American Indian Health - Eastern New Mexico University

American Indian Health

Integrating Traditional Native Healing Practices and Western Medicine

Sala Horowitz, PhD

Significant disparities in health status and access to health care have historically existed for American Indians (also known as Native Americans) in the United States, compared to other demographic groups. Following an overview of these demographics and challenges, this article focuses on efforts to draw on Native American healing traditions to improve the health of members of these communities and discusses the trend in Western medicine toward more culturally sensitive and culturally appropriate health care.

Native American Demographics

There are an estimated 4.9 million persons, in 565 federally recognized tribes, who are classified as American Indian or Alaska Native (AI/AN), alone or in combination with one or more other designated racial classifications. This demographic group comprises 1.6% of the U.S. population. The Indian Health Service (IHS) of the U.S. Department of Health and Human Services provides health services to approximately 1.9 million American Indians and Alaska Natives, the majority of who live on reservations and in rural communities in 36 states, primarily in the western United States and Alaska.

The rest of this population, which resides in urban areas, has less access to IHS programs and a documented high prevalence of, and risk factors for, numerous health problems. Factors limiting access to quality health care include cultural/linguistic barriers, geographic isolation, and low income.1

Shared Visions for Addressing Native American Health Challenges

The Association of American Indian Physicians (AAIP; see Resources) held its 40th annual meeting and national conference during August 8?15, 2011, in Portland, Oregon. While acknowledging historical American Indian health problems and tensions between their traditions and mainstream medicine, the main focus of "Shared Visions: Blending Tradition,

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DOI: 10.1089/act.2012.18103 ? MARY ANN LIEBERT, INC. ? VOL. 18 NO. 1

FEBRUARY 2012

Culture, and Health Care for Our Native Communities," was on the strengths that traditional beliefs, practices, and resources can bring to healing contexts.2

Roger Dale Walker, MD, outgoing president of the AAIP and a professor of psychiatry, public health, and preventive medicine at Oregon Health & Science University (OHSU) in Portland, (see Resources), commented that: "American Indians in the United States are dying in large numbers from diseases they shouldn't have to die from." Dr. Walker welcomed American Indian health care and top U.S. health leaders to the conference, which included, for the first time, the president of the American Medical Association.3 (Dr. Walker, a member of the Cherokee tribe, is also the director of the One Sky Center at OHSU; this center is the American Indian/Alaska Native National Resource Center for Substance Abuse and Mental Health Services; see Resources).

In addressing members of the AAIP, Donald Warne, MD, of the Oglala Lakota tribe, and director of the Office of Native American Health in Sioux Falls, South Dakota, noted that the life expectancy for Native Americans is 63 years, compared with 74 years for the general U.S. population. The death rate among Native Americans for diabetes is 3 times higher than the general population, 6 times as high for alcohol abuse, and 60% higher for suicide. Native Americans also have higher rates of other chronic diseases and health problems, sudden infant death syndrome, and accidents (see Selected Native American Health Statistics). Lamenting that we have "gotten away from the art of medicine" in being "focused on the science of medicine," Dr. Warne said: "Health providers could help reduce those disparities by adopting some traditional healing practices to balance physical, emotional, mental, and spiritual health." Referring to the fragmented nature of much of W estern medicine, Dr. Warne added that, as a family physician, he has seen many Native Americans suffering simultaneously from diabetes, depression, and alcoholism, and being treated by different providers who typically do not consult with one another regarding these linked conditions. Balance is the key to traditional Native American health practices.4 The principle

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ALTERNATIVE AND COMPLEMENTARY THERAPIES ? FEBRUARY 2012

of balance is also a core value of complementary and alternative

Principles of Native American Healing

medicine (CAM).

