1. 1 The American Indian/Alaska Native National Resource Center for Substance Abuse and Mental Health Services Providing Behavioral Health Care in Native Communities: Social Determinants of Health Oregon Health and Science University Portland, Oregon March 2, 2010 Dale Walker, MD Patricia Silk Walker, PhD Douglas Bigelow, PhD Bentson McFarland, MD, PhD, Laura Loudon, MS Michelle Singer Global Health Lecture Series

2. 2 One Sky Center

3. 3 Jack Brown Adolescent Treatment Center Alaska Native Tribal Health Consortium United American Indian Involvement Northwest Portland Area Indian Health Board Na'nizhoozhi Center Tribal Colleges and Universities One Sky Center National Indian Youth Leadership Project Cook Inlet Tribal Council Tri-Ethnic Center for Prevention Research Red Road Prairielands ATTC Harvard Native Health Program One Sky Center Partners

4. 4 One Sky Center Outreach

5. 5 Goals for Today Define Social Determinants of Health Review An Environmental Scan for Natives Discuss Fragmentation and Integration Present Some Behavioral Health Care Issues Present Examples of Treatment and Prevention Summarize Critical Issues for Native Peoples

6. 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. 6

7. Social Determinants of Health Ubiquitous Powerful influence on health Underlie: –Differences between individuals within countries –Differences between groups, populations and countries –Changes in health over time Complex pathways

8. WHO Social Determinant Themes Social exclusion Urbanization Globalization Health systems Priority public health conditions Early child development Women and gender equity Employment conditions Measurement and evidence 8

9. 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 9

10. 10 INDIGENOUS PEOPLE WORLD MAP - 370 million indigenous peoples living in more than 70 countries

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15. 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 prevalence 3.Greater severity 4.Much less access to Tx 5.Cultural relevance more challenging 6.Social context disintegrated 15

16. Native Healthcare Resource Disparities 16

17. 17 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

18. 18 How are we functioning? (Carl Bell and Dale Walker 7/03) One size fits all Different goals Resource silos Activity-driven

19. 19 We need Synergy and an Integrated System (Carl Bell and Dale Walker 7/03) Culturally Specific Best Practice Integrating Resources Integrating Resources Outcome Driven

20. 20 Behavioral Health Care Issues

21. 21 SAMHSA Office of Applied Studies, 2001 Adult Serious Mental Illness By Race/Ethnicity: 2001

22. 22 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

23. 23 Mental Illness: A Multi-factorial Event Edu., Econ., Rec. Family Disruption/ Domestic Violence Family Disruption/ Domestic Violence Impulsiveness Negative Boarding School Hopelessness Historical Trauma Family History Suicidal Behavior Suicidal Behavior Cultural Distress Psychiatric Illness & Stigma Psychodynamics/ Psychological Vulnerability Psychodynamics/ Psychological Vulnerability Substance Use/Abuse Individual

24. 24 Key Adolescent Risk Factors Aggressive/Impulsive DepressionSubstance Abuse Trauma

25. Six behaviors that contribute to serious health problems: Tobacco use Poor nutrition Alcohol and other drug abuse Behaviors resulting in intentional or unintentional injury Physical inactivity Risky sex http://www.cdc.gov/HealthyYouth/healthtopics/index.htm

26. 26 Suicide Among ages 15-17, 2001 Death rate per 100,000 0 Source: National Vital Statistics System - Mortality, NCHS, CDC. 2010 Target Total American Indian Asian Hispanic Black White Females Males

27. 27 Suicide: A Native Crisis Source: National Center for Health Statistics 2001

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29. 29 North Dakota Teen Suicide Rates (2000-2004 rate per 100,000 teens 13-19 years old)

30. 30 Disaster Defined FEMA: A natural or man-made event that negatively affects life, property, livelihood or industry often resulting in permanent changes to human societies, ecosystems and environment. NHTSA: Any occurrence that causes damage, ecological destruction, loss of human lives, or deterioration of health and health services on a scale sufficient to warrant an extraordinary response from outside the affected community area. NOAA: A crisis event that surpasses the ability of an individual, community, or society to control or recover from its consequences.

31. 31 Models of Care

32. 32 Domains Influencing Behavioral Health: A Native Ecological Model IndividualPeers/FamilySociety/CulturalCommunity/Tribe Risk Protection

33. 33 No Problems Universal/Selective Prevention Brief Intervention Treatment Mild Problems Moderate Problems Severe Problems Thresholds for Action Spectrum of Intervention Responses

34. 34 The Intervention Spectrum for Behavioral Disorders Case Identification Standard Treatment for Known Disorders 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. Indicated— Diagnosed Youth Selective— Health Risk Groups Universal— General Population

35. 35 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 Risk and Protective Factors: Individual

36. 36 Individual Intervention Identify risk and protective factors counseling skill building improve coping support groups Increase community awareness Access to hotlines other help resources

37. 37 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

38. Culture-Based Interventions Story telling Sweat Lodge Talking circle Vision quest Wiping of tears Drumming Smudging Traditional Healers Herbal remedies Traditional activities 38

39. 39 Indigenous Knowledge Local knowledge unique to a given culture or society; it has its own theory, philosophy, scientific and logical validity, used as a basis for decision-making for all of life’s needs. Definition:

40. 40 Traditional Medicine The sum total of health knowledge, skills and practices based upon theories, beliefs and experiences indigenous to different cultures…used in the maintenance of health. WHO 2002 Definitions:

41. 41 ID Best Practice Best Practice Clinical/services Research Traditional Medicine Mainstream Practice

42. 42 What are some promising strategies?

43. 43 An Ideal Intervention Broadly based: Includes individual, family, community, tribe, and society Comprehensive: Prevention: Universal, Selective, Indicated Treatment Maintenance

44. Choctaw Nation of Oklahoma Adventure Therapy “Natural Highs Program” Transformation process Experiential activities Relationship building Changing the way you live and think Changing how you think and how you believe about life and yourself Creation of challenge in a safe environment Horses, Canoes, Tradition Camps 44

45. Meth Free Crow Walk: Youth as our Warriors in Reclaiming our Nation Meth Free Crowalition Establish a “War Against Meth” Focus on accountability, prevention, intervention, and treatment Combine forces for Unity. Diverse community representation Youth and Community Development: mentorship, leadership, trust, establish community norms 45

46. 46 Integrated Treatment Premise: treatment at a single site, featuring coordination of treatment philosophy, services and timing of intervention will be more effective than a mix of discrete and loosely coordinated services Findings: decrease in hospitalization lessening of psychiatric and substance abuse severity better engagement and retention (Rosenthal et al, 1992, 1995, 1997; Hellerstein et al 1995.)

47. 47 Comprehensive School Planning Prevention and behavioral health programs/services on site Handling behavioral health crises Responding appropriately and effectively after an event Public awareness and media campaigns Youth Development Services Social Interaction Skills Training Approaches Mentoring Tutoring Rites of Passage

48. 48 Partnered Collaboration Research-Education-Treatment Grassroots Groups Community-Based Organizations State/Federal

49. Six Key Principles Evidence-based predictors of change Leadership Mobilization Community driven Public health approach Strength based Culturally informed Proactive 49

50. 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 50

51. Early child development and education Healthy Places Fair Employment Social Protection Universal Health Care Health Equity in all Policies Fair Financing Good Global Governance Market Responsibility Gender Equity Political empowerment – inclusion and voice Areas for Action

52. 52 NIDA American Indian Research Scholars Mentorship Program

53. Location of Mentors = and Mentees = in Project 53 X X X X XX X X X

54. 54 Contact us at 503-494-3703 E-mail Dale Walker, MD onesky@ohsu.edu Or visit our website: www.oneskycenter.org