Increasing the cultural competence of health care providers serving diverse populations
In order to provide equitable and effective health care, clinicians need to be able to
function effectively within the context of the cultural beliefs, behaviors, and needs of
consumers and their communities. According to the 2002 Institute of Medicine report
Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, racial and
ethnic minorities tend to receive lower quality health care than non-minorities even
when access to insurance and income is accounted for. Failing to support and foster
culturally competent health care for racial and ethnic minorities can increase costs for
individuals and society through increased hospitalizations and complications.
In 2006, the population of American Indians and Alaskan Natives in the US was 3.2 million, with 43 percent of the population living in California, Oklahoma, Arizona, and Texas. In Minnesota, American Indians represented 1.2
percent of the total population in 2008. With lack of migration to Minnesota from other states,
this population will see a slower growth rate
than other minority groups. A growth rate of
only 13 percent is projected between 2005 and
2035, with a declining population projected for
Hennepin and Ramsey counties. The average age
of Indians in Minnesota is expected to become
older, with the under 15 age group projected to fall considerably.
The two largest groups of Indians in Minnesota are the Anishinabe, meaning “first men,” and the Dakota, meaning “friends.” The Anishinabe are the third largest Indian tribe in
North America and were originally located around the Great Lakes region, primarily in
the Lake Superior area. Anishinabe are often referred to as Ojibwe or Chippewa. They
generally accept the name Ojibwe, but dislike Chippewa. The Dakota Nation includes
native peoples who once lived in the forests and along the Mississippi River in northern
Minnesota. It eventually divided into three groups—the Dakota, Nakota, and Lakota.
Each group moved into different areas of the upper midwest. In the Dakota language,
Minnesota means “waters that reflect the sky.”
The following cultural patterns may represent many American Indians, but do not represent all people in a community. According to the University of California School of Nursing, in Culture and Clinical Care, many aspects of Indian culture today reflect the
culture of the general US population.
Social structure
The American Indian concept of family includes immediate and extended family members,
as well as community and tribal members. Women are the
traditional care givers. Grandparents help counsel and care
for their grandchildren, and children are expected to respect
and care for their elders and take pride in their culture. At
powwows, elders are served meals first and are given special
seating areas. Indian communities encourage education
with an emphasis on the unique cultural legacies of the
community. Younger people often leave home to become
educated, then return to help their families and tribes.
Diet
The traditional diet of American Indians was
generally nutritious and low in fat, but today a typical diet is similar to that of the general US population, although it is often poorer in quality, consists of high-fat, salty, and
sugary foods, and lacks sufficient fruit, vegetables, grains,
and dairy products. Indians are more likely to report not
having enough to eat than other US households. Traditionally,
the Anishinabe and Dakota ate fresh or dried wild
game and foul and gathered wild rice, berries, acorns, ginger,
and leaves and twigs for teas. They planted potatoes, corn,
pumpkins, squash, and turnips, and made maple syrup.
Fish, the principal food of the Anishinabe, was boiled,
cooked over a fire on a stick, or eaten in soup, and was
dried, salted, or frozen in the snow to preserve.
Religion
Spirituality is central to the identity of the American Indian, and is viewed holistically. People and nature are interconnected. Every animate and inanimate form of life has a spirit and is considered sacred. For
example, water is viewed as a sacred, life-sustaining source
and a way of connecting with the earth. The head and
hair are considered particularly sacred. Respecting and
nurturing life and developing a positive relationship with
the spirits is core to Indian spirituality. Indians nurture that
relationship through prayer and a purification ritual in a
sweat lodge. They burn sage and sweet grass, and smoke
a special ceremonial tobacco for cleansing, blessings, and
healing. Drumming, dancing, and singing also are traditional
spiritual expressions associated with healing.
American Indians have endured decades of assimilation
policies designed to strip them of their identity and
integrate them into the dominant society. Many Indian
people who grew up in the mid-twentieth century describe
a feeling of shame in their heritage during that time. This
was partly due to the fact that it was illegal for Indians to practice their religious ceremonies until the American Indian Religious Freedom Act was passed in 1978. As a result, many Indians today have Christian ties or practice no religion at all.
Medical care
According to the Centers for Disease
Control and Prevention, the top causes of death in the
American Indian population are heart disease, cancer,
unintentional injuries, diabetes, and stroke. Also prevalent
are chronic liver diease and cirrhosis, chronic respiratory
disease, suicide, influenza/pneumonia, and kidney disease.
Obesity, smoking, and alcohol abuse in this population are
related to many of these diseases.
Among racial and ethnic groups, the prevalence of smoking is highest among American Indians/Alaska Natives (32
percent). Because their lands are sovereign nations, Indians are not subject to taxes or to state laws prohibiting the sale
and promotion of tobacco products to minors. Chronic cigarette smoking and spit tobacco used by this population
have increased its risk of developing tobacco-related health problems, such as heart disease, cancer, and stroke.
Because health is related to spirituality in Indian culture, sickness may be viewed as a result of disharmony between the sources of life. A patient may seek western medicine for treatment as well as medicine from a traditional healer—a medicine man—to address the disharmony that caused the
illness. The medicine man has been given the power to heal through his relationship with spiritual beings. Spirits work through him, helping him diagnose and treat physical and
spiritual illness. Traditionally, the medicine man is chosen
by the spirits and comes from a specific family lineage. His
life is hard because he cannot deny a request for treatment
and never charges for his services. Indian patients may be
reluctant to discuss use of these traditional practices with a
clinician.
Indians have been taught to resist any expression of pain. Although they may not express pain directly, they may
report feeling uncomfortable or may use storytelling or
circular conversation to build trust and describe symptoms.
A personal story about a sick neighbor may be used as a
metaphor for the patient’s symptoms. Direct eye contact
is often avoided out of respect or out of concern for soul
loss. Time and silence are often used to prepare to listen, to
maintain harmony, and to be non-confrontational. Patients
may occasionally be late or miss appointments because
of a different perception of the concept of time—time orientation for Indians has been traditionally cyclical and
present-oriented compared to the linear, future-oriented
concept of time in Western culture.
Death and dying
Because of the importance of family
in American Indian culture, immediate and extended family members should be informed of an impending death. A
family-centered approach is recommended for conveying serious medical information and explaining issues such
as autopsy and organ donation. Organ donation may be viewed as a desecration of the body.
The entire family may be included when making decisions and signing documents. Due to the misuse of signed
documents throughout the history of the American Indian, some Indian patients may be unwilling to sign informed
consents, advance directives, and durable power of attorney forms. Patients may perceive verbal agreement as sufficient.
Honoring ancestors is especially important in Indian culture. Several Indian nations across the US are currently in the process of attempting to retrieve the remains of ancestors that have been unearthed by archeologists so they can be properly buried.
Culture in context
Culture is essential in assessing a person’s health and well-being. Understanding a patient’s practice of cultural norms can allow providers to quickly build rapport and ensure effective patient-provider communication. Efforts to reduce health disparities must be holistic, addressing the physical, emotional, and spiritual health of individuals and families. Also important is making connections with community members and recognizing conditions in the community.
Get to know your patients on an individual level. Not all patients from diverse populations conform to commonly known culture-specific behaviors, beliefs, and actions. Generalizations in this material may not apply to your patients
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