Jared Jobe, PhD, a Cherokee,

? Identification with one's cultural heritage

who is a health science administrator at the National Heart, Lung and

? Pursuit of a balanced life in relation to the interconnected mind, body, spirit, and environment

Blood Institute in Bethesda, Maryland, stated in his presentation: "We need to address the underlying

? Maintenance of family and community networks ? Inclusion of a traditional healthy diet and activities

wounded spirits, the loss of culture, the loss of land, and how that affects people's spirits." Dr. Jobe not-

? Use of traditional healers and interventions (e.g., spiritual ceremonies, drumming, sweat lodge purification)--alone or in combination with Western medicine

ed that public health leaders could help Native Americans improve

Roger Dale Walker, MD, Oregon Health & Science University.

their health by urging them to return

ditional Native American healer or medicine man (of the 812

to traditional diets,which included fish,berries,nuts,vegetables,

respondents who reported using all types of such healers).9

and game meats, and physical activities such as lacrosse, a game

In a study of Native American patients in an urban Native

they invented.

health center in Wisconsin, 38% reported that they see a tra-

"Traditional ways of living are extremely healthy, and this is

ditional healer, and the majority said that they would consider

the antidote to the harms of losing land and a way of life," he

seeing one in the future. These users of traditional healers rat-

said.4 These losses have been termed "historical trauma" by

ed the traditional healers' advice more highly than the advice

the U.S. Substance Abuse and Mental Health Services Ad-

of their physicians (61% of the time), and only 15 % informed

ministration, Center for Mental Health Services, and is de-

their physicians about seeing Native healers.10

fined as: "the emotional and psychological wounding over

the lifespan and across generations, emanating from massive group trauma experiences."5

Native Healing Philosophy, Traditions,

Other items on the conference agenda included:6

and Attitudes

? "Learning for Future Physicians Interested in American Indian and Rural Healthcare"

? "Mental Health Problems and Solutions in Indian Country" ? "Living a Balanced Life with Diabetes: A Resource Tool

Kit for American Indian/Alaska Healthcare Professionals" ? "Community-Based Participatory Research" ? "Traditional Approaches to Modern Health Disparities" ? "Development of Drumming-Assisted Recovery for Na-

tive Americans: A New Drum Therapy Treatment Protocol for American Indian/Alaska Natives with Substance Abuse Disorders."

The Drum-Assisted Therapy study is research currently in progress, funded by the National Center for Complementary and Alternative Medicine (NCCAM), National Institutes of Health, in Bethesda, Maryland. The purpose of the study is to develop a protocol for a randomized clinical trial comparing a traditional drumming intervention to standard behavioral treatment for substance abuse disorders.7

Utilization of Native Healers

The NCCAM considers the practices of traditional healers to be a form of complementary and alternative medicine (CAM).8 The 2007 National Health Interview Survey, the first one that asked about utilization of this modality, found that 224 adults age 18 (27.5%) had used the services of a tra-

Although the recognized AI/AN tribes in North America do not comprise a monolithic group, their communities share many elements in their healing traditions. Native practices have been categorized as belonging to the realms of: "The Native American Pharmacy" (medicinal herbs and other plants); "The Native American Spa" (healing with heat in sweat lodges for purification, massage, drumming, dance, and nutrition); and "The Healing Spirit" (dream therapy, spirituality and prayer).11

As with other users of CAM modalities, Native people hold a holistic perspective on health based on a balance of the interrelationships of body, mind, spirit, and the environment. For example, the traditional Navajo "Walking in Beauty" worldview holds that everything in life is connected and influences everything else, and "sees illness as a result of things falling out of balance, on losing one's way on the path of beauty." Relationships with families, the community, the universe, and healers are paramount.12

Connection with the Native community and participation in Native cultural practices has been found to be among the predictors of wellness in this population. For example, this was the case in a recent survey of 457 American Indian adults at 13 rural health care sites in California. The researchers therefore recommended culturally appropriate health education and interventions that emphasize cultural and community connectivity for improving wellness status.13

Historical mistrust of mainstream medical practitioners and practices was among the culture-specific barriers cited for Na-

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Selected Native American Health Statistics

Cancer ? American Indian/Alaska Native (AI/AN) men are twice as likely to have liver and colon cancer as non-Hispanic white males. ? AI/AN women are 2.4 times more likely to have, and twice as likely to die from, liver and colon cancer, compared to non-Hispanic white

women. ? AI/AN women are 40% more likely to have renal/pelvic cancer as non-Hispanic white women.

Diabetes ? AI/AN adults were 2.3 times more likely as white adults to be diagnosed with diabetes. ? AI/ANs were twice as likely to die from diabetes as non-Hispanic whites in 2005. ? AI/AN adults were 1.6 times as likely to be obese as non-Hispanic whites.

Heart disease ? AI/AN adults are 1.2 times as likely as white adults to have heart disease. ? AI/ANs are 1.4 times as likely as white adults to be current cigarette smokers. ? AI/AN adults were 1.3 times as likely to have high blood pressure as non-Hispanic whites.

