Continuing Education Activity

Cultural competency is prioritized when providing care to American Indian/Alaska Native (AI/AN) patients due to the higher likelihood of increased mortality rates within this population, as they are more frequently affected by type 1 diabetes and other chronic disorders. Primary care physicians must implement preventive measures, including early interventions such as referring patients to nutritionists, conducting regular blood glucose checks, and initiating early screening for chronic uncontrolled hypertension, renal disease, cardiovascular diseases, and cancer. This activity reviews the clinical and public health challenges experienced by AI/AN patients, emphasizing the crucial role of interprofessional teams in evaluating and treating these conditions and addressing associated adversities.

Objectives:

• Identify the unique cultural and historical factors that influence the healthcare experiences and outcomes of American Indian/Alaska Native patients.

• Screen for the prevalence of chronic conditions, including diabetes, cardiovascular diseases, and mental health disorders, among American Indian/Alaska Native patients and understand their impact on health outcomes.

• Implement culturally competent preventive measures, such as nutritionist referrals, blood glucose monitoring, and early screening for hypertension and cancer, to address specific health needs for American Indian/Alaska Native patients.

• Coordinate care with interdisciplinary healthcare teams, including traditional healers, to ensure holistic and culturally competent care plans for American Indian/Alaska Native patients.

Introduction

Contemporary healthcare demands culturally competent interventions that recognize individual needs while fostering a connection to the broader context, considering factors such as race, culture, and gender. These interventions are paramount for minority groups such as American Indians/Alaska Natives (AI/ANs). Approximately half of AI/AN patients have reported having a personal physician or healthcare provider.

This trend underscores the urgent need to establish national and local surveillance standards to reduce social inequities, enhance culturally competent preventive measures, and expedite healthcare access for AI/AN patients. We conduct a retrospective analysis of critical health and clinical data among AI/AN individuals to highlight patient needs that can potentially improve healthcare practices and Native health-focused programs for AI/AN patients. This study may also provide insights into inclusive practices applicable to the care of various other minority groups.[1][2]

Function

Cultural competence within a healthcare setting is as vital as any life-saving medical device or procedure, serving as the foundational cornerstone for fostering compassion. In addition, it is essential to remember that data never fully represents an individual. However, when a group of people reports specific trends related to an issue, it becomes a collective responsibility for all individuals involved to take unified actions to address these issues.

• Ethnic minorities, including the AI/AN population, are more likely to develop chronic health conditions.

• Individuals with chronic conditions tend to have more frequent visits to healthcare facilities, leading to increased interactions with their physicians and healthcare providers.

• Patients may experience adverse health consequences without implementing projects to improve culturally competent outcomes for physicians and healthcare providers.

• Insufficient cultural competency can hinder communication quality between patients and physicians, thereby elevating the risk of misdiagnosis and undermining public trust.

• Ethnic minority patients have previously reported reduced rapport with their physicians, limited involvement in medical decisions, and overall lower levels of satisfaction.[3]

Embracing diversity and multiculturalism enhances interactions among physicians and patients, thereby improving physicians' image as compassionate professionals. When presenting cases, medical students are taught to prioritize a patient's age and gender as a secondary consideration and race as a potential factor. These details are essential for understanding an individual's unique characteristics and background. Fostering diversity and embracing multiculturalism in the medical field strengthens the rapport among healthcare providers and their patients, ultimately enhancing doctors' perception as empathetic and compassionate professionals. As healthcare students commence their medical education journey, they are typically instructed to initiate case presentations with the patient's age, followed by gender, and often, their race or ethnicity. This standardized approach underscores the importance of recognizing each patient's identity and background.

Acknowledging these individual characteristics goes beyond mere formality, as it recognizes each person's unique life experiences, health determinants, and possible genetic or environmental risk factors. By identifying these nuances, healthcare professionals can customize their approach and treatment plans, ensuring that each patient receives care that is both personalized and culturally sensitive. This comprehensive understanding ultimately improves patient outcomes and nurtures mutual trust and respect in patient care.

Every individual presents a unique set of backgrounds and circumstances to their physician, necessitating the creation of personalized treatment plans tailored to these specific patient details. However, this process is considered a fundamental aspect of medical practice. In daily medical practice, treatment protocols can sometimes appear less distinct because all humans are part of the same species and share similar medical principles; thus, everyone should be treated equally. This is particularly evident in general caregiving settings with larger patient populations than in other sectors. However, physicians need to resist the temptation of prioritizing symptomatic treatment over holistic patient care.

