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Cultural Considerations
While Serving the Indian Health Population

Many individuals do not realize the impact that cultural competence has on the outcomes of interactions or services they provide. While there is no universally accepted definition of “cultural competence”, the term has come to mean a set of skills that allows someone to increase their understanding, and appreciation of cultural differences between groups. As pharmacists and pharmacy technicians, we have a unique opportunity to positively influence the health status of our communities by utilizing our skills and training along with serving in a culturally competent way. To be culturally competent, it is important to address and understand our own cultural views along with those of the American Indian or Alaskan Native (AI/AN) patients that we serve. Cultural competency is not served well by stereotypes and generalizations. C.R. Myers (Medicine’s Melting Pot. Minn Med 1996) describes four major cultural competency challenges that health care providers face:

• Recognizing clinical/health related differences in individuals depending upon ethnicity/culture. For example, American Indians/Alaskan Natives have a higher risk for developing diabetes than other cultural groups.
• Understanding communication differences that may include the need for an interpreter; how to explain certain disease states; how to ask about topics that are considered taboo, etc.
• Respecting different belief systems with regards to ethics. This can challenge firmly held western beliefs. For example, whether to discuss issues like “do not resuscitate (DNR) status”.
• Encouraging trust/respect so that an individual feels comfortable being honest about their health and practices. Some cultures will respect clinical authority so much that they will agree with the clinician with the intent to provide ‘acceptable’ answers.

Most of us have encountered these or similar challenges as we have been exposed to the various beliefs, traditions, and customs of the community we are serving. Our individual cultural competency shapes the way our relationships are formed, and positively or negatively affects how the community interacts with us. Cultural competence helps health care providers to address the diverse perspectives on health, wellness, life and disease that Native individuals can only provide.

Knowledgeably seeking awareness and respectful understanding of the traditions that are the way of life for many American Indians and Alaskan Natives enhances our role as a health care provider. In fact, the Office of Minority Health states,

“Cultural competency is one of the main ingredients in closing the disparities gap in health care. It’s the way patients and doctors can come together and talk about health concerns without cultural differences hindering the conversation, but enhancing it” (Read the full quote ).

Culturally competent communication with a patient means that we “…recognize the cultural beliefs, values, attitudes, traditions, language preferences, and health practices of American Indian/Alaskan Natives and…apply that knowledge to produce positive health outcomes” (Read the full quote).

We recommend that in addition to reading the material presented here, you seek out additional training sources to enhance your cultural competency. Your community members will notice that you are making an effort to respectfully understand their culture. There are several good references, to start or continue your journey with cultural competency, provided in the Resources section at the end of this issue. Your Service Unit or Tribal Organization may also provide you with a cultural competency overview. Be aware that you’ll find that even within communities, the cultural norms can vary.

The following general information is provided by a few of the over 100 American Indian or Alaskan Native pharmacists and pharmacy technicians that currently serve in Indian Health. The cultural differences that are described here are not all inclusive, but instead an overview of some American Indian/Alaskan Native cultural variations. You will realize that we all have something to learn from the communities we serve, whether we are native or non-native individuals. Consequently, we should consider learning to adapt our approaches to our patients, to the culture, and the philosophy and belief system of our communities.

Greeting
Each community has their way of greeting one another upon meeting. Most Navajos for example, will shake hands lightly or barely touch at all. Some communities might not shake hands or avoid non-medical contact altogether. The belief is that they do not know who you are and/or do not want “badness” to come to them. Other communities, once they know you, might embrace you and breathe in near your hands to reap “blessings” that have been bestowed upon you (e.g., intelligence, good health, etc.).

Some communities might take time to see how an individual is doing before they jump right into discussing the business at hand. We recommend simply taking a moment to sincerely ask, “How are you doing?” versus a more direct and clinical approach of asking, “What brings you in today?” Listen to their response, while attempting to keep their comments to a minute or two, before inquiring of the person’s medical needs. With limited time in the clinic setting, you can modify your approach to fit the needs of the community. Realize that respect and approaching patients in a culturally appropriate manner will assist you in building relationships with individuals.

Eye Contact
Many communication courses teach that effective, engaged conversations include direct eye contact as a form of feedback from an individual who is interested in what you are saying. However, some communities engage with their ears and will look down or away as a form of respect and interaction. This is particularly true of elders and more traditional American Indians/Alaskan Natives. In fact, in some communities, to look directly in someone’s eyes while talking to them can be disrespectful. Actively assess your response with the individual and keep in mind that eye contact might be appropriate if the person is young and “modern”. Please keep in mind that everyone is different and up to 80% of communication can be non-verbal cues.

