Culturally Relevant Palliative and End-of-Life Care for U.S. Indigenous Populations: An Integrative Review.

PURPOSE: American Indians/Alaska Natives (AIs/ANs) have higher rates of chronic illness and lack access to palliative/end-of-life (EOL) care. This integrative review ascertained the state of the science on culturally acceptable palliative/EOL care options for Indigenous persons in the United States. DESIGN: Databases searched: CINAHL, PubMed/MEDLINE, SocINDEX, PsycINFO, PsycARTICLES, ERIC, Health Source: Nursing/Academic Edition, and EBSCO Discovery Service 1880s-Present. Key terms used: palliative care, EOL care, and AI/AN. INCLUSION CRITERIA: peer-reviewed articles published in English. Findings/Results: Twenty-nine articles were identified, 17 remained that described culturally specific palliative/EOL care for AIs/ANs. Synthesis revealed four themes: Communication, Cultural Awareness/Sensitivity, Community Guidance for Palliative/EOL Care Programs, Barriers and two subthemes: Trust/Respect and Mistrust. DISCUSSION/CONCLUSION: Limitations are lack of research funding, geographic isolation, and stringent government requirements. Palliative/EOL care must draw on a different set of skills that honor care beyond cure provided in a culturally sensitive manner.

Polymorphisms in stearoyl coa desaturase and sterol regulatory element binding protein interact with N-3 polyunsaturated fatty acid intake to modify associations with anthropometric variables and metabolic phenotypes in Yup'ik people.

SCOPE: n-3 polyunsaturated fatty acid (n-3 PUFA) intake is associated with protection from obesity; however, the mechanisms of protection remain poorly characterized. The stearoyl CoA desaturase (SCD), insulin-sensitive glucose transporter (SLC2A4), and sterol regulatory element binding protein (SREBF1) genes are transcriptionally regulated by n-3 PUFA intake and harbor polymorphisms associated with obesity. The present study investigated how consumption of n-3 PUFA modifies associations between SCD, SLC2A4, and SREBF1 polymorphisms and anthropometric variables and metabolic phenotypes. MATERIALS AND METHODS: Anthropometric variables and metabolic phenotypes were measured in a cross-sectional sample of Yup'ik individuals (n = 1135) and 33 polymorphisms were tested for main effects and interactions using linear models that account for familial correlations. n-3 PUFA intake was estimated using red blood cell nitrogen stable isotope ratios. SCD polymorphisms were associated with ApoA1 concentration and n-3 PUFA interactions with SCD polymorphisms were associated with reduced fasting cholesterol levels and waist-to-hip ratio. SLC2A4 polymorphisms were associated with hip circumference, high-density lipoprotein and ApoA1 concentrations. SREBF1 polymorphisms were associated with low-density lipoprotein and HOMA-IR and n-3 PUFA interactions were associated with reduced fasting insulin and HOMA-IR levels. CONCLUSION: The results suggest that an individual's genotype may interact with dietary n-3 PUFAs in ways that are associated with protection from obesity-related diseases in Yup'ik people.

Exploration of Why Alaskans Use Complementary Medicine: A Focus Group Study.

PURPOSE: To explore why Alaskans choose to pursue complementary medicine as a health care option. DESIGN: Qualitative descriptive. METHOD: A purposive convenient recruitment methodology was used to recruit project participants. Focus groups were conducted to collect the research data. FINDINGS: Five themes were identified that highlighted why participants use complementary medicine: dissatisfaction, effective, holistic, relationship focused, and a personal journey.

The genetic prehistory of the New World Arctic.

The New World Arctic, the last region of the Americas to be populated by humans, has a relatively well-researched archaeology, but an understanding of its genetic history is lacking. We present genome-wide sequence data from ancient and present-day humans from Greenland, Arctic Canada, Alaska, Aleutian Islands, and Siberia. We show that Paleo-Eskimos (~3000 BCE to 1300 CE) represent a migration pulse into the Americas independent of both Native American and Inuit expansions. Furthermore, the genetic continuity characterizing the Paleo-Eskimo period was interrupted by the arrival of a new population, representing the ancestors of present-day Inuit, with evidence of past gene flow between these lineages. Despite periodic abandonment of major Arctic regions, a single Paleo-Eskimo metapopulation likely survived in near-isolation for more than 4000 years, only to vanish around 700 years ago.

