He lives with his grandson Taylor in a mobile home on the Pine Ridge Indian Reservation.

Today he arrives at the Indian Health Service Pine Ridge Hospital emergency room with shortness of breath. John walked to the emergency room after attending a traditional sweat lodge, where he became short of breath. The shortness of breath seemed to lessen somewhat after leaving the lodge, but he became concerned as this was the first time this occurred for him during the ceremony.

John has a past medical history of type 2 diabetes and hypertension. He is of normal weight, checks his blood sugar once a week with a glucometer and the readings show he is maintaining control of his blood sugars through his diet. He has been self-employed for most of his life making traditional beadwork and dance regalia for pow-wow dancers, and peace pipes that he sells at pow-wows.

There is high unemployment and a high level of poverty on the Pine Ridge Reservation:         

Key demographic and economic indicators

John is thankful for the traditional Lakota life skills his uncle taught him as he was growing up. While he has no health insurance, he has access to Indian Health Service (IHS) health insurance benefits because he is a resident of the Pine Ridge Reservation and is an enrolled tribal member.

John stays active by attending a senior men’s group for coffee once a week and often attends community lunches at the senior center that are available at no cost for Pine Ridge elders. He has four children who he and his wife of 40 years raised on the reservation. John is grieving the loss of his wife who passed away due to breast cancer one year ago. Two of his children have moved to Sioux Falls, South Dakota, and one to Minneapolis, Minnesota.  He misses his wife greatly as together they were committed to raising their 10-year-old grandson Taylor after his mother, their youngest daughter, died from suicide. John is now raising his grandson alone. Taylor is at home today while John visits the emergency room. He does not own a car and walks to his destinations on the reservation.    

You are the nurse preparing to meet and assess John in the emergency room consultation area.   

Before meeting John, answer the following questions:

1. Describe the Native American sweat lodge and ceremony. What are some health considerations a participant should be aware of before participating in a sweat lodge?
2. John is seeking emergency room (ER) care at the Pine Ridge hospital today. Describe and discuss the IHS health insurance benefits for Native elders.
3. Discuss what you have learned about poverty on this reservation and its likely influence on John’s lifestyle and choices.
4. Describe what you know of the health status of the Pine Ridge Oglala Lakota (Sioux) tribe.  What are primary health concerns and what do you propose could be discussed with John during his visit at the ER today to promote greater health and well-being for him? Where would you go to learn more on these areas of discussion?
5. There is a long tradition of grand families or kinship care in Native America. In this type of care, many potential caregivers and supports in a nurturing network share responsibility for child rearing.  American Indian and Alaska Native children are more likely to live in grand families – families where grandparent/s are raising children without parents in the home, than any other racial or ethnic group. Over two hundred years of US federal policy has threatened this natural kinship structure to assimilate Native Americans into the White culture. The effects persist today as unresolved grief, also referred to as historical trauma. Knowing this background, what would you like to discuss with John and his grandson Taylor who he is raising?
6. After your health assessment you would like to highlight and support John’s strengths towards his future health and well-being. What are areas of strength from what you have learned today?  Give specific examples on dialogue you would choose and what questions you would ask in this conversation. 

Root cause of health inequity

Centuries of US federal policy that has threatened natural Native American kinship and family structure and forced assimilation of Native Americans into the White culture. Also, “…health outcomes for Native Americans are adversely impacted by wholly inadequate access to comprehensive health services.” (Smith, 2022)

Policy Considerations

1. Ensure there are strong caregiver voices in shaping programs, policies, and strategies that result in better outcomes for American Indian and Alaska Native children and their families.
2. Advocate on behalf of Native American grand families and kinship caregivers at the federal, state, and local levels.
3. Seek out Native American caregiver input on draft publications and other materials for grand families and kinship families.
4. Model the value of caregiver engagement – (e.g., more internet content to deliver needed communication with response to all questions and comments)
5. Foster leadership development

Calls to Action

• Begin action in areas of critical aid (e.g., food, critical supplies), empower tribal members, and support sustainable infrastructure.
• Develop new pathways with large organizations and develop volunteer networks to bring people together.

References

Smith, M. (2022). Native Americans: A crises in health equity. In American Bar Association’s Human Rights Magazine, 43(3). https://www.americanbar.org/groups/crsj/publications/human_rights_
magazine_home/the-state-of-healthcare-in-the-united-states/native-american-crisis-in-health-equity/

True Sioux Help Foundation (2022). https://www.truesiouxhope.org

W.K. Kellogg Foundation (2020). American Indian & Alaska Native grandfamilies: Helping children thrive though connection to family and cultural identity tool kit.  Grandfamilies.org Michigan: Battle Creek. https://www.gu.org/resources/american-indian-alaska-native-grandfamilies-helping-children-thrive-through-connection-to-family-and-cultural-identity/

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Lily has gestational diabetes mellitus (GDM) and her baby boy is larger than normal for his gestational age. There are several concerns with GDM including possible hypertension and pre-eclampsia which can threaten the health of both Lily and her baby. She is grateful her mother is a registered nurse and can help during the prenatal appointments with questions and clarifications regarding her Dr.’s recommendations. Lily’s mother also had GDM when she was pregnant and shares her experiences with her daughter which include understanding that a possible caesarean section may be required to deliver the baby safely.  She and her mother have a close relationship and Lily wants to go to nursing school after the baby is born. Lily’s mother has been an excellent support to guide her daughter as the pregnancy has progressed and Lily is thankful as the father of her baby did not want to be involved with their child. Since Lily is under the age of 24, she will continue to be covered by her mother’s health insurance that is in place for both from her mother’s previous employment.

Lily wants to deliver her baby naturally, to raise her child within the cultural traditions she was raised with, and to find cultural-based support for herself as a single mother in her new location. She is very nervous about a possible caesarean section which can be the doctor’s preference to deliver the baby if her blood sugar is not well-controlled and the baby is too large to deliver naturally.

You are the public health nurse meeting Lily and her mother at their first clinic appointment at the new Obstetrics/Gynecology clinic where the tribal clinic has transferred her health care.  The clinic is in a culturally diverse area of the city and is piloting a holistic assessment tool using an explanatory model to attempt to include more culturally diverse clients and their families’ perspectives in the care and teaching models of the clinic. The explanatory model has been shown to facilitate communication with increased understanding between health practitioners and clients, with a positive effect towards health outcomes.

You are preparing to visit with Lily and her mother, and to interview Lily using the 8 questions of Kleinman’s explanatory model regarding her GDM, perspectives on her health and the health of her baby.

Answer to following questions:

1. How common is GDM in Native American women? What are prevalence rates in recent years and what does current research attribute to these rates?
2. What do you know about the reservation community where Lily and her mother have lived and the overall health disparities there?  Is there information that would be helpful to know and understand to offer cultural and traditional approaches for Lily’s health care? If so, describe how you would obtain this information?  
3. Discuss what you have learned about poverty on the reservation and its possible influence on Lily’s GDM.
4. Research and then describe some traditional Native American cultural perspectives on pregnancy and childbirth.
5. Research and then describe some traditional Native American cultural perspectives on pregnancy and childbirth.
6. The Kleinman Explanatory model provides eight questions to focus on and learn more about the client’s understanding of health and illness. Compare and contrast use of this explanatory model versus OB/GYN health care assessment provided without use of this model.

Root cause of health inequity

Centuries of US federal policy that has threatened natural Native American kinship and family structure and forced assimilation of Native Americans into the White culture. Also, “…health outcomes for Native Americans are adversely impacted by wholly inadequate access to comprehensive health services” (Smith, 2022).

Policy Considerations

1. Include more culturally sensitive and inclusive pre-conception counseling and diabetes risk-reduction education.
2. In 2010, the Centers for Disease Control and Prevention (CDC) funded the American Indian Physician’s Association (AAIP) for five years to partner with rural, reservation and urban community-based coalitions to plan, develop, implement, and evaluate evidence-based and culturally appropriate strategies to address type 2 diabetes and healthier lifestyles. Among the lessons learned from this project were the following:
   • Cultural training to non-Native partners is imperative for success; allow Native community members to provide this insight.
   • Support re-engagement with the land towards developing stronger tribal identities and re-creating opportunities to have traditional ceremony.
   • Transforming narratives of trauma into hope and resilience.
3. Research shows promise at the feasibility of mother-daughter GDM dyads as an approach to diabetes and GDM risk reduction.

Calls to Action

• Consult with tribal and urban health care leaders to increase preconception counseling for those with a history of GDM in the family.
• Stop acceptance of health disparities as the norm in Native communities and transform systems towards greater health equity.

References

Association of American Indian Physicians. (2021). Diabetes – The national program to eliminate diabetes-related health disparities in vulnerable populations. Aaip.com

Johnson-Jennings, M. et al. (2020). Returning to our roots: Tribal health and wellness through land-based healing. Genealogy, 4(3), mdpi.com

Moore, K., et al. (2018). Feasibility of mother–daughter dyadic gestational diabetes (GDM) risk reduction intervention for American Indian and Alaska Native (AIAN) teens. Diabetes, 67 (Supplement 1).  