Stroke ? AI/AN adults are 60% more likely to have a stroke than their white counterparts. ? AI/AN adults are more likely to have the risk factors for stroke of being obese and/or having high blood pressure.

HIV/AIDS ? AI/ANs have a 40% higher AIDS rate than their non-Hispanic white counterparts (20% higher in men; twice as high for women).

Infant mortality ? AI/ANs have 1.4 times the infant mortality rate as non-Hispanic whites. ? AI/AN babies are 30% more likely to die from complications from low birth weight or congenital malformations, compared to non-

Hispanic white babies, and twice as likely as non-Hispanic white infants to die from sudden infant death syndrome. ? AI/AN infants are 3.7 times as likely as non-Hispanic white infants to have mothers who began prenatal care in the third trimester or

did not receive prenatal care at all.

Eating disorders ? AI young women reported significantly greater disordered eating behaviors than white women.a

Substance abuse ? AI/AN adults had the highest rate of substance abuse treatment needs (19.4%), compared to the overall rate of 9.7% of adults age 18

or older in a given year (2003?2007).b ? Compared with the national average for adolescents age 12?17, AI/AN adolescents had higher rates of past month cigarette use

(16.8% versus 10.2%), marijuana use (13.8% versus 6.9%), and nonmedical use of prescription-type drugs (6.1% versus 3.3%).c

Suicide ? The prevalence rate of suicide within the AI population is 1.5 times the national rate. A sense of belonging showed a negative associa-

tion with suicidal ideation.d ? Youth ages 15?24 account for 40% of all suicides in this population. Nonfatal injuries resulting from suicidal behavior may account for

13 events for every fatality.e

Source: Ref. 1, except where noted otherwise. aStriegel-Moore RH, Roselli F, Holtzman N, et al. Behavioral symptoms of eating disorders in Native Americans: Results from the ADD Health Survey Wave III. Int J Eat Disord 2011;44:561?566; bSubstance Abuse and Mental Health Services Administration. National Survey on Drug Use and Health Report: Treatment for Substance Use and Depression among Adults by Race/Ethnicity. Online document at: data/2k9/163/SusUseRaceEthinicity.htm Accessed Nov 16, 2011; cSubstance Abuse and Mental Health Services Administration. The National Survey on Drug Use and Health: Substance Use Among American Indian or Alaska Native Adolescents. Online document at: . 2k11/005/WEB_SR_005.htm Accessed October 4, 2011; dHill DL. Relationship between sense of belonging as connectedness and suicide in American Indians. Arch Psychiatr Nurs 2009;23:65?74; eHummingbird LM. The public health crisis of Native American youth suicide. NASN School Nurse 2011;26:110?114.

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tive women not getting mammograms, despite a disproportionately high incidence of breast cancer and deaths from the disease in this population. (Disincentive factors that they share with non-Native women include cost, transportation, and fear of the test and its potential results.)14

From a survey of low-income American Indian, African American, and Caucasian women age 18 and older (N = 367) relating to their food-related environment, health beliefs, and behavior, investigators concluded that nutrition education and intervention efforts require tailored approaches that take into account racial/ethnic identity among the many environmental, personal, and behavioral factors contributing to the obesity epidemic.15

Concepts Relevant to Health Care Integration

When considering how to integrate Native American traditions into Western settings, a number of concepts are particularly helpful:

? Heritage consistency--This is the degree to which one's lifestyle is consistent with his or her traditional culture; it influences health-related beliefs and behavior.16

? Culturally adapted and culturally based health interventions--A distinction has been made between these two interventions in efforts to address historical disparities in Native service utilization and intervention outcomes. Whereas culturally adapted interventions adapt an existing evidence-based intervention to a particular cultural context, culturally based interventions are designed specifically for a cultural group.17

? Cultural safety--This concept was first applied to protect the identities of indigenous minorities working in dominant-culture health institutions and is being increasingly used in honoring traditional worldviews and ways of life in Western health contexts.18 An example of culturally sensitive care in an end-of-life setting was a study of interviews with bereaved family members of a First Nations patient in a hospital-based setting.19 The family members had expressed a wish for space to accommodate a larger number of visitors than is typical of mainstream Western facilities. The family members also expressed a desire for respectful directness in communication.20

