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Transcultural Health Care: A Culturally Competent Approach, 4th Edition

American Indians
Alaskan Natives (AI/ANs)

Larry Purnell, PhD, RN, FAAN

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Overview/Heritage

Amount of Indian blood necessary to be considered a tribal member varies among the tribes—¼ to be a Navajo, which is the largest tribe in United States and live in the Southwest
556 different tribes in the United States and Canada
Each tribe unique but share similar views regarding cosmology, medicine, and family organization

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Overview Heritage

Forced migration by United States government
Life on MOST reservations is hard with high poverty and high unemployment although a few have significant money due to oil, land leases, gambling casinos, etc.
Children were taken from them and placed in “White Man’s Schools”

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

AI/AN Cultural Values

Group, clan, or tribal emphasis
Present oriented
Time is always with us
Age
Cooperation
Harmony with nature
Giving/sharing

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

AI/AN Cultural Values

Pragmatic
Mythology
Patience
Mystical
Shame
Permissiveness
Extended family and clan

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

AI/AN Cultural Values

Non-aggressiveness
Modesty
Silence
Respect other’s religion
Religion is a way of life
Land, water, forest belong to all
Beneficial, reasonable use of resources

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Overview/Heritage Continued

Low educational levels for most tribes, preferring children to remain at home and learn Indian ways
For the traditional, health care is an undesirable profession because one should not work with the dead or ill
Navajo sometimes have a special cleansing ceremony to allow them to work in a hospital

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

AI/AN Communication

Language and dialect vary by tribe, but most speak English and in the southwest many speak Spanish instead of English
Minor variations in pronunciation can change the meaning of the word
Talking loudly or interrupting someone is considered rude

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

AI/AN Communication

Navajos generally do not share thoughts and feelings easily outside family and friends, making it difficult to obtain trust in the healthcare setting
Comfortable with long periods of silence
Touch is unacceptable unless you know the person very well

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

AI/AN Communication

No set pattern for willingness to share tribal ceremonies
Pueblo groups usually do not share any tribal ceremonies
Light passing of the hands for a handshake
Considered rude to point with the finger; instead shift your lips in the desired direction

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

AI/AN Communication

Direct eye contact is rude and confrontational—deadpan facial expression
Proximity for conversations usually greater than 24 inches
Time sequence is present, past, and future

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

AI/AN Communication

The future is out of one’s control.
Very few are future oriented and for the Navajo there is no future verb tense
Time is not something that can be controlled, nor should time control the person; events start when the people arrive

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Family Roles and Organization

Navajo, like most Native Indian tribes, is matrilineal in decision-making and land rights
Relationship between brother and sister is more important than that between husband and wife
Children's names are not revealed at birth

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Family Roles and Organization

Older people are addressed as grandmother, grandfather, mother, father, or a nickname.
Algonquin are egalitarian society
Dene and Athabascan are patriarchal
Navajo, Iroquois, Pueblos, and Haida are matriarchial societies

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Family Roles and Organization

AI/AN naming traditions vary greatly from tribe to tribe and are frequently determined by nature, animals, or character.
In the past, AI/AN women practiced breastfeeding exclusively.
Since the early to mid-1980s, the use of formula has become popular.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Family Roles and Organization

A primary social premise is that no person has the right to speak for another.
Parents are permissive in childrearing practices and may allow a child decide whether if not go to school or take medicine.
Ceremony plays a vital, essential role in AI/ANs everyday life.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Family Roles and Organization

When a couple marries in the Pueblo tribes, the man goes to live in the woman’s house.
In Navajo tradition, families have separate dwellings but are grouped by familial relationships.
The Navajo family unit consists of the nuclear family and relatives such as sisters, aunts, and their female descendants.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Family Roles and Organization

In all American Indian and Alaska Natives extended family members play an important role in the infants’ life.
Older adults are looked on with clear deference
Elders play an important role in keeping rituals and in instructing children and grandchildren.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Family Roles and Organization

Social status is determined by age and life experiences.
Among the Pueblos governors are chosen from a particular clan; unless one is born in the clan they cannot run for tribal governor. Generally, individuals are discouraged from having more possessions than their peers, and those who display more material wealth are ignored.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Family Roles and Organization

Standing out is not encouraged among the different tribal groups.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Workforce Issues