Stotz, S., et al. (2021). Stopping gestational diabetes in American Indian and Alaska Native girls: Nutrition as a key component to gestational diabetes risk reduction. Current Developments in Nutrition, Volume 5(4), June 2021, p. 13-21.

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Josephine was born on and grew up on the reservation in the traditional part of the village. While her family was very poor, her mother was known as a matriarch to the tribe and often lived on the river in a wig-wam in the warm season, to practice traditional cooking and ceremonies. Josephine remembers the strength of her mother well and her two sisters, all who passed early in their lives. Her mother taught her to cook many different types of wild game such as venison and rabbit, and how to make fried bread.

Josephine has three children, but because of poverty on the reservation, she could not provide for her children’s most basic needs.  Her children were removed from her home by the state child welfare agency and placed in non-Native American foster homes several hours away. When her children were taken, Josephine lost contact with them and lives with deep depression and anxiety.

It’s been many years since that time, and Josephine moved to a large metropolitan area closer to where her oldest son lives.  She lives in a one-bedroom subsidized apartment in a senior hi-rise building. She continues to require dialysis three days a week, each session lasting 4 hours. She is picked up by Metro Mobility, a shared public transportation service, and returned home after dialysis. When she is not at dialysis, she enjoys her independence using a walker to get around and takes the city bus to the bingo hall downtown, stopping at Wendy’s for her favorite meal if she has money left from her social security check. She has a close friend and neighbor Kristine, who lives in the same building, and they visit regularly. Josephine’s oldest son and several grandchildren visit her on holidays.

Josephine completed the third grade, and her vision is poor so that she has a hard time reading instructions and medication bottles. Therefore, she doesn’t follow her medication guidelines and pours all medications into a large dish on the coffee table and takes some when she remembers. She attends dialysis reliably and her dialysis nurses enjoy her company as they have learned much about her life of transitions from the reservation to life in the city.

At her high-rise apartment, the management company deals frequently with mice and cockroach infestations. As she cannot see well, and her glasses prescription is out of date, she finds it difficult to do housecleaning to prevent infestations. Despite these challenges, Josephine finds solace in her health care, being near her son, and her ability to be independent.

For Josephine to continue to receive medical, community, and financial support the state has asked you as a public health nurse to visit and assess her safety at home and her health needs. Your hope is with these continued services, Josephine can reside as she wishes in her apartment, in the least restrictive environment, and delay institutionalization to a nursing home or assisted living facility.

As part of preparation to visit Josephine, answer the following questions:

1. Describe in detail the traditional wigwam that is known to the Ojibwe and First Nations communities. Explain its construction and materials used.  Where in the United States could you see a wigwam?
2. Describe the Indian Child Welfare Act (ICWA). Include the reasons for its inception and its status today.
3. Discuss what you have learned about the life expectancy of American Indians and Alaska Natives in the United States and health trends expected for the future.
4. After your assessment with Josephine, you want to increase cultural support for her and other Native American elders in the area. Name at least three cultural resources you think will be helpful for her to connect with.  
5. What are your primary concerns for Josephine so that she can continue to live where she desires?

Root cause of health inequity

Centuries of US federal policy that has threatened natural Native American kinship and family structure and forced assimilation of Native Americans into the White culture. Also, “…health outcomes for Native Americans are adversely impacted by wholly inadequate access to comprehensive health services” (Smith, 2022).

Policy Considerations

Calls to Action

• It is of utmost importance that Elders are treated with respect and reverence.
• Encourage more programs in tribal and urban areas to support and care for elders.

References

National Indian Council on Aging Incorporated. (2021). Recommendations for older Americans act reauthorization. nicoa.org

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He now lives with his aunt in Phoenix, Arizona, approximately ten hours north of the reservation.  Two important events in Matt’s life have recently occurred – graduation from high school, and his mother re-married.  Matt doesn’t approve of his new stepfather who is non-Native, and his stepfather doesn’t approve of Matt and his plan to pursue a career as a men’s fancy dancer – a fast, elaborately choregraphed Native American pow-wow dance.

Matt also does not approve of the disrespectful way his new stepfather addresses he and his mother. So, he decided to move away from the reservation and live with his aunt in Phoenix. Matt didn’t know his biological father and he and his aunt became very close when she lived with their family on the reservation. He’s looking forward to living in her home. He also wants to start a life in Phoenix where he and his girlfriend from the reservation can be together.  

Matt is an experienced fancy dancer and has been dancing since he was 5-years old. He has years of experience competing at pow-wows and was able to make money for he and his mother to live from and to afford his dance regalia. After moving to Phoenix, he attended an exhibition dance to try out for his long-held dream to dance with the Native American dance troupe Indigenous Enterprise.

However, after the try outs he felt dizzy, nauseated, and weak. His aunt drove him to the Indian Health Service – Phoenix Indian Medical Center emergency room, where she knew Matt could be seen based on a sliding-fee scale as Matt has not found a job in Phoenix and has no health insurance.

After conducting several tests, the emergency room doctor diagnosed Matt with type 2 diabetes. Matt was surprised to learn he had been diagnosed with type 2 diabetes, as he is not overweight, and he knew this was a disease normally found later in adulthood. He also knows his mother, friends, and extended family on the reservation who also have type 2 diabetes who have struggled to live with the disease.

The emergency room doctor has asked for a public health nursing assessment to be done as soon as possible to assess Matt’s lifestyle, nutritional status, activity level, community supports, and teaching needs related to his new diagnosis. You are the public health nurse experienced in health care for adolescents and have been asked to visit Matt at his aunt’s home in Phoenix. Before setting up a home visit to meet Matt, you want to prepare.

To prepare for this home visit, answer the following questions:

1. Summarize what is known about the history and presence of type 2 diabetes on the Tohono O’oodham and Pima reservations. List and describe important information you would like to understand before meeting with Matt to discuss his diagnosis.
2. List and describe the life stressors that are occurring for Matt. Using a holistic approach explain how stress can impact diabetes.
3. Describe how you as a public health nurse will approach a visit with Matt who is 18-years old. Describe specifically how the visit will be different than meeting with an adult with the same diagnosis. Identify developmental considerations you will make as you facilitate a discussion with Matt and what you will do to include those considerations in your discussion.
4. You would like to learn more about Matt’s areas of need and his strengths during your first visit. After your health assessment is complete, you would like to highlight and support Matt’s strengths towards health, well-being, and managing his life with type 2 diabetes. What strengths can you identify from what you have learned today? 
5. Identify at least three culturally based community referrals you could provide to Matt and his aunt to support his health and well-being. How can his culture be a support to him now? Explain your views and provide rationale for your answers. Knowing Matt’s cultural background and goals for the future, is there anything else you would like to recommend for Matt to support him as he begins his life in Phoenix? 

Root cause of health inequity

Centuries of US federal policy that has threatened natural Native American kinship and family structure and forced assimilation of Native Americans into the White culture. Also, “…health outcomes for Native Americans are adversely impacted by wholly inadequate access to comprehensive health services” (Smith, 2022).

Policy Considerations

1. National strategy related to developing Native American youth leaders.
2. Prepare Native American youth with political knowledge and skills to further their abilities as national and tribal leaders, such as training in financial literacy, resiliency, community wellness, policy identification and developments.
3. Increase funding for tribal colleges
   • https://collegefund.org
   • https://theconversation.com/tribal-colleges-empower-native-students-with-an-affordable-culturally-relevant-education-but-need-more-funding-160578
4. Greater protection of and maintaining traditional Native American languages, sacred lands, and traditional lifeways
5. Create data institutes on Native American youth to discuss policy development on data quality and data use

Calls to Action

• Explore the conditions needed to support Native youth, their identity and worldview as a mentor.
• Include the voices of Native youth in leading change.

References

National Congress of American Indians. (2021). Native children’s policy agenda: Putting first kids 1^st. https://www.ncai.org/resources/ncaipublications/Aug_2015_Native_Childrens_Policy_Agenda.pdf

National Congress of American Indians. (2021). Native youth programs. https://www.ncai.org/native-youth

Martin, L. & Moss, M. (2016).Life in the urban setting for AI/AN adolescents. In M. Moss (Ed.) American Indian health and nursing (p. 301-304).Springer.

Schulz, L. O. & Chaudhari, L. S. (2015, March). High-risk populations: The Pimas of Arizona and Mexico. Current Obesity Reports, 4(1), 92-98. doi:10.1007/s13679-014-0132-9.

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According to a friend and owner of the local bar and grill, Joe visits weekly to fill his containers with fresh water and walking a half-hour there and back to his home. Joe has type 2 diabetes, does not have a medical provider, obtains most of his food from the distribution program in town and from friends and relatives who bring meals for him when they can. Joe is also well-known in the community as his father and grandfather were medicine men. Several friends check in on him when they can and bring food. Joe has great pride in his tribe, community, and has no desire to leave the reservation.

Joe has one son who lives four hours away. His son visits when he returns home for pow-wows a few times each year. Joe lives on his social security checks along with some tribal support income for elders when it is available.  

One evening as Joe walked back home with water from the bar and grill, he became very tired and sat down on the side of the road and fell asleep. Some out-of-town visitors driving by found Joe and assisted him to his home and then called the county police. The police informed Cherokee Nation Tribal health who are sending a public health nurse to talk with Joe about his health and to assess his safety and well-being at home.  You are the nurse planning to visit Joe to do the assessment and to develop a relationship with him to hopefully continue visits to promote his health and safety at home. Ultimately, you know he would best be served in a different living situation where there is more support readily available, but you also understand his strong commitment to continue living where he has been for his life on the Cherokee reservation.

Answer the following questions:

1. Describe the status of aging Native Americans in the United States including social, economic, and health status implications.  
2. Research the geographic location, history, and health indicators of the Cherokee Nation. What would be helpful to know about this tribe as you prepare to visit Joe and attempt to understand his needs? 
3. What is a medicine man and how does a medicine man serve a tribal community? How does traditional Native American medicine differ from the current health care system in the United States? (Conley, 2007)
4. After your health assessment you would like to highlight and support Joe’s strengths to him and to his son. What strengths would you like to discuss with Joe from what you have learned today?  Give specific examples on what words/phrases you would use to describe these areas and what questions you would ask of Joe in this conversation.

Root cause of health inequity

Centuries of US federal policy that has threatened natural Native American kinship and family structure and forced assimilation of Native Americans into the White culture. Also, “…health outcomes for Native Americans are adversely impacted by wholly inadequate access to comprehensive health services” (Smith, 2022).

Policy Considerations

In 2005, the National Congress of American Indians (NCAI) prepared several policy recommendations for Native Elders. One set of recommendations was focused on increasing the availability of health care and other services in rural reservation areas. Some of these recommendations that apply to Joe:  

1. Increase senior centers for frontier Native Elders
   • The Federal Administration on Aging (AoA) Office for American Indian, Alaska Native, and Native Hawaiian Programs needs to advocate with states and other federal agencies to increase senior centers for frontier Native Elders. Recognizing the vital link in the service delivery network, senior centers function as meal sites, screening clinics, recreational centers, social service agency branch offices, mental health counseling clinics, older worker employment agencies, volunteer coordination centers, and community meeting halls. The significance of senior centers cannot be underestimated. They provide a sense of involvement in the community, offer the opportunity to pursue activities of personal interest, and bring a sense of belonging to elders. Senior centers could also serve as a central location for provision of information technology services. These could include assisted telecommunication links with public services such as Social Security. Increasing the availability of senior centers for Native elders residing in frontier counties has the potential of enhancing the network for Native elders and provide a common gathering place in which other community members can learn from and interact with Native elders. The inter-generational connections are essential to sharing and preserving culture and community, especially for those most geographically challenged. Additionally for senior centers, telecommunication needs should be identified. (NCAI, 2005).
2. Home safety audits
   • A special initiative under the US Department of Housing and Urban Development (HUD) needs to provide assessments on a regular basis of Native elder’s current housing environments in relationship to their health needs. An implied goal of independent living is embedded in these recommendations. Individual homes need to meet the needs of their residents. Home safety audits are needed as standard practice for the elder population to ensure optimal conditions for independent living. These environmental assessments can be broadly defined to include medical equipment such as safety bars in bathrooms, toilet risers, and such items that enable elders to function at optimal levels in their home environments. By assuring that Native elders live in homes appropriately equipped for their health needs, they can remain in their homes and communities rather than be moved to alternative care sites. In addition, maintaining elders in their preferred home and communities is cost effective, and adds to their quality of life. Communities also benefit by having their elders living among other generations. Some Native elders’ housing is so sub-standard that they would require new housing options if their homes were audited for safety.
3. Funds to assist Native elders upgrade their current living environments
   • Funding is needed to be set aside for this purpose in addition to funds to implement more home safety audit programs.
4. Improve plumbing and sanitation conditions for frontier Native elders and all Native Americans
   • Congress should increase funds for the Native American Housing Assistance and Self-Determination Act (NAHASDA) to improve plumbing and sanitation conditions for frontier Native elders and all Native Americans. Plumbing was identified as an unmet health need for frontier Native elders. Access to plumbing and proper sanitation is essential to maintaining good health. As some frontier Native elders assist in providing care for their children and grandchildren, improvement in their living conditions translates to improved living conditions for their families. It is a basic public health function that needs to be available to all Native elders. Improvements in plumbing and sanitation require funding which is currently unavailable at the level of need.

Calls to Action

• Prioritize tribal infrastructure programs, namely, tribal water settlements.
• Funding is needed for affordable broadband access to the Internet
• Increase funding for the Native American Housing Assistance and Self-determination Act for long term housing and community development

References

Conley, R. J. (2007). Cherokee medicine man: The life and work of a modern-day healer. University of Oklahoma Press. 

National Congress of American Indians. (December 2021). NCAI policy research center. https://www.ncai.org/prc

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Sean is energetic and outgoing and has made friends quickly in his new school that provides an alternative to public school education for children who would benefit from additional educational support services. Sean is obese and has been recently diagnosed with hypertension and type 2 diabetes. In this new school there are only a few Native American peers for Sean and no cultural support partners or programs for Native American students. Sean doesn’t currently have an adult male role model in his life. However, he remembers his father well, who was the lead singer for a powwow drum group for his home reservation.

Sean is very proud of his dad and wants to learn to sing and to drum like him. Sean also wants to be a football player.

You are the public health nurse who visits the school weekly to provide health screening services and noticed Sean brings snacks to school that include soft drinks, potato chips, and candy. You are participating in his parent/guardian: teacher conference next week and would like to talk with Sean’s grandmother about how to support Sean to best live with his diagnosis and promote his optimal health at school.

To prepare for his parent/guardian: teacher conference next week, you are reviewing the following questions:

1. Is type 2 diabetes in Native American children common in the United States? Share what you know about the disease and its evolution to younger age groups in this country and globally.
2. Discuss what you have learned about poverty and its possible influence on Native American children like Sean.
   • Too Many Children Continue to Live in Poverty in Minnesota (PDF)
   • One-third of Native American and African American children are (still) in poverty
3. Before meeting with Sean’s grandmother, you want to learn more about the role of the Native American elder and grandmother in the family and how to best communicate respectfully with her to discuss Sean’s health and nutrition. Where would you go to learn more on these topics?
   (Byers, 2010: https://www.researchgate.net/publication/233123902_Native
   _American_Grandmothers_Cultural_Tradition_and_Contemporary
   _Necessity)
4. What is the meaning and purpose of the Native American drum? How are traditional drums made?  Recent research has shown the sound of the drum can positively impact health – research and discuss your findings on this statement.
   http://www.oneskycenter.org/wp-content/uploads/2014/03/D.Dickerson-UtilizationofDrummingforAmericanIndians
   andAlaskaNativeswithSubstanceAbuseDisorde.pdf
5. You would like to highlight and support Sean’s strengths towards his future health and well-being. What strengths would you like to discuss with Sean and his grandmother? Give specific examples on the words/phrases you would use and what questions you would ask in this conversation.
6. Name two culture-based referrals or resources for Sean you would like to suggest for his grandmother at the parent/guardian: teacher conference. Describe how you see these referrals providing added support for Sean and for his grandmother?

Root cause of health inequity

Centuries of US federal policy that has threatened natural Native American kinship and family structure and forced assimilation of Native Americans into the White culture. Also, “…health outcomes for Native Americans are adversely impacted by wholly inadequate access to comprehensive health services” (Smith, 2022).

Policy Considerations

1. Seek reimbursement for culturally adapted services and kinship navigator programs
   • Effective January 2021, the US Children’s Bureau provided new guidance on allowable flexibilities related to cultural adaptations of evidence-based prevention programs and services in Title IV-E prevention services for tribal communities. Prevention services include mental health services, parent training, and substance abuse prevention and treatment. Tribes agree and may seek reimbursement for culturally adapted services.
2. Continue collecting data on all the Indian Child Welfare Act (ICWA) data elements
   • The Biden-Harris Administration is looking to hear from tribes on their position regarding restoration of 2016 data elements on Native American and LGBTQ+ child welfare that were removed by the prior Trump Administration from the adoption and foster care analysis reporting system (AFCARS). As the Federal lawsuit is pending, tribes are urged to consult with their state child welfare agency on how they will collect data on all the Indian Child Welfare Act (ICWA) data elements to assure representation in data for tribal communities.   
3. Growth of ICWA On-Reservation and Off-Reservation programs
   • The Biden-Harris Administration budget request has proposed several increases to child welfare programs that tribes will administer. The request will include items for the ICWA On-Reservation and Off-Reservation programs. The National Indian Child Welfare Association (NICWA) is following specific requests for these funds for the future of each program.

