Cultural Competence In Caring For American Indians and Alaska Natives

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Continuing Education Activity

Cultural competency is emphasized in treating American Indian/ Alaskan Native (AI/AN) patients because the mortality rates are more likely to increase in the population since they acquire Type 1 Diabetes and other chronic disorders more often. Preventative measures are required from their primary care physicians. Early measures include nutritionist referrals, blood glucose checking, and early screening for chronic uncontrolled hypertension, renal disease, cardiovascular diseases (CVDs), and cancer. This activity reviews the clinical and public health issues faced by AI/AN patients. It highlights the role of the interprofessional team in evaluating and treating those conditions and addressing such adversities.


  • Describe the typical reasons for a delayed diagnosis of chronic diseases within AI/AN patients.
  • Explain the psychosocial considerations for patients with AI/AN racial background.
  • Outline the management considerations for patients with limited healthcare access in AI/AN areas.
  • Summarize how to counsel a patient with chronic diseases from AI/AN background.


Modern healthcare requires culturally competent interventions that acknowledge individual needs while connecting the individual to the whole, considering race, culture, and gender. These interventions are crucially significant for minorities such as the American Indians/Alaska natives (AI/AN). About half of AI/AN patients reported having a personal physician or healthcare provider.

This trend indicates an immediate need to set surveillance standards across national and local levels to narrow social inequity, establishing culturally competent prevention skills, and accelerating healthcare access for AI/AN patients. We retrospectively review significant health and clinical details of AI/AN to highlight patient needs that may help improve healthcare practices and specific native-health-based programs for AI/AN patients; this study may also generalize inclusive practices for treating several other minorities.[1]


Cultural competence in a healthcare setting is as important as any other life-saving medical device or procedure, as it is the first brick of building compassion. It is important to remember that data is never representative of an individual; however, when a group of people reports certain trends about an issue, it becomes a duty for every individual involved to take united actions to resolve such issues. 

  • Racial minorities such as the AI/AN population are more likely to acquire chronic health conditions.
  • Patients with chronic conditions visit healthcare facilities more than other people, increasing their interaction with physicians and healthcare providers.
  • Patients will face deleterious health results if projects are not established to enhance culturally competent outcomes for physicians and providers
  • Lack of cultural competency will deter communication quality between the patients and physicians, increasing the risk of misdiagnosis and loss of public trust.
  • Ethnic minorities have previously reported less connection with physicians, minimal involvement in medical decisions, and low satisfaction.[2]

The acceptance of diversity and multiculturalism enhances physician-patient interaction and improves physicians' image as caring professionals overall. Physicians learn as medical students that every case is presented first by age, then by gender, and then often by race. These details are crucial to represent what the individual stands for.

Every individual comes to the physician with a unique slate; the physician must design an individualized treatment plan based on those concrete details; this, however, is a textbook procedure. On a day-to-day basis, treatment protocols blur as all human beings belong to the same species, so the science is approximately the same for treating everyone; especially on a general caregiving level where the patient count is higher than other sectors, it can sometimes become tempting for physicians to focus on symptomatic treatment than consider the patient as a whole. This temptation, however, must be avoided.

Issues of Concern

AI/AN patients have lower life expectancy than most other ethnic groups. Compared to whites, members from this group are also likely to lack opportunities to pursue higher education, leading to lower quality of life; thus, they are susceptible to developing various deleterious chronic conditions. A survey-based analysis shows AI/AN members are prone to consume sugar-sweetened beverages leading to obesity that predisposes them to hypertension and diabetes. A sedentary lifestyle along with residential inactivity has also been reported, leading to poor health. Lack of higher education provides a barrier to the population from attaining high-paying jobs, therefore, immobilizing progress and causing unemployment. These factors call for direct action to escalate preventive measures for tackling chronic conditions within the population but also social inequity.[3]

The economic deficits of the AI/AN population have also affected its healthcare costs. Most members reportedly covered their own healthcare expenses and others by the Indian Health Service (IHS). The IHS grants access to medical care at federal clinics and hospitals, toughening their pathway to acquire specialist-level consults in non-IHS sites. Health coverage in this scenario may seem like an unattainable reality for these members.[4]

The location of IHS facilities is another crucial issue in maintaining AI/AN health. IHS facilities are usually located in remote areas on Indian reservations. When AI/AN populations move out of the areas seeking jobs or higher education, they lose access to the facilities, which results in limited healthcare access for the AI/AN.

