Special Considerations when working with American Indian and Alaska Native patients . . .

“American Indian / Alaska Native” (AI/AN) refers to people having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment. It includes people who indicated their race or races in the Census by marking this category or writing in their principal or enrolled tribe, such as Rosebud Sioux, Chippewa, or Navajo. ^[21]

AI/AN citizens suffer from some distinct health disparities: ^[22]

• AI/AN as a group are almost three times as likely to have diabetes as non-Hispanic/Latino European Americans of similar age.
   
• Native Alaskans suffer disproportionately higher rates of cancers of the colon and rectum compared to European Americans.
   
• The five-year survival rate for American Indian women with cervical cancer is poorer than that for most other racial/ethnic groups.
   
• Lactose intolerance is common among American Indians.

This is only a small representation of the health disparities faced by many American Indians and Alaska Natives. While not all of these can be attributed to cultural concerns, communication difficulties and provider biases may contribute to some of these issues.

There are over 560 federally recognized tribes and over 100 state recognized tribes. Each tribe has its own distinct history and culture.^[24] Thus, it is difficult to identify a single cultural “guide” to use when helping these patients. However, some considerations may help when working with AI/AN patients. Again, we emphasize that these are generalizations that may be useful in formulating questions or determining patient preferences but should not be used to stereotype patients. These recommendations come from a variety of sources that have been cross referenced for consistency:^{[3, 7, 14, 23]}

Communications

Non verbal . . .

• Pauses in this culture are significant and important. They represent respect for the speaker and a careful consideration of what is being discussed. Do not rush or interrupt. Allow time after the patient has stopped speaking to ensure they are finished.
   
• Patients may not wish to make eye contact do to fears of “soul theft” or out of respect
   
• Always ask before touching the patient.

Verbal . . .

• Patients may use circular story telling to describe symptoms or the purpose of the visit
   
• Use of metaphors and allegories may actually describe patient’s symptoms
   
• Patients may be reluctant to refer to deceased family members by name. Keep this in mind when taking medical history

Religion and Spirituality

Relics/Regalia . . .

• Items may carry a special significance to the patient. Do not touch or remove without permission
   
• Do not casually admire or handle any religious items or idols

Common health beliefs across tribes . . .

• There is a supreme creator
   
• Health is harmony in mind, body and soul
   
• Death is not enemy but a natural part of life
   
• Illness is an imbalance

Family/Hierarchy

Health Decision Making May be Communal . . .

• In most tribes, decision making is a family process. Ask the patient who else is to be included in care
   
• Elders are revered and should be allowed to be part of decision process

Special Considerations

Prejudice/discrimination . . .

• Out of respect for the diversity within this racial group, ask patients to identify their tribe
   
• Due to history of deceptions experienced by this group, patients may be reluctant to sign informed consent
   
• Be prepared to explain the necessity of documents and to allow thoughtful consideration by the patients

Other . . .

• The Native cultures tend to have much more of a present orientation. This can present challenges in explaining preventive care or as well as medical instructions. When specific timing is critical, emphasize this to the patient.

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