American Indians / Alaska Natives
Cultural History & Beliefs
American Indians and Alaska Natives (AI/AN) are indigenous to the continent of North America, with a history of over 10,000 years. There are about 562 federally recognized AI/AN tribes, plus an unknown number of non-federally recognized tribes. Each tribe exists as a sovereign entity with its own culture, language, beliefs, and practices. Native Americans have a holistic view of the world where people, community, nature, and spirituality are interconnected and interrelated. With some Native Americans, sickness is viewed as the result of disharmony between the sources of life. Traditional practices are important to their wellbeing and survival and include an array of rituals, ceremonies and herbal remedies. Non-verbal communication sets the tone for relationships. Time and silence are used to establish and maintain harmony.
State of HIV/AIDS
The U.S. Centers of Disease Control and Prevention estimates that today more than1 million Americans are infected with HIV. Sixty-three percent are minorities, with over half a million having died of AIDS (1). Approximately 300,000 persons (30%) do not know they are positive. 1 Today, AIDS is the leading cause of death among minorities between the ages of 25 and 44. In recent years, new medications have helped people living with HIV/AIDS to live longer and significantly reduce the number of deaths resulting from AIDS. The number of new infections has remained constant in the last decade at approximately 40,000 each year, with nearly 70% occurring among minorities. Of the estimated 3,026 American Indians and Alaska Natives who have received a diagnosis of AIDS, 1,529 of them have died. American Indians and Alaska Natives have the shorter survival time and Asian and Pacific Islanders have the longest survival time. (Should this be quantified?) While rates among Native Americans are only 1%, it is prudent that public health officials focus on prevention — the best means of stopping the spread of the disease.
Patient Barriers to Care
Declines in overall AIDS mortality in the US may be generating perceptions that it is under control. Among American Indian/Alaska Natives of all age groups, however, HIV/AIDS rates are still a major public health concern. It is important to remember in dealing with American Indian/Alaska Natives that they are a very diverse population whose language, dialect, culture, and concerns differ significantly. Providing appropriate interventions and therapeutic measures have been hindered by numerous barriers to care, both real and perceived. Researchers have found an association between education / literacy and HIV treatment options and adherence. Individuals with lower education and/or literacy levels were less likely to be referred for advanced treatment protocols. These individuals would also be more likely than participants with higher literacy levels to miss medication schedules because they were confused about dosage amounts. Many of the other specific barriers include:
- Disproportionate economic hardship
- Inadequate education
- Distrust of Western systems
- Distrust of Western medicine
- Lack of providers who share population’s culture and worldview
- Unsafe and inadequate water supply in many communities
- Communication issues that result from more than 200 Native languages
- View of sickness and its relationship to disharmony
- Privacy and honor
- Cultural avoidance of discussing issues related to sexual behavior, alcohol or drug use
- Stigmatization associated with disease
- High illiteracy rate
- Joblessness
- Substandard housing
Variety of systems providing health care to tribes across the nation (Indian Health Service only treats persons affiliated with registered tribes and many Native people have chosen not to become part of organized systems.)
American Indians and Alaska Natives are at higher risk for mental health disorders than other racial and ethnic groups in the United States (Nelson, et al, 1992). The most significant mental health concerns are the high prevalence of substance abuse, depression, anxiety, violence, and suicide.
American Indians and Alaska Natives have consistently been one of the poorest groups in American society. This was first systematically documented by the Merriam Report (Institute for Government Research 1928), which demonstrated that American Indian and Alaska Natives were plagued by a host of social and economic ills, including illiteracy, ill health, joblessness, substandard housing, and poverty. Although the economic status of American Indians and Alaska Natives has improved over the past half century as a result of multiple federal programs, Indian policies, and successful economic development activities initiated by tribes on reservations, American Indians and Alaska Natives still remain the most economically disadvantaged group in the United States (Snipp 2000).An estimated 21.5% of Alaska Native families have incomes below the federal poverty level, compared with 6.8% for all Alaska families. The unemployment rate for Alaska Native men is 27.3%; 16% for Alaska Native women. Due to the lack of jobs in rural areas, unemployment rates in villages are staggering. In one out of every eight villages, unemployment among Native men is in excess of 50%; in 1/3 of all Native villages, male unemployment (32%) nearly quadruples statewide average unemployment rates.
It is estimated that more than half (60%) of the American Indian/Alaska Native population reside in urban areas, with all others residing on reservations or historical sites (Ho 1987). About three-fourths of the Indian population is concentrated in the Midwest and Western United States.
Access and use of traditional Indian medicine varies from tribe to tribe and is affected by levels of acculturation. Traditional practices may include ceremonies specifically for the community or the individual and family. Ceremonies may be complex, requiring extensive time commitments by the participants or simple, only requiring a brief period of time. Traditional medicine has been used to cure multiple types of illness. Many medical providers have recognized the importance of traditional medicine among American Indians and Alaska Natives. The Indian Health Service has established relationships with tribal community elders, allowing them to come into the local IHS health care facility at the request of tribal members and provide healing services to the patient in the hospital. Other initiatives include traditional healers in medical training and social service program classes offered by tribal community colleges.
There is a shortage of health care professionals in Native communities: fewer than 90 for every 100,000, compared to the national rate of 229 per 100,000. Geographic isolation, economic factors, poor nutrition, and suspicion toward the American health care system are some of the reasons why health among the AI/AN population is poorer than other groups.
States have limited powers over the tribes that reside within their boundaries. These powers are defined by federal law. On some reservations, however, a high percentage of the land is owned and occupied by non-Indians. This was the result of non-Indians homesteading on tribal lands that were deeded to the non-Indians under the Indian Land Claims Act of 1924.
It is estimated that 33% of American Indian and Alaska Natives are younger than 15 years of age compared to 22% for the general U.S. population About three-fourths of the Indian population is concentrated in the Midwest and Western United States.
NMAETC Recommendations for Clinical Delivery
- Recognize that many patients who present in your office may come from a culture that is suspicious of the American health care system.
- Make sure your providers and staff treat each individual who calls or visits your office with dignity and respect.
- Reflect the populations you serve in the materials displayed in your office.
- Use easy to understand language when discussing health concepts.
- Understand the role of family in patient decisionmaking and be open to patients bringing family members to the appointments.
- Where possible, make child care available.
- Structure programs to meet all patients’ mental, physical, and social service needs.
- Schedule appointments in times and locations that are suitable for people who work.
- Be open to making community presentations on HIV/AIDS and other health problems in the communities you serve.
Data Sources: American Indian / Alaska Native
- Glynn M., Rhodes P., Estimated HIV prevalence in the United States at the end of 2003. National Prevention Conference; June 2005; Atlanta. Abstract 595.
- Fleming, P.L., et al., “HIV Prevalence in the United States, 2000,” 9th Annual Conference on Retroviruses & Opportunistic Infections, Feb. 24-8, 2002, Seattle, WA, Abstract 11.
- CDC & Prevention, HIV/AIDS Surveillance Report, 2002, 14; 1-40.
- CDC & Prevention, HIV/AIDS Surveillance Report, 2003, 15; 1-5. CDC, Proportion of Reported AIDS Cases and Population, by Race/Ethnicity, 2003– 50 States and D.C. HRSA, AI/AN and HIV/AIDS, Jan 2005
- BESAFE, NMAETC Cultural Competency Model 2004