• Comprehensive:
Prevention: Universal, Selective,
Indicated
Treatment
Maintenance
• Addresses opportunity, empowerment,
security, dignity
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Native Partnered Collaboration
State/Federal
Grassroots
Groups
Community-Based
Organizations
Education-Treatment-Research
OHSU
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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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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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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
Gender Equity
Political empowerment
– inclusion and voice
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
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