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

2 Let the Party Begin!

Tribes of the NPAIHB

3

4

One Sky

Center

Opportunity, Research

ExcellenceTribal Leadership

Training, Consultation, Technical Assistance

Education

Mentorship

5

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

6

7

INDIGENOUS PEOPLE WORLD MAP - 370 million indigenous peoples living in more than 70 countries

8

9

10

11

12

Native Healthcare Resource Disparities

13

14

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

15

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

16

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

17

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

18

19SAMHSA Office of Applied Studies, 2001

Adult Serious Mental Illness By Race/Ethnicity: 2001

20

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

21

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

22

Key Adolescent Risk Factors

Aggressive/Impulsive

DepressionSubstance Abuse

Trauma

23

0

2

4

6

8

10

12

14

16

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

24

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

9

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

25

26

North Dakota Teen Suicide Rates

(2000-2004 rate per 100,000 teens 13-19 years old)

27

Models of Care

28

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

29

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

30

Domains Influencing Behavioral Health: A Native Ecological Model

Individual Peers/Family Society/CulturalCommunity/Tribe

Risk

Protection

31

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

32

Individual Intervention

• Identify risk and protective factors counseling skill building improve coping support groups • Increase community awareness• Access to hotlines other help resources

33

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

34

35

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

.

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.

39

WHO Commission on Social Determinants of Health | August 28 2008

Conceptual Framework of Health Determinants

40

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

41

42

An Ideal Intervention• Broadly based:

Includes individual, family,

community, tribe, and society

• Comprehensive:

Prevention: Universal, Selective,

Indicated

Treatment

Maintenance

• Addresses opportunity, empowerment, security, dignity

43

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

44

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

47

Contact us at

503-494-3703

E-mail

Dale Walker, MD

onesky@ohsu.ed

u

Or visit our

website:

www.oneskycent

er.org

48