Many AI/ANs remain traditional in their practice of religious activities. Family matters are more important than work, resulting in high rates of absenteeism.
In addition, tribal ceremonies are seen as necessary and they often must take time from work or school.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Workforce Issues

Tribal members in the community function informally as cultural brokers and assist by helping non–American Indian staff to understand important cultural issues.
Conflict is addressed indirectly through third parties in some tribes

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Workforce Issues

Group activities are an important norm in AI/AN cultures.
One individual should not be singled out to answer a question because the student’s mistakes are generally not forgotten by the group.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Workforce Issues

Issues of superior-subordinate roles exist and are related to age.
IHS is the only organization allowed to discriminate in hiring practices; it is required to hire an AI/AN when possible.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

ClickerCheck

AI/AN tribes and clans are

Patriarchal.

Matriarchal.

Egalitarian.

Depends on the tribe and clan.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Correct Answer

Correct answer: D

Some tribes and clans are patriarchal, some are matriarchal, and some are more egalitarian. Variations exist within the tribe and clan as well.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Biocultural Ecology

Skin color among AI/ANs varies from light to very dark brown, depending on the tribe.
Each of the American Indian tribes vary in terms of facial features and height.
Never assume that an AI/AN patient is from a particular tribe, if wrong, he or she will be offended.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Biocultural Ecology

Historically, most diseases affecting AI/ANs were infectious such as tuberculosis, smallpox, and influenza.
Diseases of the heart, malignant neoplasm, unintentional injuries, diabetes mellitus, and cerebrovascular disease are the top five leading causes of AI/AN deaths

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Biocultural Ecology

Type 1 diabetes mellitus is almost nonexistent in AI/ANs but type 2 diabetes mellitus is the third most prevalent chronic disease affecting all AI/AN tribes.
The incidence of diabetes varies among tribes has steadily increased and is approaching 30 percent.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Biocultural Ecology

Albinism occurs in the Navajo and Pueblo tribes.
Navajos who lived in Rainbow Grand Canyon are genetically prone to blindness that develops in individuals during their late teens and early 20s.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Biocultural Ecology

The Zunis have an incidence of cystic fibrosis seven and one-half times that found for Caucasians.
Methamphetamine (meth) abuse and suicide are two top concerns in Indian country.
Suicide rates among American Indians and Alaska Natives (AI/ANs) are 1.7 times higher than the national average.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Biocultural Ecology

Alcohol use is more prevalent than any other form of chemical misuse.
Many accidents are attributed to driving while under the influence of alcohol.
Spousal abuse is common and frequently related to alcohol use. The wife is the usual recipient of the abuse, but occasionally, the husband is abused.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Nutrition

Food has major significance beyond nourishment in AI/AN populations.
Food is offered to family and friends or may be burned to feed higher powers and those who have died.
Life events, dances, healing, and religious ceremonies evolve around food.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Nutrition

Corn is an important staple in the diet of American Indians.
Rituals such as the green corn dance of the Cherokees and harvest-time rituals for the Zuni surround the use of corn.
Corn pollen is used in the Blessingway and many other ceremonies by the Navajo.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Nutrition

Each tribe has its own version of fry bread.
Access to fresh fruits and vegetables is minimal during wintertime.
AI/AN diets may be deficient in vitamin D because many members suffer from lactose intolerance or do not drink milk.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Childbearing Family

Traditional AI/ANs do not practice birth control and often do not limit family size.
In Apache and Navajo tribes, twins are not looked on favorably and are frequently believed to be the work of a witch.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Childbearing Family

Some want their blood and urine specimens returned to them upon discharge.
Many use herbs during labor and delivery.
A ceremony may be performed by the medicine man during labor and delivery.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Childbearing Family

Be flexible with positioning for delivery.
Some may want the umbilical cord, meconium, and afterbirth.
Some may use peyote during labor and delivery.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

ClickerCheck

The most common form of substance abuse among AI/ANs is

Alcohol.

Peyote.

Marijuana.