Questions
Most individuals realize that health care providers utilize questions to better understand medically related issues. However, be aware that asking additional questions that are not related to the medical concern can actually offend an individual who may perceive you as “nosey”. This may be true if you are asking about why a certain tradition is practiced the way it is or what goes on in the kiva, for example. Stay focused on the medical aspects of care, but if you need additional information, creatively unite it with the issue at hand.

In addition, pharmacists usually need to know a complete medication list and will often ask about herbal use. Some individuals might feel uncomfortable sharing that sort of information because it can be related to sacred ceremonies. Instead, one might say, “We try to get a complete medication list to make sure medications are not interacting or harming the body. Would you be comfortable sharing with me the names of any herbal or traditional medicines you might be using?” If the individual says, “no” then don’t pursue it. The person might not know the common name of the plant or may only know the native name in their traditional language. In addition, it may be taboo to discuss certain information or even say the names of the medicines outside of a ceremony or blessing.

Explaining potential outcomes/side effects
Many communities believe that by talking about a potential problem, it will make the problem come true. If you want to discuss a potential complication or side effect, we recommend that you use the third person dialogue such as, “In some people…who don’t control their blood pressure, their kidneys can get tired out from having to work so hard. This may cause the kidneys to stop working”, rather than saying, “If you don’t control your blood pressure, your kidneys will stop working”.

Native Language
Many communities speak their native language when they are among each other. Although you might not understand the words, do not feel left out as this is their preferred method of communicating and for most, English is not their primary language. You may also find that some native languages intersperse English words while they talk because there are no native words to describe what they are trying to say. One pharmacist, speaking on behalf of her community says,

“Please do not become offended when a conversation is being carried out amongst one another in the Crow language. An unwritten understanding is that we speak our language to one another first, then translate for non-speakers who may be present. A Crow speaker does not intend to be rude or make one uncomfortable by speaking the language.”

Unfortunately, you might also recognize that the younger generation may not speak their language fluently or at all. If you find the need to use an interpreter, remember to address the patient NOT the interpreter. The interpreter is there to assist you and is not the patient in need of medical care. You’ll realize that some sites utilize the pharmacy technicians as interpreters even though the patient has a native speaking family member with them. This is done because sometimes the family member is not familiar with medical terminology or does not speak fluently and the pharmacist would not know what is being said by the family member.

Taboos
You might hear some individuals tell their children not to play with crutches or wheel chairs as they believe that will bring harm upon the child. Other taboos may include not throwing medication away, and not pointing at people with fingers. In most cultures, the elderly are highly respected and some customs involve walking around an elder a certain way. In others, it is highly taboo to cross directly in front of an elder. Be mindful of these practices when engaged among your patients both inside and outside of the pharmacy.

Beliefs within the communities might be similar to this or you may encounter others as you continue to work within Indian Health. Some of the oldest customs are still being practiced today and, due to oral translations over time, little may be known about why some things are done and some are not. It is considered rude and intrusive to ask why certain things are taboo or done a certain way. If you feel that you need to know something that will help you provide better care for the patient, consider asking a native coworker or someone that has been in the community for an extended amount of time. At times, you may need to suppress your curiosity as curiosity alone can be intrusive and disrespectful.

Food
In some communities, you should not refuse food when offered, or ask for something that’s not offered. This is considered rude. Many tribes offer food or beverage as a courtesy to their guests. Many tribes share the same history of “feast and famine” so sharing food has become a cultural norm. Sharing also promotes the cultural understanding of “give and take”. For example, “If I share with you now, there might come a day that when I am in need then you will share with me.”

If you are providing education, be aware of the foods that are commonly prepared in that particular community. For example, if the individuals eat fry bread, you might suggest making the bread with ½ wheat flour and ½ white flour along with cooking in vegetable or canola oil instead of lard. You might also suggest smaller portion sizes. We do not suggest that you recommend changing their eating habits completely, for example telling them fry bread is bad and they should never eat this type of bread. Rather encourage healthy choices with their daily or ceremonial diet.

Be aware that some individuals rely upon commodity food and/or do not have fresh fruit and vegetables readily available. Consider attending local powwows or talking circles to see what they traditionally eat and how it’s prepared. Again, encourage individuals to do the best that they can with what is available to them.

Medicine Man/Woman
Many tribes acknowledge individual tribal members as healers and/or spiritual leaders. In the “old days” and today, many young men fast and seek visions through practices unique to their tribe. Through these practices, a man may be chosen by his medicine fathers as a person worthy to obtain medicine objects and healing ways. In this belief, the power comes through these sources but the ultimate power is in the Creator or Maker of All Things.

