The Social Determinants
of Health
One Sky Center
Association of American Indian Physicians
39th Annual Meeting
R Dale Walker, MD Patricia Silk Walker, PhD Michelle Singer
August 8, 2010
Santa Ana Pueblo, New Mexico
Education
Mentorship
Opportunity,
Research
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
Define Social Determinants of Health
Present Examples of Treatment and Prevention
Summarize Critical Issues for Native Peoples
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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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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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Behavioral Health Care Issues
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Native Health Issues
1.
2.
3.
4.
5.
6.
7.
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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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Frequent Mental Distress
by Race/Ethnicity and Year
Percent
American Indian/
Alaskan Native**
African-American**
Hispanic
White**
Asian, Pacific Islander**
** Non-Hispanic
Year
* Zahran HS, et al. Self-Reported Frequent Mental Distress Among Adults —
United States, 1993–2001. Centers for Disease Prevention and Control, 17
MMWR 2004;53(41):963-966.
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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Key Adolescent Risk Factors
Aggressive/Impulsive
Substance Abuse
Depression
Trauma
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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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Suicide: A Native Crisis
AI Male
Black Male
AI Female
50
40
30
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Age Groups
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Source: National Center for Health Statistics 2001
85+
80-84
75-79
70-74
65-69
60-64
55-59
50-54
45-49
40-44
35-39
30-34
25-29
20-24
15-19
0
10-14
10
5-9
Rate/100,000 .
60
White Male
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North Dakota Teen Suicide Rates
(2000-2004 rate per 100,000 teens 13-19 years old)
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Models of Care
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Spectrum of Intervention Responses
Thresholds for Action
No
Problems
Mild
Problems
Moderate
Problems
Severe
Problems
Treatment
Brief Intervention
Universal/Selective
Prevention
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The Intervention Spectrum for
Behavioral Disorders
Case
Identification Standard
Treatment
for Known
Indicated—
Disorders
Diagnosed
Youth
Selective—
Health Risk
Groups
Universal—
General Population
Compliance
with Long-Term
Treatment
(Goal:Reduction in
Relapse and Recurrence)
Aftercare
(Including
Rehabilitation)
Source: Mrazek, P.J. and Haggerty, R.J. (eds.), Reducing Risks for Mental Disorders, Institute of Medicine,
Washington, DC: National Academy Press, 1994.
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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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Risk and Protective Factors:
Individual
Risk
Mental illness
Age/gender
Substance abuse
Loss
Previous suicide attempt
Personality traits
Incarceration
Failure/academic problems

Protective
Cultural/religious beliefs
Coping/problem solving skills
Ongoing health and mental health
care
Resiliency, self esteem, direction,
mission, determination,
perseverance, optimism, empathy
Intellectual competence, reasons
for living

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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
Socio-economic
biological
Science
&
technology
ageing
Health
ICT
behavioral
HEALTH
&
Human
SOCIAL
rights
JUSTICE
environmental
health
GENDER
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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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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Partnered Collaboration
State/Federal
Grassroots
Groups
Community-Based
Organizations
Research-Education-Treatment
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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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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
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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