? Cultural identity--Although Native cultural identity showed no direct effect on population-specific protective processes in treating alcohol and drug abuse in one analysis of data from the Sacred Mountain Youth Project (N was not specified), a secondary analytical model found that the factors of social support and family and peer influences were associated with cultural identity as buffers between stressful life events and these risky behaviors.21

? Cultural competency--Mainstream medical schools are increasingly incorporating cultural competencies in their curricula. In March 2001, the Office of Minority Affairs, of the U.S. Department of Health and Human

Services, issued National Standards for Culturally and Linguistically Appropriate Services (CLAS), required for all health care organizations that receive federal funds. Private practitioners were also encouraged to incorporate these standards into their practices. Comprised of 14 standards, the CLAS recommendations entail provision of patients with: respectful care in a manner compatible with their cultural health beliefs, practices, and preferred language; a diverse staff and leadership that represent the demographic characteristics of the area; and staff trained in culturally appropriate care. Patient empowerment and "authentic" community involvement are also part of the guidelines.22

Examples of Health Integration Efforts

A Native Clinical Perspective In a memoir of her path in becoming the first Navajo wom-

an surgeon, Lori Arviso Alvord, MD--a former professor of surgery and psychiatry and associate dean for student and multicultural affairs at Dartmouth Medical School in Hanover, New Hampshire--addresses the difficulty of, and need for, combining the best of Western medicine with Native values and customs. Dr. Alvord described her work when she was a surgeon at the Gallup Indian Medical Center, which served people in the Navajo reservation and surrounding areas, in Gallup, New Mexico, in creating culturally competent healing environments: "As I adapted my practice to my culture, my patients relaxed in situations that could otherwise have been highly stressful to them," resulting in better outcomes.

For example, Dr. Alvord saw the vital signs of an elderly patient who had undergone standard treatments for advanced cancer stabilize upon hearing a medicine man's singing (the Navajo word for healer literally translates as "singer") outside of his hospital room, which evoked hope and a will to live in him. When scheduling surgery, Dr. Alvord consequently allotted time for such Native rituals or ceremonies requested by patients to be conducted first.12

When Dr. Alvord served on the NCCAM's National Advisory Council for Complementary and Alternative Medicine in 2007, she advocated further for applying the traditional reciprocal, respectful patient?healer relationship to improve conventional Western health care. According to Dr. Alvord, scientific studies have validated some of these traditional Native mind?body practices to the extent that the National Institutes of Mental Health had, at one time, funded the training of Navajo medicine men/women, to address their dwindling numbers. Dr. Alvord has also worked to counter less-helpful aspects of Native health-related beliefs and attitudes (e.g., the belief that cancer is contagious).12

Treatment, Training, and Research Partnerships According to Lewis Mehl-Madrona, MD, who is of Cher-

okee and Lakota heritage, Native American healing practices are being sought out by non-Natives as well as Native

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Resources

Organizations

Association of American Indian Physicians (AAIP) 1225 Sovereign Row, Suite 108 Oklahoma City, OK 73108 Phone: (405) 946-7072 Fax: (405) 946-7651 Website:

The mission of the AAIP is "to pursue excellence in Native American health care by promoting education in the medical disciplines, honoring traditional healing principles, and restoring the balance of mind, body, and spirit."

One Sky Center (OSC) Oregon Health & Science University 3181 SW Sam Jackson Park Road, GH 151 Portland, OR 97239 Phone: (503) 494-3703 Fax: (503) 494-2907 E-mail: onesky@ohsu.edu Website:

OSC is an American Indian/Alaska Native National Resource Center for Substance Abuse and Mental Health Services. OSC promotes prevention and treatment of mental-health and substance-abuse problems, and provides information on services extant among Native people, by identifying and disseminating culturally appropriate, effective evidencebased practices. The OSC also works on projects with the mainstream community members who interface with Native people.

Recommended Reading

The Scalpel and the Silver Bear: The First Navajo Woman Surgeon Combines Western Medicine and Traditional Healing By Lori Arviso Alvord, MD, and Elizabeth Cohen Van Pelt New York: Bantam Books, 1999

Americans. When Dr. Mehl-Madrona was at the Center for Complementary Medicine, University of Pittsburgh Medical Center in Pennsylvania, dialogues between him and traditional Native American healers resulted in developing an approach-- described as a "dynamic energy system"--for bridging cultures. This approach was intended to facilitate the interaction of non-Native with traditional Native healers in an integrated program to treat chronic illness.