Discrimination and participation in traditional healing for American Indians and Alaska Natives.

Contemporary American Indians and Alaska Natives (AIs/ANs) who live in urban areas today face the daunting task of navigating an urban landscape while maintaining the facets of their respective Native cultures. While AIs/ANs continue to grapple with the intergenerational trauma associated with forced assimilation, relocation movements, and boarding schools, these traumas have manifested themselves in elevated rates of psychopathology. AIs/ANs have elevated rates of domestic abuse, poverty, suicide, and substance misuse. Furthermore, AIs/ANs, like many other minority cultures often face discrimination in their everyday lives. In light of the aversive experiences they face, AI/AN people have followed the tenets of ritual and traditional healing to address imbalances in the body, mind, and spirit. For providers working with AI/AN clients, it is important to understand who is using traditional healing and why they are using alternative services. Secondary data analyses of survey data from 389 urban AIs/ANs were utilized in order to determine the relationship between experiences of discrimination and traditional healing use. Analyses indicated that experiences of discrimination in healthcare settings were significantly associated with participation in traditional healing. Analyses also indicated that nearly a quarter of the sample reported discrimination in a healthcare setting, roughly half of the sample had used traditional healing, and that the majority of those who had used traditional healing were women, and ages 35-44 (27%). This study calls attention to the socio-demographic factors implicated in traditional healing use by urban AI/AN people, in addition to the clinical and demographic characteristics of this sample.

Health ownership in American indigenous communities.

INTRODUCTION: Although the Indian Health Service (IHS) has adequately stifled acute infectious diseases that once devastated American Indian and Alaska Native (AIAN) communities, this system of health provision has become obsolete in the face of chronically debilitating illnesses. Presently, AIAN communities suffer disproportionally from chronic diseases that demand adequate, long-term health maintenance such as hepatitis, renal failure, and diabetes to name a few. A number of research endeavors have sought to define this problem in the literature, but few have proposed adequate mechanisms to alleviate the disparity. The objective of this study was to examine the efficacy of both the Indian Health Service (IHS) and the relative few tribal healthcare systems (PL 93-638) respectively in their sociopolitical contexts, to determine their utility among a financially lame IHS. METHODS: Domestic and international indigenous health systems were compared through analysis of the current literature on community and indigenous health. Informal interviews were carried out with indigenous practitioners, community members, and political figures to determine how AIAN communities were receiving PL 93-638 programs. RESULTS: Although the IHS has adequately stifled the acute infectious diseases that once devastated AIAN communities, this system of health provision has become obsolete in the face of chronically debilitating illnesses. A number of research endeavors have sought to define this problem in the literature, but few have proposed adequate mechanisms to alleviate the disparity. International indigenous health systems are noted to have a greater component of community involvement in the successful administration of health services. CONCLUSION: Reinstating notions of ownership in multiple paradigms, along with novel approaches to empowerment is requisite to creating viable solutions to the unique health circumstances in Native America. This article demonstrates the importance and need of more qualitative data to better characterize how PL 93-638 healthcare delivery is actually experienced by AIAN patients.

Evidence-based practices, attitudes, and beliefs in substance abuse treatment programs serving American Indians and Alaska Natives: a qualitative study.

Substance abuse disproportionately impacts American Indian/Alaska Native (AI/AN) communities in the United States. For the increasing numbers of AI/AN individuals who enter and receive treatment for their alcohol or other drug problem it is imperative that the service they receive be effective. This study used qualitative methodology to examine attitudes toward evidence-based practices, also known as evidence-based treatments (EBTs) in minority-serving substance abuse treatment programs in the San Francisco Bay area. Twenty-two interviews were conducted in the study, of which seven were with program directors and substance abuse counselors at two urban AI/AN focused sites. These clinics were more likely than other minority-focused programs to have experience with research and knowledge about adapting EBTs. Only in the AI/AN specific sites did an issue arise concerning visibility, that is, undercounting AI/AN people in national and state databases. Similar to other minority-focused programs, these clinics described mistrust, fear of exploitation from the research community, and negative attitudes towards EBTs. The underutilization of EBTs in substance abuse programs is prevalent and detrimental to the health of patients who would benefit from their use. Future research should explore how to use this research involvement and experience with adaptation to increase the adoption of EBTs in AI/AN serving clinics.

Concept analysis of Diné Hózhó: a Diné wellness philosophy.

American Indian Alaska Native people of the United States face challenges in attaining physical, mental, spiritual, and environmental health. This article presents a concept analysis of Diné Hózhó, a complex and misunderstood wellness concept the Diné (Navajo) strive to attain. Findings from a literature review are presented to explore anthropological definitions and uses of the concept Hózhó. The method of concept analysis of Walker and Avant is utilized, model cases are presented. Recommendations for application in nursing practice are presented.

The end of the Kachemak tradition on the Kenai Peninsula, southcentral Alaska.

The Kachemak tradition was established by ca. 3000 B.P. in Kachemak Bay. Probably somewhat later a variant termed Riverine Kachemak, with a population adapted to salmon and terrestrial resources, appeared on the northern Kenai Peninsula. The Kachemak tradition people seem to have abandoned Kachemak Bay by ca. 1400 B.P. Seven of 12 available Kachemak tradition dates predate 1400 B.P. even at two sigma. Scattered younger dates are thus suspect outliers. The end of Riverine Kachemak tradition has been placed at ca. 1000 B.P., at which time the population was supposedly replaced by in-migrating groups ancestral to the Dena'ina Athapaskans. Close examination of the numerous available radiocarbon dates shows that most Riverine Kachemak dates cluster in the early centuries of the First Millennium A.D. and most Dena'ina dates substantially postdate 1000 A.D. Probably the Riverine Kachemak and Dena'ina peoples never met on the Kenai River. However, the correspondence in date ranges between Kachemak Bay and Riverine Kachemak is striking, suggesting their fates were linked. Both traditions collapsed by 1400-1500 B.P. The causes are probably multiple but do not include cultural replacement.

Stress, coping, and well-being among the Yup'ik of the Yukon-Kuskokwim Delta: the role of enculturation and acculturation.

OBJECTIVES: To report on the relationships between cultural identity and stress, coping, and psychological well-being in Yup'ik communities. STUDY DESIGN: A quantitative self-administered questionnaire. METHODS: A health and wellness survey was completed by a total of 488 Yup'ik participants (284 women and 204 men) from 6 rural villages in the Yukon-Kuskokwim Delta region. Respondents were fairly equally distributed across an age range of 14 to 94 (mean +/- SD = 38.50 +/- 17.18). RESULTS: Participants who reported living more of a Kass'aq way of life (greater acculturation) reported experiencing greater psychosocial stress, less happiness, and greater use of drugs and alcohol to cope with stress. Participants who reported identifying more with a traditional Yup'ik way of life reported greater happiness, more frequent use of religion and spirituality to cope with stress, and less frequent use of drugs and alcohol to cope with stress. CONCLUSIONS: In conjunction with previous research, the data strongly indicates that in general, Yup'ik people in the Y-K Delta tend to associate stress and negative health outcomes with the process of acculturation, and health and healing with the process of enculturation. Research that focuses on documenting the intrinsic strengths of indigenous worldviews may contribute to positive transformations in community health.

Healthy nations: reducing substance abuse in American Indian and Alaska Native communities.

Since 1993, 14 American Indian and Alaska Native (AIAN) communities have worked diligently to reduce the harm due to substance abuse in their communities. Funded by the Robert Wood Johnson Foundation's Healthy Nations Initiative I, these communities implemented creative strategies that span the continuum from community-wide prevention, early identification and treatment to aftercare. Drawing upon the unique strengths of their own cultural traditions to find solutions to local substance abuse problems, these efforts have identified important and useful lessons for not only other AIAN communities, but also for sponsors of substance abuse programming in Indian country and elsewhere. Described here are successful strategies for developing and sustaining substance abuse programs in AIAN communities and an assessment of their impacts and accomplishments.

Circle of healing: traditional storytelling, part one.

The session began with three presenters - LouAnn Benson, Walter Porter, and Lisa Dolchok - all of whom are or have been affiliated with the Circle of Healing Program at Southcentral Foundation in Anchorage, Alaska. The Southcentral Foundation is a Native Health Corporation that administers what used to be the Indian Health Service Hospital and Medical Center. In the Circle of Healing Program, the Southcentral Foundation has designed and implemented an approach to health care that allows its patients simultaneously to access Western medicine, traditional Native healing, and other alternative approaches to health care, such as acupuncture. An important figure in this effort is Dr. Robert Morgan, a psychologist who has worked with the program for several years, and who helped suggest presenters for this part of the program. Originally, Bob planned to be present in Quebec City, but family priorities meant a change in plans. Bob's absence had a silver lining, however, because in his stead he sent LouAnn Benson, one of his able colleagues, who talked about the program from the perspective of an insider.

Circle of healing: traditional storytelling, part three.

Southcentral Foundation had to overcome several organizational and procedural hurdles when developing their Circle of Healing program. Among these hurdles was finding a way to credential Alaska Native healers so the Foundation could be reimbursed for their services and pay the healers, and so the healers could work in the hospital along with the staff delivering Western and alternative medical treatment. Southcentral Foundation chose to develop a process for certifying Alaska Native healers as tribal doctors. Rita Blumenstein is the first such person to be certified. Lisa Dolchok is the second. An important strength of Lisa's presentation is that she helps us broaden our understanding of healing from an Alaska Native perspective. So often we equate healing with curing, and while it can have this dimension, Lisa reminds us there is much more to it. She echoes LouAnn Benson's presentation in asserting that healing can address illness of the spirit or wounds to the soul.

Life, death, and humor: approaches to storytelling in Native America.

Edith Turner has been studying healing as a sensitive, spiritually attuned participant-observer for a long time. Despite her academic background, experiential learning and knowing are important parts of Turner's approach to research. Her efforts to understand healing have taken her on journeys to Africa, Mexico, Ireland, and more recently, Alaska's North Slope. In these contexts, she has experienced healing offered by others, and learned to heal in various traditional ways herself. In her book, The Hands Feel It (1996), Turner focuses on the role that touch and spirit presence have in healing in a North Slope Iñupiat community. However, her book makes clear that narrative and storytelling are important parts of the healing process, as well. In this paper, Turner elaborates on some aspects of the connection between narrative and healing based on her North Slope experience.

Healing the body, healing the self: the interrelationship of sickness, health, and faith in the lives of St. Lawrence Island Yupik residents.

For about 15 years, Carol Jolles has been traveling to St. Lawrence Island, Alaska to study the role faith plays in the lives of Sivuqaq (Gambell) residents. From the outset, she was aware of the strong presence of two Christian faith traditions in the community. She was present when people "spoke in tongues" (entered a spiritual state, sometimes identified as an altered state of consciousness), and she was aware that people relied on prayer, often uttered in a spiritually inspired context, to ease the pain of daily life and to find the strength to do difficult tasks. Many months passed, however, before she realized that many people relied on faith to heal. From the perspective of her long-term working relationships and friendships with community members, Jolles takes a fresh look at some of the situations from her early work where faith and healing were intertwined. She also looks at more recent examples to place faith-based healing in a more general context. In the process, she focuses on a few special individuals to highlight the components of faith and healing associated with illness and mental distress.

Alcohol dependence among Alaska Natives entering alcoholism treatment: a gender comparison.

OBJECTIVE: An ongoing study of phenotypes of alcohol dependence among Alaska Natives provides an opportunity to investigate the nature and patterns of alcohol problems among Alaska Native men and women admitted to treatment in three residential programs in Anchorage, Alaska. METHOD: A comprehensive, standardized clinical assessment (including the SSAGA-I diagnostic interview, family history information, personality traits and cognitive functioning) of consecutive admissions to each of the three programs is being undertaken by trained interviewers. To date, 200 (103 male) subjects have been assessed. The mean (+/- SD) age of the sample is 32+/-8.5 years old. The development of alcohol problems, the psychological and physical consequences of chronic drinking, the flushing response, withdrawal symptoms and comorbid lifetime psychiatric conditions were examined. RESULTS: The sample was characterized by an early onset of drinking and an acute exacerbation and clustering of drinking problems during late adolescence, followed by the development of severe alcohol dependence. A high lifetime prevalence of DSM-III-R major depressive disorder was found, typically complicated by chronic drinking. The rates of other substance dependencies were relatively low, except for cannabis and cocaine dependence among female subjects. CONCLUSIONS: This sample of treatment-seeking Alaska Natives was found to have an early onset and severe form of DSM-III-R alcohol dependence, with few gender differences noted. While the prevalence of alcohol abuse and alcohol dependence among Native American populations has been reported to be quite high, the onset and patterning of symptoms among this sample of treated Alaska Natives has revealed more similarities with treated alcoholics from the majority population than important differences specific to Alaska Natives.

Traditional and western healing practices for alcoholism in American Indians and Alaska Natives.

The American Indian and Alaska Native population is a culturally diverse population with a current census of 1,959,000. Prior to White contact, there was historically little use of alcoholic beverages except for American Indians in the Southwest. After White contact, use and misuse of alcohol escalated rapidly; however, the prevalence, patterns, and problems of drinking alcoholic beverages vary enormously even in tribes closely linked geographically. American Indians and Alaska Natives have preserved and revitalized a number of traditional healing practices and applied these to the treatment of alcohol-related problems. These healing practices include the following: nativistic movements, sacred dances, sweat lodges, talking circle, four circles, and cultural enhancement programs. Additionally, Western treatment approaches have been applied in the treatment of problems related to alcohol, such as medication for detoxification, disulfiram (Antabuse), Alcoholics Anonymous, and behavioral interventions. Several investigators have completed a small number of naturalistic follow-up studies, but no one has undertaken a randomized controlled trial looking at specific methods of alcohol treatment in American Indians or Alaska Natives. American Indian and Alaska Native communities have adapted and integrated both Traditional and Western approaches to fit their own unique sociocultural needs.

The Inuit diet. Fatty acids and antioxidants, their role in ischemic heart disease, and exposure to organochlorines and heavy metals. An international study.

Traditional food is culturally, economically and nutritionally important for the Greenlandic Inuit people. In the 1970s the preventive effect of marine fat on cardiovascular disease, thrombosis and atherosclerosis was described. The low incidence of ischemic heart disease among Greenlanders has been related to the high intake of marine food. Since 1990 routine autopsies have taken place in two towns in Greenland, Nuuk and Ilulissat. The autopsies represent 26% of the total number of deaths in these two towns. Samples have been collected from 104 autopsies. International cooperative studies have analysed specimens in relation to ischemic heart disease as a benefit related to diet, as well as the level of heavy metals and organochlorine in organs as a risk related to diet. High amounts of mono-unsaturated and Omega-3 poly-unsaturated fatty acid were found in adipose tissue. Liver analyses of selenium have confirmed the expected high intake among Greenlanders. Reduced atherosclerotic lesions were found in the coronary arteries. Blood pressure levels calculated from renovascholopathia of hypertension indicate prevailing levels similar to those in industrialized countries. Some factors in Greenland may be protecting the coronary arteries, thereby of setting the expected effect of hypertension. The level of methyl mercury in organs is generally high. PCB concentrations found in organs of Greenlanders are higher than among other populations. Health and risk effects of the traditional foods need further investigation.