Furthermore, the AI/AN face a chain of barriers to accessing their providers due to travel costs and longer hold times. Language barriers within IHS facilities make it difficult to provide appropriate preventative measures for the patients. Specified data on Native American health is still hard to allocate in the current system. Despite Congressional demands for the IHS to analyze and document clinical performance for quality control, follow-up data is tough to acquire. Since IHS is federally funded, data allocation on quality control is significantly tougher. IHS quality was often diluted by deprived funding that rid the facilities of timely preventative measures and clinician attendance.[5][6]

Physicians noted the following issues in treating indigenous populations:

  • Access to highly trained and qualified specialist-physicians is comparatively minimal.
  • Hospitalization for non-emergency purposes
  • Diagnostic screening of the highest caliber
  • Refined quality outpatient mental health rehabilitation sites

An adequate number of general practitioners and providers (59%) reported having difficulty handling issues without specialist referral was more (16%) and mildly greater than the usual. Although 32 percent of physicians cited a shortage of specialist services in close vicinity as a crucial challenge, a much greater majority (63 percent) thought that a "very important" wall was an insufficiency of IHS resources to allow the possibility of treatment by subspecialists.[6]

For screening mammography (54 percent) and diabetic eye tests, a limited number of primary care doctors (60 percent) responded with the availability of preventive programs. Clinical performance ranged widely across the screening sites for ductal carcinoma (interquartile difference of 31 percent to 55 percent) and diabetic eye examination (intergrading range 44 percent to 58 percent ). Health centers with a higher percentage of doctors indicating that mammography testing was readily accessible had an adequate screening rate for breast cancer (46 percent) than those hospitals with the lowest percentage of doctors responding to service availability (35 percent), with a strong association at the level of the health center (p = 0.04, simp = 0.27).[6]

Clinical Significance

Diabetes mellitus (DM) is the leading cause of death for AI/AN patients:

  • Compared to members of other populations, AI/AN patients may develop DM at a younger age.
  • DM may lead to cardiovascular disease (CVD), and the CVD-led death rate is comparatively higher in AI/ANs than in others.
    • In the AI/AN population, a genome-wide scan identified a number of chromosome linkages that indicate that genetic factors contribute to their elevated danger of DM and CVD.[7]
    • Pertinently, research often indicates that cultural norms and historical factors play important roles in the prevalence of DM and CVD in this population, in addition to race/ethnicity.[8]

Consequently, when designing preventive programs to reduce the prevalence of obesity, diabetes, and CVD incidence among adults and children in the AI/AN community, several factors should be considered for counting cultural, economic, and regional factors into account.[9] Prevention programs should concentrate on:

  • Behavioral risk factors and improvements in lifestyle
  • The avoidance of smoking
  • A balanced diet
  • Increased physical activity.

Evidence indicates that many risk factors lead to the increased incidence of CVD in the AI/AN population:

  • Tobacco misuse
  • High cholesterol levels
  • DM
  • Hypertension.

Analysis of SHS outcome results from chronic heart disease (CHD) revealed that the following were important risk factors for CHD in this population:[10]

  • Age
  • Low-density lipoprotein (LDL) cholesterol
  • Gender
  • Total cholesterol
  • High-density lipoprotein (HDL) cholesterol
  • Smoking
  • Albuminuria
  • DM
  • High blood pressure

Interviews of AI adults residing in the seven Montana reservations conducted through the BRFSS demonstrated an alarmingly high level of modifiable risk factors for CVD among those with and without DM. Established significant risk factors for DM and CVD include:

  • Physical inactivity
  • Obesity
  • Hypertension

Of these factors, physical inactivity is changeable, and a controllable risk factor is obesity. By managing regular exercise and obesity, AI/AN members can prevent DM and CVD. Exercise and weight loss are well known to reduce blood pressure, improve insulin sensitivity, avoid or postpone the onset of T2D, lower the risk of CVD, and decrease the risk of heart attack and cerebral stroke.[11]

Native/Indigenous people have several different definitions and perceptions regarding mental illness and assumptions on why and how it occurs. There is no difference between physical complaints and psychological problems, and native/indigenous individuals may convey emotional distress in ways that are not compliant with standard diagnostic categories.[12] 

Native/Indigenous people who meet the requirements for conditions of depression, anxiety, or drug dependence are far more likely than specialties or other medical outlets to seek support from a spiritual and/or traditional healer. A lack of knowledge of mental health conditions and resources available and a lack of programs and providers sensitive to aboriginal and indigenous cultures can discourage care for indigenous people.[13]