In evaluating a treatment program for patients with diabetes mellitus, 80% of 116 patients showed significant benefits from a 7?10-day intensive healing program, compared to the control group consisting of patients from his emergency room practice. Dr. Mehl-Madrona concluded that, within this holistic theoretical framework, physical illness could be treated well by ceremonies or counseling, because intervening at any one level (i.e., body?mind?spirit) affects the others.23

Similarly, Dr. Mehl-Madrona found, based on an evaluation of a 3-year outpatient program for improving treatment of Native patients with diabetes, that collaborative health care was more beneficial than conventional individualized care or standard group health education alone. Shared collaborative care included the simultaneous provision of medical, psychologic,

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and spiritual care. Reasons for this result were given as including increased social support, stress reduction, more-positive health beliefs, and collaborative care serving as a kind of naturalistic biofeedback.24

Storytelling, a traditional Native mode of sharing lived experience, has been shown to play a role in healing. In obtaining narratives from 47 patients with cancer with a poor prognosis who survived beyond the predicted 5 years, before and after their work with a traditional Native healer, Dr. MehlMadrona found increases on the dimensions of a scale used to measure a sense of meaning and purpose, faith, and hope, after the patients worked with the Native healers.25

This traditional healing approach was also shown to be effective for treating Native youth with substance-abuse problems (with abusing inhalants specifically) in a residential treatment facility.26 A community substance-abuse treatment center for First Nations (Canadian indigenous) people incorporated the traditional symbol of the medicine wheel, representing harmony and spirituality, into its program with other Native and Western therapeutic approaches.27

The medicine wheel is a sacred symbol that represents all knowledge of the universe. The circle represents the pattern of ongoing life and death, and horizontal and vertical lines drawn through the center represent the sun and the human's sacred path. The lines present the cardinal directions, and each is associated with a color and a particular messenger. For example, East is associated with yellow and the brown eagle. An eagle feather attached at the center is a sign of the Great Spirit's power over everything.28

Traditional healers and elders have rarely been consulted on what mental health practitioners should be taught to be effective and appropriate in treating indigenous people. In preparation for developing a crosscultural training program for human service providers, healers and elders were consulted in identifying values and principles important to working with traditional healers. Elders in the project were also to be asked to serve in the roles of community mentors and adjunct faculty with equal status as academically trained faculty members.29

With respect to conducting academic health research with American Indian tribes, it has been recognized that informed consent needs to go beyond the conventional institutional review board because of the potential for adverse consequences at the community level.Tribal nations themselves are believed to be the best ones to identify potential negative outcomes. In addition, the principles of indigenous rights and sovereignty should be applied in agreements with participating tribes regarding study assumptions, methods, interpretation, and publication.30

Community-based and tribally based participatory research approaches have been developed to inform such research partnerships among academic institutions, tribes, and Native organizations, to develop strategies to understand, prevent, and treat substance abuse better in this population. On their side of the collaboration, indigenous participants can identify unique challenges, resources, and culturally ap-

ALTERNATIVE AND COMPLEMENTARY THERAPIES ? FEBRUARY 2012

propriate approaches.31 For example, in conjunction with a First Nation community, the Canadian Institutes of Health Research is conducting a study to evaluate whether a traditional high-protein diet or an intervention based on the current Canadian dietary recommendations (high carbohydrate, high fiber) has a greater impact on risk factors for type 2 diabetes mellitus and/or cardiovascular disease.32

In a step toward a randomized controlled trial, a study protocol is examining a culturally tailored smoking cessation program for American Indians, who have the highest prevalence of smoking (40.6%) in the United States and high tobaccorelated mortality.33 In another example of incorporating a traditional component into a health education and intervention program, a study had recently been completed that examined an existing social network?based lay advisor intervention-- an intergenerational one--to determine whether such an approach increased the effectiveness of a program to mobilize a Native community to participate in a program to reduce detrimental lead exposure from mining among their children.34

The "Blending Two Worlds Study" seeks to provide a culturally sensitive, supportive treatment environment for children, adolescents, and families in the Native community who are experiencing stress, anxiety, and depression. Researchers also seek to gain insight into, and validate the role of, traditional healing options for the management of these health problems, and to encourage Native clients to seek treatment earlier from a culturally supportive system.35 In addition, consulting highly trained Native healers, when attempting to integrate any kind of traditional healing together with conventional care, is essential.36