Calls to Action

• Gain understanding of intergenerational trauma.
• Provide resources to families and health professionals on how to provide cultural based support to Native youth as a protective factor

References

Byers, L. (2010). Native American grandmothers: Cultural tradition and contemporary necessity. Journal of Ethnic & Cultural Diversity in Social Work, 19(4), p. 305-316

National Indian Child Welfare Association. (2021). Child and family policy update: November 2021. http://www.nicwa.org/policy-update/

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Violet has just graduated with honors from high school. Being an honors student, she was admitted early to a pre-med program on a full scholarship from the Indian Health Service as her mother could not financially support her or contribute to the university’s tuition.

Violet had repeatedly witnessed her father’s violence against her mother during her life. Her father passed away due to pancreatic cancer. As Violet has left the reservation and is living on her own, she has begun to experience panic attacks due to memories of violence she witnessed. She started to see a counselor with her mother’s encouragement to help learn how to manage the panic attacks and anxiety.

In her recovery journey, Violet has learned that violence against Native American women is at epidemic proportions, and it is important for her to continue to reach out for help and seekmental health services whenever needed. Native American women have been frequent recipients of violence due to poverty and victimization as well as racism, sexism, and the legacy of colonialism. In the United States the data on this tragic problem is just now becoming available.

What Violet has experienced has not been easy and communicating with her counselor and family who care for her will help her to manage symptoms and become stronger for her life ahead. She also turns to her cultural practices of smudging, singing, and prayer to connect her to greater harmony and healing within her spirit. She returns home to her reservation to visit her mother and extended family, and to meet with a medicine woman from her tribe. She also likes to participate in powwows wearing her mother’s traditional ribbon skirt when she can.

Answer the following questions:

1. Research and discuss about why Native American women are targeted more for violent acts.
2. What is smudging and what are powwows?
3. What is the “Not Invisible Act of 2020” and what could it do to create improved lives for Native American women and girls?

Policy Considerations

1. Coordinate prevention efforts grants, and programs related to missing and murdered Indigenous peoples
   • Congress unanimously passed the Not Invisible Act in October 2020 to increase intergovernmental coordination to identify and combat violent crime against American Indians and Alaska Natives and on Indian lands. The Act calls for the Interior Department to coordinate prevention efforts grants and programs related to missing and murdered Indigenous peoples. The Act will increase coordination to investigate and resolve cases and ensure accountability and address the underlying causes behind the numbers including among others, sexual violence, human trafficking, domestic violence, violent crime, systemic racism, economic disparities, and substance use and addictions.
2. Commitment to work with tribal nations
   • President Biden declared May 5, 2021, as Missing and Murdered Indigenous Persons Awareness Day with a commitment to work with tribal nations to address the disproportionate high number of missing or murdered Indigenous people.

Calls to Action

• Require diverse representation of people from Indian Country at the table with federal officials.
• Ensure that Native women, girls, and 2SLLGBTQQIA people are represented in governance and that their rights are respected
• Challenge the acceptance and normalization of violence.

References

US Department of Justice. (2021). Office of public affairs press release: Justice and interior departments take next steps in implementation of not invisible act. Wednesday, August 4, 2021. https://www.justice.gov/opa/pr/justice-and-interior-departments-take-next-steps-implementation-not-invisible-act

US Department of the Interior – Indian Affairs. (2021). The not invisible act commission. https://www.bia.gov/service/not-invisible-act-commission

The post American Indian/Alaska Native People Profile #7: Violet appeared first on Campaign for Action.

In 2021, the Campaign’s Lisa Martin, PhD, RN, FAAN, Equity, Diversity & Inclusion Senior Advisor, produced eight profiles focused on American Indian/Alaska Native people and how all nurses and health care providers, and policy, could address the inequities in each situation.

Below you will find each profile. All are fictional, but they detail some everyday, complex scenarios involving the social determinants of health and other factors that Native people routinely deal with.

The post Profiles: How American Indian/Alaska Native Nurses and Policy Can Address Inequities appeared first on Campaign for Action.

Although Valerie has tried several approaches to losing weight, none have been successful as she dislikes dieting – she finds it is just too difficult when she prepares all meals at home and is the cook for her family. She accepts her responsibility to keep her family content with their meals, and they love her cooking.

Valerie worked at a factory in town for many years, but because of hip and knee problems, she could no longer stand for the long hours required and had to stop working. She became certified as disabled and now watches TV at home, plays video games, and makes traditional Native American beadwork that she sells on eBay.