Methamphetamine.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Correct Answer

The most common substance abuse among AI/AN tribes is alcohol which is 1.7 times higher than other groups who have been studied.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Death Rituals

Most AI/AN tribes believe that the souls of the dead pass into a spirit world and became part of the spiritual forces that influenced every aspect of their lives.
Today some tribes maintain their traditional practices but use a mortuary or use the IHS morgue to prepare their dead.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Death Rituals

The Pueblo tribes prepare their own dead and only certain family members are allowed to prepare the body.
Hopis bury their dead before the next setting of the sun and bury them in upright sitting positions with food and goods in the grave with the person.
After the Zuni burial, the members must take off three days from work for a cleansing ceremony.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Death Rituals

The body must go into the afterlife as whole as possible.
In some tribes, amputated limbs are given to the family for a separate burial and later the limb is buried with the body.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Death Rituals

In some tribes, family members are reluctant to deal with the body because those who work with the dead must have a ceremony to protect them from the deceased’s spirit.
In the Navajo, if the person dies at home, the body must be taken out of the north side of the hogan and a ceremony conducted to cleanse the Hogan or it must be abandoned.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Death Rituals

Older adults are reluctant to discuss advance directives once they discover what it means.
Effective discussions require that the issue be discussed in the third person, as if the illness or disorder is happening to someone else.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Death Rituals

If a provider makes a statement such as “if you don’t get medical care, you will die,” this implies that the provider wishes the client dead.
If the patient does die or is extremely ill, the provider might be considered a witch.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Death Rituals

The Navajo are not generally open in their expression of grief; they often will not touch or pick up the body or prepare the body for burial.
Grief among the Pueblo and Plains Tribes are expressed openly and involves much crying among extended family members

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Spirituality

AI/AN religion predominates in many tribes.
When illnesses are severe, consultations with appropriate religious organizations are sought.
Sometimes, hospital admissions are accompanied by traditional ceremonies and consultation with a pastor.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Spirituality

AI/AN tribal traditional members start the day with prayer, meditation, and corn pollen.
Prayers ask for harmony with nature and for health and invite blessings to help the person exist in harmony with the earth and sky.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Spirituality

The meaning of life for AI/ANs is derived from being in harmony with nature.
The individual’s source of strength comes from the inner self and depends on being in harmony with one’s surroundings.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Spirituality

Spirituality cannot be separated from the healing process in ceremonies.
Illnesses, especially mental illnesses, result from not being in harmony with nature, from the spirits of evil persons such as a witch, or through violation of taboos.
Healing ceremonies restore an individual’s balance mentally, physically, and spiritually.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Health-care Practices

Traditional AI/AN beliefs influence biomedical health-care decisions.
asking patients questions to make a diagnosis fosters mistrust.
This approach is in conflict with the practice of traditional medicine men, who tell people their problem without their having to say anything.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Health-care Practices

IHS has attempted to shift its focus from acute care to health promotion, disease prevention, and chronic health conditions.
Wellness-promotion activities include a return to past traditions such as running for health, avoiding alcohol, and using purification ceremonies.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Health-care Practices

Medicine men, diagnosticians, crystal gazers, and shamans tell them how to restore harmony.
Many families do not have adequate transportation and must wait for others to transport them to their appointments.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Health-care Practices

Frequently, pain control is ineffective because the intensity of their pain is not obvious to the health-care provider because patients do not request pain medication.
Herbal medicines may be preferred and used without the knowledge of the health-care provider.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Health-care Practices

Mental illness is perceived as resulting from witches or witching (placing a curse) on a person.
In these instances, a healer who deals with dreams or a crystal gazer is consulted. Individuals may wear turquoise or other items such as a medicine bag to ward off evil.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Health-care Practices

The concept of rehabilitation is relatively new to AI/ANs because, in years past, they did not survive to old age to which chronic diseases became an issue.
Autopsy and organ donation are becoming a little more accepted among traditional AI/ANs.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Health-care Practitioners

AI/AN healers are divided primarily into three categories: those working with the power of good, the power of evil, or both.
Some are endowed with supernatural powers, whereas others have knowledge of herbs and specific manipulations to “suck” out the evil spirits.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Health-care Practitioners

Health-care providers must be careful not to open medicine bags or remove them from the patient.
These objects contribute to patients’ mental well-being, and their removal creates undue stress.

Transcultural Health Care: A Culturally Competent Approach, 4th Edition

Health-care Practitioners

Treatment regimens prescribed by a medicine man not only cure the body but also restore the mind.
Individuals living off reservations frequently return to participate in this ceremony, which returns them to harmony and restores a sense of well-being.