understanding native health: a social determinants approach one sky center oregon health and science...
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Understanding Native Health: A Social
Determinants Approach
One Sky Center
Oregon Health and Science UniversityNative American Heritage Celebration
R Dale Walker, MD Patricia Silk Walker, PhD Michelle SingerNovember 8, 2010Portland, Oregon
Presidential Proclamation--National Native American Heritage
Month
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Tribes of the NPAIHB
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One Sky
Center
Opportunity, Research
ExcellenceTribal Leadership
Training, Consultation, Technical Assistance
Education
Mentorship
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Goals for Today
• 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
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 HealthB. Primary HealthC. Alcoholism / Substance Abuse
2. Bureau of Indian Affairs (BIA)A. EducationB. VocationalC. Social ServicesD. Police
3. Tribal Health4. Urban Indian Health5. State and Local Agencies6. Federal Agencies: SAMHSA, VAMC,
Justice
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How are we functioning?(Carl Bell and Dale Walker 7/03)
One size fits allOne size fits all
Different goals Different goals Resource silosResource silos
Activity-drivenActivity-driven
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We need Synergy and an Integrated System (Carl Bell and Dale Walker 7/03)
Culturally Specific
Culturally Specific
Best Practice
Best Practice
IntegratingResources
IntegratingResources
Outcome Driven
Outcome Driven
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Behavioral Health Care Issues
Native Health Issues
1. Alcoholism 6X
2. Tuberculosis 6X
3. Diabetes 3.5 X
4. Accidents 3X
5. Poverty 3x
6. Depression 3x
7. Suicide 2x
8. Violence?
1. Same disorders as general population
2. Greater prevalence3. Greater severity4. Much less access
to Tx5. Cultural relevance
more challenging6. Social context
disintegrated
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19SAMHSA Office of Applied Studies, 2001
Adult Serious Mental Illness By Race/Ethnicity: 2001
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Frequent Mental Distress by Race/Ethnicity and Year
Percent
* Zahran HS, et al. Self-Reported Frequent Mental Distress Among Adults — United States, 1993–2001. Centers for Disease Prevention and Control, MMWR 2004;53(41):963-966.
American Indian/ Alaskan Native**
Hispanic African-American**
White**
Asian, Pacific Islander**
** Non-Hispanic
Year
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Mental Illness: A Multi-factorial Event
Edu., Econ., Rec.Edu., Econ., Rec.
Family Disruption/Domestic ViolenceFamily Disruption/Domestic Violence
ImpulsivenessImpulsiveness
Negative Boarding SchoolNegative Boarding School
HopelessnessHopelessness
Historical TraumaHistorical Trauma
Family HistoryFamily History
SuicidalBehaviorSuicidal
Behavior
Cultural DistressCultural Distress
Psychiatric Illness& StigmaPsychiatric Illness& Stigma
Psychodynamics/Psychological VulnerabilityPsychodynamics/Psychological Vulnerability
Substance Use/AbuseSubstance
Use/Abuse
Individual
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Key Adolescent Risk Factors
Aggressive/Impulsive
DepressionSubstance Abuse
Trauma
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0
2
4
6
8
10
12
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Suicide Among ages 15-17, 2001Death rate per 100,000
0
Source: National Vital Statistics System - Mortality, NCHS, CDC.
2010 Target
TotalAmeric
an
IndianAsian
HispanicBlack
White Females Males
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Suicide: A Native Crisis
Source: National Center for Health Statistics 2001
0
10
20
30
40
50
605-
9
10-1
4
15-1
9
20-2
4
25-2
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30-3
4
35-3
9
40-4
4
45-4
9
50-5
4
55-5
9
60-6
4
65-6
9
70-7
4
75-7
9
80-8
4
85+
Age Groups
Rat
e/10
0,00
0 .
White Male AI Male Black Male AI Female
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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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No No ProblemsProblems
Universal/Selective Universal/Selective PreventionPrevention
Brief InterventionBrief Intervention
TreatmentTreatment
Mild Mild ProblemsProblems
Moderate Moderate ProblemsProblems
Severe Severe ProblemsProblems
Thresholds for ActionThresholds for Action
Spectrum of Intervention Responses
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The Intervention Spectrum for Behavioral Disorders
CaseIdentification Standard
Treatmentfor KnownDisorders
Compliancewith Long-TermTreatment(Goal: Reduction inRelapse 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.
Indicated—Diagnosed Youth
Selective—Health RiskGroups
Universal—General Population
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Domains Influencing Behavioral Health: A Native Ecological Model
Individual Peers/Family Society/CulturalCommunity/Tribe
Risk
Protection
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Risk
Mental illnessAge/genderSubstance abuseLossPrevious suicide attemptPersonality traitsIncarcerationFailure/academic problems
Protective
Cultural/religious beliefsCoping/problem solving skillsOngoing health and mental health care Resiliency, self esteem, direction, mission, determination, perseverance, optimism, empathyIntellectual competence, reasons for living
Risk and Protective Factors: Individual
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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
• Cognitive/Behavioral Approaches• Motivational Interventions• Psychopharmacological Interventions• Modified Therapeutic Communities• Assertive Community Treatment• Vocational Services• Dual Recovery/Self-Help Programs• Consumer Involvement• Therapeutic Relationships
Culture-Based Interventions
• 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?
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….
36www.thelancet.com Dec 9, 2006. MarmotAmartya Sen 1998 Nicholas Stern 2004
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HealthEducation
Social Justice
Gender
EnvironmentalHumanRights
Aging
Science &
Technology
Behavioral
Socio-culturalSocio-
economic
Biological
Role of Inequities in Role of Inequities in HealthcareHealthcare
Simulation :Estimated % Contribution to Health Disparity
health care10%
behaviors20%
culture10%
environment15%
racism15%
poverty25%
other5%
genes3%
Adapted from V. Hogan
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
• 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
Research-Education-Treatment
Grassroots Groups
Community-BasedOrganizations
State/Federal
Six Key PrinciplesEvidence-based predictors of
change
• 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
45http://www.indigenous-mental-health.ca/
Early child development and education
Healthy Places Fair Employment Social Protection
Universal Health Care
Health Equity in all Policies
Fair Financing Good Governance
Responsibility
Gender Equity
Political empowerment – inclusion and voice
Areas for ActionAreas for Action
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Contact us at
503-494-3703
Dale Walker, MD
u
Or visit our
website:
www.oneskycent
er.org
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