Valerie smokes a pack of cigarettes a day as does her husband and eldest daughter. Her youngest daughter passed away when she was an infant due to sudden infant death syndrome (SIDS).  Valerie’s loss of her daughter started her long history with depression which causes her to eat and smoke to cope with her grief. After the loss of her infant daughter to SIDS, her doctor started her on antidepressant medication therapy. 

Valerie knows she is obese, but she tells her family that being large is what makes her strong. She was not born on the reservation, or lived there during her life, but is connected to many friends and relatives through Facebook and tries to visit during the powwow season. Even though she has lived in a rural area for her life, she considers her reservation her home.

You are the public health nurse who will be visiting Valerie at home as requested by her doctor to follow her hypertension and assess her response to her antidepressant medication.  You are preparing for the visit.

Answer the following questions:

1. Learn about the Strong Heart Study and summarize what it reveals about obesity in Native Americans and the relationship of obesity to health outcomes.
2. Can traditional Native American culture positively impact the high rates of obesity in Native Americans? Give specific examples.
3. What are the priority concerns for Deborah that you would like to discuss during your visit and what are her strengths? What are some ways that you can prepare to talk to her about achieving optimal health for herself and her family?

Policy Considerations

1. Embed health equity in disease control and health prevention efforts
   • The Centers for Disease Control and Prevention (CDC) is working to remove environmental and systemic barriers to health. The CDC’s Division of Nutrition, Physical Activity, and Obesity (DNPAO) leads the nation’s public health efforts to promote good nutrition, regular physical activity, and a healthy weight for all. The CDC works with partners and state, tribal, local, and territorial health agencies to bring greater health equity. Health equity is embedded in several CDC initiatives such as:
     • the national initiative, “Active People, Healthy Nation”
     • the REACH (Racial and Ethnic Approaches to Community Health) program where recipients work to reduce health disparities among populations with a high burden of chronic disease through culturally tailored interventions to address preventable health risks.
     • The High Obesity Program (HOP) works to increase access to healthier foods and accessible places for physical activity in communities where more than 40% of adults have obesity.
2. Reduce racial misclassification in AI/AN mortality data and cancer incidence
   • There is a strong need to continuously improve data collection and analysis for American Indian/Alaska Native populations, reducing misclassification on death certificates is one example. Efforts to reduce racial misclassification in AI/AN mortality data and cancer incidence can enhance understanding of AI/AN health disparities and highlight differences by region. Overall, the AI/AN death rate for SIDS among infants is more than twice that for the non-Hispanic White population. This disparity cannot be attributed to economic status, maternal age, birth weight, or prenatal care. However, educational campaigns have been effective in decreasing SIDS through improving infant sleep practices.

Calls to Action

• Recognize the important of spiritual support when clinical depression is present. Traditional healers and spiritual leaders can be a resource towards greater health.
• Add Indigenous foods into the diet and empower Indigenous agricultural economies.
• Increased opportunities for tribal communities to teach at a systems level.

References

Centers for Disease Control and Prevention. (2021). Division of nutrition, physical activity, and obesity – Health equity. https://www.cdc.gov/nccdphp/dnpao/health-equity/index.html

Solomon, T. et al. (2017). What’s killing our children? Child and infant mortality among American Indians and Alaska Natives. https://nam.edu/wp-content/uploads/2017/03/Whats-Killing-Our-Children-Child-and-Infant-Mortality-among-American-Indians-and-Alaska-Natives.pdf National Academy of Medicine, Washington DC

The post American Indian/Alaska Native People Profile #8: Valerie appeared first on Campaign for Action.

Education Map 2010

This map highlights the percentage of registered nurses with a bachelor’s degree in nursing or higher in 2010 by state.

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Education Map 2018

This map highlights the percentage of registered nurses with a bachelor’s in nursing or higher in 2018 by state. Displaying this map after the previous map powerfully depicts the national trend of more nurses earning their BSN.

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Education Map 2010-2018

This combined map depicts the change over time in percentage of registered nurses with a bachelor’s in nursing or higher from 2010 to 2018 by state.

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Note: These maps use American Community Survey data to depict the national trend. States who collect their own workforce data may find the state numbers in these maps may vary from their numbers, and therefore may prefer to continue to share their state-level data.

Interpretation of data used for BSN maps

This memo is intended to address questions about state-level data on the percentage of registered nurses who have a bachelor’s degree in nursing or higher degree in any field.

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The post Campaign Maps Show Nurses’ Progress in Earning BSN Degree appeared first on Campaign for Action.