Issues of Concern

AI/AN patients exhibit a lower life expectancy than most other ethnic groups. Compared to white individuals, AI/AN groups are also more likely to face limited opportunities for pursuing higher education, which can increase their vulnerability to various detrimental chronic conditions and lower quality of life. A survey-based analysis indicates that AI/AN individuals are inclined to consume more sugar-sweetened beverages, which can contribute to obesity and subsequently predispose them to hypertension and diabetes. This population has also reported a sedentary lifestyle and limited physical activity in residential settings, leading to poor health outcomes. The lack of higher education creates a barrier for this group to access high-paying jobs, which results in unemployment and impedes progress. These factors necessitate immediate action to enhance preventive measures to address chronic conditions within the population and mitigate social inequities.[4][5]

The economic challenges faced by the AI/AN population have also impacted their healthcare costs. Many members are reported to cover their healthcare expenses, whereas others rely on the Indian Health Service (IHS) for their healthcare coverage. Although the IHS grants access to medical care through federal clinics and hospitals, accessing specialist-level consultations outside the IHS system can be challenging. In this context, attaining comprehensive healthcare coverage may be an elusive goal for these members.[6]

The geographical placement of IHS facilities represents another pivotal concern in maintaining the health of AI/AN individuals. IHS facilities are usually located in remote areas within Indian reservations. When AI/AN individuals relocate in pursuit of employment or higher education outside of these areas, they lose access to these facilities, resulting in restricted healthcare access.

AI/AN individuals encounter a series of barriers when accessing healthcare providers, including travel costs and extended waiting times. Language barriers within IHS facilities present challenges in delivering suitable preventive measures for these patient groups. Obtaining specific data on Native American health remains challenging within the current system. Despite Congressional mandates for the IHS to analyze and document clinical performance for quality control, obtaining follow-up data remains a formidable challenge. As the IHS operates with federal funding, allocating data for quality control becomes more challenging. The quality of IHS services has often been compromised due to inadequate funding, leading to delayed preventive measures and reduced clinician attendance at facilities.[7][8][9]

Physicians have identified the following challenges when providing care to indigenous populations:

• Limited access to highly trained and qualified specialist physicians

• Hospitalization for non-emergency purposes

• Access to top-tier diagnostic screening

• Availability of high-quality outpatient mental health rehabilitation facilities

A significant proportion of general practitioners and providers (59%) reported facing challenges when addressing issues without specialist referrals, notably higher (16%) than the usual rate. Although 32% of physicians cited a shortage of nearby specialist services as a significant challenge, a majority of 63% of physicians identified insufficient IHS resources as a "very important" barrier to accessing subspecialist care.[8]

For screening mammography (54%) and diabetic eye examinations, a relatively small percentage of primary care doctors (60%) indicated the availability of preventive programs. Clinical performance exhibited significant variation across the screening sites for ductal carcinoma, with an interquartile difference of 31% to 55%, and diabetic eye examinations, with an integrating range of 44% to 58%. Health centers where a higher percentage of doctors reported that mammography testing was readily available demonstrated a more satisfactory breast cancer screening rate (46%) than centers where fewer doctors reported service availability (35%). This association was statistically significant at the health center level (P = .04, simp = 0.27).[8]

Clinical Significance

Diabetes mellitus (DM) is the foremost cause of mortality among AI/AN patients. The impact of DM on AI/AN patients is multifaceted, as mentioned below.

• In contrast to individuals from other populations, AI/AN patients may experience the onset of DM at a younger age.

• DM can contribute to the development of cardiovascular diseases (CVDs), and the subsequent mortality rate due to CVD is notably higher in AI/AN individuals compared to other populations.  

• Within the AI/AN population, a genome-wide scan has identified several chromosome linkages that indicate genetic factors contribute to their elevated risk of DM and CVD.[10]

• Pertinently, research frequently highlights the significance of cultural norms and historical factors, in addition to race or ethnicity, all of which collectively contribute to the prevalence of DM and CVD within the AI/AN population.[11]

Consequently, when designing preventive programs to reduce the prevalence of obesity, diabetes, and CVD among adults and children in the AI/AN community, it is imperative to consider various factors, including cultural, economic, and regional aspects.[12] Prevention programs should focus on the following key elements:

• Addressing behavioral risk factors and promoting lifestyle improvements

• Encouraging tobacco avoidance

• Promoting a balanced diet

• Increasing physical activity levels

Significant evidence links tobacco misuse, high cholesterol levels, DM, and hypertension to the increased incidence of CVDs in the AI/AN population.[13]

An analysis of SHS outcome data pertaining to chronic heart disease (CHD) has highlighted the following significant risk factors for CHD within this population:[14][15]

• Age

• Gender

• Total cholesterol

• Low-density lipoprotein cholesterol

• High-density lipoprotein cholesterol

• Smoking

• Albuminuria

• DM

• High blood pressure

During interviews conducted through the BRFSS, it was found that AI adults residing in the 7 Montanna reservations had a significantly high level of modifiable risk factors for CVD, both with and without DM. Prominent risk factors for DM and CVD include physical inactivity, obesity, and hypertension. Physical inactivity is considered a modifiable risk factor, and obesity is a controllable risk factor. AI/AN individuals can manage DM, CVD, and obesity through regular exercise. Engaging in exercise and achieving weight loss are recognized strategies for reducing blood pressure, improving insulin sensitivity, preventing or delaying the onset of type 2 diabetes, lowering the risk of CVD, and reducing the likelihood of heart attacks and strokes.[16][17]

Native or Indigenous people hold diverse definitions and perceptions of mental illness, as well as various assumptions about its causes and origins. These groups of people may not differentiate between physical complaints and psychological issues, and they may express emotional distress in manners that do not align with conventional diagnostic categories.[18][19]

Native or Indigenous individuals who meet the criteria for conditions such as depression, anxiety, or drug dependence are significantly more inclined to seek assistance from a spiritual and/or traditional healer rather than from specialists or other medical sources. A lack of awareness regarding mental health conditions and available resources, coupled with a shortage of programs and healthcare providers culturally sensitive to Aboriginal and Indigenous cultures, can deter Indigenous individuals from seeking medical care.[20][21]

Other Issues

The prevalence of reservation segregation, poverty, and isolation significantly contributes to the challenges faced by AI/AN tribal citizens, exacerbating disparities in their mental health status. Despite the significant existing literature on the subject, interpreting research findings on the prevalence of mental health issues of AI/AN patients was challenging until recent developments.[22] This publication paradox exists because external practitioners working in AI/AN contexts seek publication avenues for their anecdotal observations, leading to the high visibility of anxiety experienced by AI/AN groups. In addition, conducting controlled studies in AI/AN populations presents substantial challenges.[23] 

The previous challenges included in this population are listed as follows:

• Limited sample sizes
• Remote and isolated locations
• Communication barriers
• Cultural disparities
• Distrust of Euro-American outsiders, including academic researchers

European and Euro-American officials have extensively scrutinized AI/ANs for decades. During the late nineteenth century, many of these findings and attributions, often critical or denigrating in nature, were framed within the language and framework of mental health and psychopathology, coinciding with the emergence of the "psy-" sciences.[24][25]

Enhancing Healthcare Team Outcomes

Culturally responsive healthcare cannot be simplified into rigid formulas or prescriptions that yield a single definitive solution. Instead, it requires a deep understanding of the fundamental principles of healthcare and how culture can influence them. Education can influence the health and healthcare experiences of individuals from diverse ethnic and cultural backgrounds. Since its inception, the growth, significance, and importance of multicultural healthcare have been pivotal. Within postgraduate clinical education, knowledge regarding community needs, traditions, and values should be integrated.[26] 

Clinicians should approach the care of a diverse range of patients from multiple perspectives, as mentioned below.

• They should establish formal, coordinated advocacy or joint initiatives with organizations such as the Association of American Medical Colleges (AAMC) and the Accreditation Council for Graduate Medical Education (ACGME). These initiatives should aim to significantly increase the representation of students and residents from AI/AN tribes in medical schools while also increasing their proportion in primary care and, eventually, hospitalist professions.

• They should gather precise racial, ethnic, and gender data about AI/AN community members and explore potential collaborations with IHS to incorporate demographic considerations into their survey tool for individual hospital compensation and productivity data. Furthermore, physicians should oversee the Practice Study Committee responsible for conducting demographic surveys of leadership on an ongoing basis. They should also explore formal expansion opportunities through ACGME by 2022.

• They should implement a public relations initiative to highlight the underrepresentation of AI/AN hospitalists in management positions within the healthcare systems and other employers. This initiative encourages purposeful endeavors to increase diversity within these leadership ranks.

• They should establish scholarships for hospitalists from underrepresented racial and ethnic groups, enabling them to attend Society of Hospital Medicine (SHM)-sponsored leadership development programs, including the Academic Hospitalist Academy, Leadership Academy, and Quality and Safety Educators Academy. This initiative aims to enhance their representation in positions of authority in healthcare.

• They should implement an educational pathway, mentorship program, or other developmental initiatives designed for aspiring hospitalist leaders and those keen on enhancing their leadership capabilities.

• They should give special attention to initiatives that increase the proportion of AI/AN hospitalists in leadership roles.

• They should assess and review existing SHM papers and position statements to ensure that discussions related to diversity, equality, and inclusion are incorporated across various aspects of hospital medicine, encompassing staff and leadership, patient care, and efforts to eliminate health disparities.

• They should set up healthcare programs led by nonprofit organizations to address primary care and specialized healthcare requirements in remote AI/AN communities. They should advocate for federal funding and additional secondary funding sources.

• They should develop culturally competent clinical guidelines for the treatment of AI/AN patients and emphasize preventive measures, including:

• Nutritionists and dietitians support
• Annual glucose checkups
• Early screening for digestive and other types of cancer

Nursing, Allied Health, and Interprofessional Team Interventions

During their training, nurses can effectively represent the diversity of the country's society by broadening their understanding of racial, ethnic, and cultural commonalities and distinctions when interacting with individuals from various racial and ethnic backgrounds.[27]

Increasing evidence suggests that diversity can enhance learning outcomes for all students in educational settings by improving the following skills:

• Critical thinking

• Academic involvement

• Motivation

• Essential social and civic skills, including empathy, as well as racial and cultural understanding

Educational institutions should view diversity as an institutional asset that enriches the educational and training experience of all physician assistants.[28][29]

To address this priority, the following measures should be considered:

• Educational institutions must prioritize inclusion by implementing proactive initiatives.

• Health professional schools should creatively engage AI/AN men, women, and their populations in pipeline and recruitment activities, whether formal or informal, as recommended by experts.

• The institutions should establish nonprofit-led allied healthcare programs to serve primary care needs in AI/AN communities.