These chosen individuals may be called upon by tribal members to intercede on behalf of an individual in need. Often, these practices are conducted in the privacy of the individual’s home or designated place. If an individual is hospitalized, usually the prayer will be conducted at the bedside. Information is often shared openly but to inquire would be considered rude. This religion is not practiced by all American Indians/Alaskan Natives but is a way of life for many and has been around for thousands of years.

Medicine men and women are treated with the utmost respect throughout the American Indian/Alaskan Native community. It may be helpful to ask a coworker who knows the local customs or authorities what to do when such a person is in their presence. It is always important to acknowledge and respect their importance in the community and among the people.

The service and assistance of a medicine man/woman might be sought by a patient for many reasons. Typically, this is neither something the patient will tell you nor is it recommended that a provider directly ask the patient if they are having or have had a ceremony. Depending on the relationship you have with your patient, allow them to volunteer this information. However, there might be something unusual noticed with the patient that might catch a provider’s attention. Before directly asking the patient what is going on, we would recommend excusing yourself from the exam room or waiting until after the medical visit is completed. As a medical provider, you could seek a tribal community member who is on staff to inquire of what was seen—without breeching HIPAA. As with any form of healing methods, adverse outcomes can occur. However, because the spiritual and mental impact on the patient is unknown, we should not judge negative outcomes of these alternative healing methods. If you show respectful concern, tribally affiliated staff will be more willing to assist in your understanding of their culture and methods of healing.

One of our contributing pharmacists provides an intriguing example of the incorporation of cultural beliefs and practices along with “western medicine”. She mentions,

“Many tribes have cleansing rituals prior to ceremonies. In one particular patient I have been dealing with for over 20 years, each time he danced (and he loved to dance in ceremonies) he was hospitalized for atrial fibrillation, edema, and has since developed CHF, as we would have anticipated. However, he is 88 now, and still dances twice a year, with the full fasting and preparation of herbs. He is himself a medicine man. We developed an agreement over the years, that he would substitute herbs, for his meds. My job was to tell him exactly what his benefit was from the white medicine, and he would match it with his herbal remedies. We did pretty well, actually. He takes our medication, unless he is cleansing, and he understands that his herbs, although they give him about the same results, cardiac wise, impair his anticoagulation. We just discontinue his warfarin for fasting, after we have worked him up to the higher level of normal, and he restarts it immediately. He drinks more tea, with aspirin like qualities, the days he is fasting, as it is allowed. It took about 3 years to get to the sharing point, but I feel quite sure together we have made it possible for him to reach his soon to be 89th birthday, and still participate with dignity in his tribal rituals”.

She continues on to share,

“We did have another medicine man, who worked out of his car in the hospital parking lot, talking about what shysters and killers of Indians we were! … I just stopped by each evening and visited with him. We began talking, and once or twice I asked about a treatment and commented about his treatment that seemed to help one of the patients, and… about how I was SURE he was aware that anticoagulation drugs were affected by herbs and that caused stroke, etc. He educated me, and I educated him. We did not always agree, but we did communicate with each other and probably the most important thing was we were seen communicating. That meant I was NOT the enemy any more. He even offered to smoke my daughter’s horse prior to the national finals rodeo…This helped a great deal. People began to ASK if their medicine man medications would help or interfere, or could be a problem. When it came right down to it, few things are ingested, and there is lots of positive reinforcement through the medicine man”.

Declining Offers/Services
You might find that some individuals avoid saying, “No” or are unwilling to decline something that is offered because to do so is considered rude. This might be evident in someone being scheduled for appointments and never showing up. They might agree to be signed up for an appointment with the intention of never showing up. We recommend trying not to shame the individual for missed appointments. Rather educate them on your clinic policy (for example, 3 no shows and they go on a waiting list) and the availability of services, and reasons to keep their appointments (e.g., “the podiatrist is only here once a month…”). You may also mention how to cancel an appointment so that another person who is need of care can have the opportunity to see the provider. This is a good opportunity to discuss what their needs are and what is acceptable and important to them.

Some individuals feel that a certain disease or condition comes to them as either a visit from bad spirits or because of an inevitable course of events over which they have no control. To “get rid of it” or “treat” it might be the goal in the eyes of a health care provider, but to the patient that might mean “going against what is supposed to happen.”