Outreach with New Technologies Like many other youth, AI/AN teenagers and young adults

are avid users of media technologies including the internet and smart phones. In a survey of 405 AI/AN youths, 13?21 years old, living in tribal and urban communities, to identify health information?seeking patterns, 75% of respondents reported searching online for health information. These data are being used by Northwest tribes in conjunction with the Northwest Portland Area Indian Health Board in Portland, Oregon, to design culturally appropriate, technologybased health interventions targeting AI/AN youth.37

Conclusion

Despite the many health challenges historically experienced by persons in Native American tribes, they also have rich traditions to draw upon to promote wellness and holistic healing. As with other CAM approaches, the distinctive practices of Native Americans are based on the principle of achieving balance of the mind?body?spirit?environment. Traditional practices as part of an overall cultural revival are increasingly being respected and incorporated into mainstream medical settings, which are, conversely, beginning to cultivate cultural competencies in serving a diverse population.

Researchers are confirming the perception that connection to one's culture and community enhances health. Both CAM and biomedicine need to continue to work in partnerships with ethnic minority populations to remove historical barriers to providing culturally safe and culturally appropriate health care. n

References

1. Office of Minority Health, U.S. Department of Health and Human Services. American Indian/Alaska Native Profile. Online document at: health.templates/browse.aspx?lvl=2&lvlID=52 Accessed September 15, 2011.

2. Association of American Indian Physicians. 40th Annual AAIP Meeting and Health Conference. Online document at: ?/page=2011AM Accessed September 24, 2011.

3. American Indian Physician Group Continues to Tackle Health Problems in Native Populations. August 4, 2011. Online document at: ohsu.edu/xd/ about/news_events/news/2011/08-04-american-indian-physicia.cfm?WT_ rank=1 Accessed November 16, 2011.

4. Graves B. At Portland Conference, Native American Doctors Urge a Return to Old Ways to Cure a Population Hit by Chronic Disease. Online document at: health/index.ssf/2011/08/tribal_doctors_re turn_to_the_o.html Accessed September 14, 2011.

5. Substance Abuse and Mental Health Services Administration.FY 2011 Grant Request for Applications (RFA): Circles of Care: Infrastructure Development for Children's Mental Health Systems in American Indian/Alaska Native (AI/ AN) Communities (Short title: Circle of Care Grants). Online document at: grants/2011/sm_11_007.aspx Accessed September 19, 2011.

6. Association of American Indian Physicians. Agenda: 40th Annual AAIP Meeting and Health Conference. Online document at: re source/resmgr/annual_meeting_2011/2011AMagenda.pdf Accessed September 24, 2011.

7. U.S. National Institutes of Health. Drum-Assisted Therapy. Online document at: Accessed October 10, 2011.

8. National Center for Complementary and Alternative Medicine. What is Complementary and Alternative Medicine? [NCCAM CAM Basics]. Online document at: Accessed October 19, 2011.

9. Barnes PM, Bloom B, Nahin RL. Complementary and Alternative Medicine Use Among Adults and Children: United States, 2007. National Health Statistics Reports; No 12. Hyattsville, MD: National Center for Health Statistics. 2008. Online document at: nchs/data/nhsr/nhsr012.pdf Accessed November 16, 2011.

10. Marbella AM, Harris MC, Diehr S, et al. Use of Native American healers among Native American patients in an urban Native American health center. Arch Fam Med 1998;7:182?185.

11. Shimer P. Healing Secrets of the Native Americans: Herbs, Remedies, and Practices that Restore the Body, Refresh the Mind, and Rebuild the Spirit. New York: Black Dog & Leventhal, 2004.

12. Alvord LA, Van Pelt EC. The Scalpel and the Silver Bear: The First Navajo Woman Surgeon Combines Western Medicine and Traditional Healing. New York: Bantam Books, 1999.

13. Hodge FS, Nandy K. Predictors of wellness and American Indians. J Health Care Poor Underserved 2011;22:791?803.

14. Daley CM, Filippi M, James AS, et al. American Indian community leader and provider views of needs and barriers to mammography. J Community Health 2011;July 24;e-pub ahead of print.