Other Issues

Due to reservation segregation, poverty, and isolation, common skew for the troubles within AI/AN tribal citizens, triggering greater differences in their mental health status. Research discussing the prevalence of mental health issues for AI/ANs has remained difficult to interpret confidently until recently, despite a disproportionately large literature on AI/AN mental health.[14] This publication paradox undoubtedly derives from both the strong conspicuousness of AI/AN anxiety to outside practitioners working in these settings (many of whom have frequently sought publication venues for their impressionistic observations) and the enormous difficulties associated with performing controlled studies in AI/AN populations.[15] Previous issues included:

  • Smaller samples
  • Remote locales
  • Communication gap
  • Cultural differences
  • Suspicion of Euro-American outsiders, including academic researchers.

For decades, AI/ANs have been the focus of European and Euro-American scrutiny. Many of these (often critical or denigrating) findings and attributions were cast in mental health and psychopathology vocabulary with the rise of the "psy-" sciences in the late-nineteenth-century.[16][17]

Enhancing Healthcare Team Outcomes

Culturally responsive health care is not a matter of clear formulas or prescriptions that provide a single conclusive answer. Instead, it needs awareness of the founding values of health care and how those principles can be affected by culture. Education may affect the health and health care of ethnic and cultural backgrounds. From its founding years, the growth, significance, and importance of multicultural health care are crucial. In postgraduate clinical education, knowledge of community needs, traditions, and values should be integrated.[18] The physicians should approach taking care of a diverse set of patients from all probable angles:

  • Establish formal, coordinated advocacy or joint initiative with organizations such as AAMC and the Accreditation Council for Graduate Medical Education (ACGME) to facilitate substantial increases in the proportion of students and residents of medical schools who are people of AI/AN tribes and in the ration who choose primary care and, eventually, hospitalist professions.
  • Collect accurate racial, ethnic, and gender data about AI/AN members and consider working with IHS to integrate demographic concerns into its survey tool for individual hospital compensation and productivity data. Regulate the Practice Study Committee in charge of the survey to continue surveying the demographics of the leadership.
    • Consider formal expansion opportunities by 2022 via ACGME.
  • Implement a public relations initiative to highlight the under-representation of AI/AN hospitalists in management roles to health systems and other employers and to inspire deliberate efforts to expand those ranks.
  • Build scholarships to attend SHM-sponsored leadership development programs such as Academic Hospitalist Academy, Leadership Academy, and Quality and Safety Educators Academy for hospitalists from underrepresented racial and ethnic groups to grow their ranks in positions of authority in healthcare.
  • Establish an educational route, mentoring program, or other development initiatives for new hospitalist leaders and those interested in improving leadership abilities.
  • Ensure that initiatives to increase the proportion of AI/AN hospitalists in leadership roles are given special attention.
  • Evaluate and review current SHM papers and position statements to ensure that diversity, equality, and inclusion are discussed, all about the staff and leadership in hospital medicine, patient care, and eliminating health inequalities.
  • Establish non-profit organizations-led healthcare programs to serve primary care and specialized needs in remote AI/AN communities.
    • Lobby for federal funding and secondary fundings.
  • Build culturally competent clinical guidelines for treating AI/AN patients, ensuring preventative measures are taken:
    • Nutritionist and dietitian coverage
    • Annual glucose checkup
    • Early digestive and other cancer screening

Nursing, Allied Health, and Interprofessional Team Interventions

Nurses can better represent the country's diverse society by having expanded perceptions of racial, ethnic, and cultural similarities and differences when meeting and engaging with people from a range of racial and ethnic backgrounds during their training.[19]

  • Increasing evidence suggests that diversity can enhance learning outcomes for all students in educational settings, enhancing skills, such as
    • Active thinking
    • Academic involvement
    • Motivation
    • Adequate social and civic skills, such as empathy and racial and cultural comprehension.

School officials should see diversity as an institutional advantage that enriches all physician assistants' education and training experience.[20]

  • Introduce inclusion initiatives representing this priority.
  • To engage AI/AN men, women, and their populations, health professional schools, should think creatively about pipeline and recruitment activities, whether formal or informal.
  • Establish non-profit organizations-led allied healthcare programs to serve primary care needs in AI/AN communities.

Article Details

Article Author

Ahmed Nahian

Article Editor:

Natasha Jouk


8/27/2021 5:42:34 PM



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