Caring For Others
Most Native American/Alaskan Native communities are very family oriented including extended family members. Therefore, realize that when you ask an individual to consider changes in their life, these changes may also affect those around them. Take into account that some individuals may place less importance on their own healthcare than on caring for others. Some may miss or cancel their appointment if a family member had a conflicting need. Being willing to incorporate the family’s needs and involvement in the educational process, will increase your cultural competence and chance of success.

Time
In many communities, time may not be as direct and concrete as in general practices throughout the U.S. “Indian Time” challenges most of us who desire to keep to schedules by the clock and some may feel that those who don’t abide likewise are lazy, unmotivated, or irresponsible. However, for many, time is relative to the events and environment of the moment and reflects flexibility. For example, there is no time component in preparation for a community ceremony or event. Instead, once everything is ready, the event or ceremony takes place and concludes when it is finished. This philosophy may carry over into the daily life of the individual with regards to his/her health so that he/she believes they will heal when it is time to be healed.

Conclusion
In a 2003 interview, filmmaker Sherman Alexie (Spokane and Coeur d’Alene) stated:

All I try to do is portray Indians as we are, in creative ways. With imagination and poetry. I think a lot of Native American literature is stuck in one idea: sort of spiritual, environmentalist Indians. And I want to portray everyday lives. I think by doing that, by portraying the ordinary lives of Indians, perhaps people learn something new.

The information provided in this “On Point” article, while mostly general in nature, has provided a cursory glimpse into some of the cultural components specific to American Indian and Alaskan Native cultures. When working within our communities, by committing to the ongoing learning process of cultural competency, we have the potential to enhance our experience, provide needed value, and as Sherman Alexie states “learn something new.”

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Resources

• Alvord, L. A., & Van Pelt, E. (1999). The Scalpel and the Silver Bear: The first Navajo woman surgeon combines Western medicine and traditional healing. New York: Bantam Books.
• Encyclopedia Smithsonian. American Indian History and Culture. Retrieved August 18, 2010.
• Amnesty International. (2007) Maze of Injustice The Failure to Protect Indigenous Women from Sexual Violence in the USA. [PDF - 3MB] New York, NY. Amnesty International Publications. Retrieved August 1, 2010.
• Burden, R. (2003). “Why Wrestle When You Can Dance?” Optimizing Outcomes With Motivational Interviewing” J. American Pharmacists Association, Volume 43(1), s46-s47.
• Cobb, J.C. (editor) (1960). Workshop Proceedings on the Emotional Problems of the Indian Students in Boarding Schools and Related Public Schools. [PDF - 5MB] Retrieved August 1, 2010.
• Dixon, M. & Iron, P.E. (2006). Strategies for Cultural Competency in Indian Health Care. Washington, DC: American Public Health Association.
• Eastman, C. A. (aka Ohiyesa). (1911).The soul of an Indian. In K. Nerburn (Ed.). (1993), The soul of an Indian--and other writings from Ohiyesa. Novato, CA: New World Library. Retrieved August 18, 2010.
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• Hendrix, L. R. (1999). Cultural support in health care: The older urban American Indian of the San Francisco Bay Area. Dissertation. The Union Institute. Cincinnati, OH. Retrieved August 18, 2010.
• Metropolitan Chicago Healthcare Council. (November 18, 2004). Guidelines for Health Care Providers Interacting with American Indian (Native American; First Nation) Patients and Their Families. [PDF - 211K] Capes Memorandum No. 04-19. Retrieved August 18, 2010.
• McNeil, J. & Downer, G.A. (2006). Be Safe: A Cultural Competency Model for American Indians, Alaska Natives, and Native Hawaiians Toward the Treatment and Prevention of HIV/AIDS. [PDF - 2MB] Howard University Medical School. Retrieved August 1, 2010.
• Rife, J.P. & Dellapenna, A.J.(2009) Caring & Curing: A History of the Indian Health Service. Terra Alta, WV. Pioneer Press of West Virginia, Inc.
• U.S. Department of Health and Human Services. (January, 2009). Culture Card A Guide to Building Cultural Awareness. [PDF] Retrieved August 1, 2010.
• U. S. Department of Health and Human Services (10/19/2005), “What is Cultural Competency”? Retrieved August 1, 2010.
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• Venner, K.L., Feldstein, S.W. & Nadine, T. (2006). Native American Motivation Interviewing: Weaving Native American and Western Practices. [PDF - 1.5MB] A Manual for Counselors in Native American Communities. Retrieved August 01, 2010.
• Champlain Valley AHEC (November 6, 2007). Cultural Competency for Health Care Providers. [PDF - 1.3MB] Retrieved September 1, 2010.