15. Dammann KW, Smith C. Food-related environmental, behavioral, and personal factors associated with body mass index among urban, low-income African American, American Indian, and Caucasian women. Am J Health Promot 2011;25:e1?e10.

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16. Spector RE. Cultural Diversity in Health and Illness, 6th ed. Upper Saddle River, NJ: Pearson, 2004.

17. Allen J, Mohatt GV, Rasmus SM. Cultural interventions for American Indian and Alaska Native Youth: The Elluam Tungiinun and Nagi Kicopi programs. In: Sarche MC, ed. American Indian and Alaska Native Children and Mental Health: Development, Context, Prevention, and Treatment. Santa Barbara, CA: Praeger, 2011:337?364.

18. Hagey R. Cultural safety: Honoring traditional ways of life. Altern Complement Ther 2000;6:233?236.

19. Horowitz S. Complementary therapies for end-of-life care. Altern Complement Ther 2009;15:226?230.

20. Kelly L, Linkewich B, Cromarty H, et al. Palliative care of First Nations people: A qualitative study of bereaved family members. Can Fam Phys 2009;55:394?395.

21. Baldwin JA, Brown BG, Wayment HA, et al. Culture and context: Buffering the relationship between stressful life events and risky behaviors in American Indian youth. Subst Use Misuse 2011;46:1380?1394.

22. Office of Minority Health, U.S. Department of Health & Human Services. National Standards for Culturally and Linguistically Appropriate Services (CLAS). Online document at: browse.aspx?lvl=2&lvlID=15 Accessed October 4, 2011.

23. Mehl-Madrona LE. Native American medicine in the treatment of chronic illness: Developing an integrated program and evaluating the effectiveness. Altern Ther Health Med 1999;5:36?44.

24. Mehl-Madrona L. Comparisons of health education, group medical care, and collaborative health care for controlling diabetes. Perm J 2010;14:4?10.

25. Mehl-Madrona L. Narratives of exceptional survivors who work with aboriginal healers. J Altern Complement Med 2008;14:497?504.

26. Dell CA, Seguin M, Hopkins C, at al. From benzos to berries: Treatment offered at an Aboriginal youth solvent abuse treatment centre relays the importance of culture. Can J Psychiatry 2011;56:75?83.

27. Gone JP. The red road to wellness: Cultural reclamation in a Native First Nations community treatment center. Am J Community Psychol 2011;47:187?202.

28. Akta Lakota Museum & Cultural Center. The Medicine Wheel. Online document at: index.cfm?cat=1&artid=47 Accessed December 28, 2011.

29. Mehl-Madrona L. What traditional indigenous elders say about crosscultural mental health training. Explore (N Y ) 2009;5:20?29.

30. Harding A, Harper B, Stone D, et al. Conducting research with tribal communities: Sovereignty, ethics and data-sharing issues. Environ Health Perspect 2011;September 2:e-pub ahead of print.

31. Thomas LR, Rosa C, Forcehimes A, Donovan DM. Research partnerships between academic institutions and American Indian and Alaska Native tribes and organizations: Effective strategies and lessons learned in a multisite CTN study. Am J Drug Alcohol Abuse 2011;37:333?338.

32. U.S. National Institutes of Health. The Effect of a Traditional Dietary Intervention on Diabetes Mellitus and Cardiovascular Disease Risk Factors in a First Nation Community: A Pilot Study (SLHDP). Online document at: ct2/show/NCT00707460?term=Native+American+he alth&rank=3 Accessed September 14, 2011.

33. Choi WS, Faseru B, Beebe LA, et al. Culturally-tailored [sic] smoking cessation for American Indians: Study protocol for a randomized controlled trial. Trials 2011;18:126.

34. U.S. National Institutes of Health. Social Network Based Intervention to Reduce Lead Exposure Among Native American Children. Online document at: ct2/show/NCT00011661?term=Native+American+ health&rank=6 Accessed September 14, 2011.

35. U.S. National Institutes of Health. Blending Two Worlds: Traditional Aboriginal Healing Strategies for Depression and Anxiety. Online document at: ct2/show/NCT00749177?term=Native+American+he alth&rank=8 Accessed September 14, 2011.

36. Mehl-Madrona L. Sweat lodge. J Altern Complement Med 2010;16:609? 610.

37. Rushing SC, Stephens D. