1. Understanding Native Health: A Social Determinants Approach One Sky Center Oregon Health and Science University Native American Heritage Celebration R Dale Walker, MD Patricia Silk Walker, PhD Michelle Singer November 8, 2010 Portland, Oregon

2. Presidential Proclamation--National Native American Heritage Month 2 Let the Party Begin!

3. Tribes of the NPAIHB 3

4. 4 One Sky Center Opportunity, Research Excellence Tribal Leadership Training, Consultation, Technical Assistance Education Mentorship

5. 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

6. 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. 7 INDIGENOUS PEOPLE WORLD MAP - 370 million indigenous peoples living in more than 70 countries

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13. Native Healthcare Resource Disparities 13

14. 14 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

15. 15 How are we functioning? (Carl Bell and Dale Walker 7/03) One size fits all Different goals Resource silos Activity-driven

16. 16 We need Synergy and an Integrated System (Carl Bell and Dale Walker 7/03) Culturally Specific Best Practice Integrating Resources Integrating Resources Outcome Driven

17. 17 Behavioral Health Care Issues

18. 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 18

19. 19 SAMHSA Office of Applied Studies, 2001 Adult Serious Mental Illness By Race/Ethnicity: 2001

20. 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. 21 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

22. 22 Key Adolescent Risk Factors Aggressive/Impulsive DepressionSubstance Abuse Trauma

23. 23 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

24. 24 Suicide: A Native Crisis Source: National Center for Health Statistics 2001

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26. 26 North Dakota Teen Suicide Rates (2000-2004 rate per 100,000 teens 13-19 years old)

27. 27 Models of Care

28. 28 No Problems Universal/Selective Prevention Brief Intervention Treatment Mild Problems Moderate Problems Severe Problems Thresholds for Action Spectrum of Intervention Responses

29. 29 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

30. 30 Domains Influencing Behavioral Health: A Native Ecological Model IndividualPeers/FamilySociety/CulturalCommunity/Tribe Risk Protection

31. 31 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

32. 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. 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

34. Culture-Based Interventions Story telling Sweat Lodge Talking circle Vision quest Wiping of tears Drumming Smudging Traditional Healers Herbal remedies Traditional activities 34

35. 35 What are some promising strategies?

36. 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…. 36 www.thelancet.comwww.thelancet.com Dec 9, 2006. Marmot Amartya Sen 1998 Nicholas Stern 2004

37. . Health Education Social Justice Gender Environmental Human Rights Aging Science & Technology Behavioral Socio-cultural Socio- economic Biological

38. Role of Inequities in Healthcare Adapted from V. Hogan

39. 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

40. Conceptual Framework of Health Determinants 40

41. 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. 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. 43 Partnered Collaboration Research-Education-Treatment Grassroots Groups Community-Based Organizations State/Federal

44. Six Key Principles Evidence-based predictors of change Leadership Mobilization Community driven Public health approach Strength based Culturally informed Proactive 44

45. The Wharer ā t ā 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 45 http://www.indigenous-mental-health.ca/

46. 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 Action

47. 47 Contact us at 503-494-3703 E-mail Dale Walker, MD onesky@ohsu.edu Or visit our website: www.oneskycenter.org

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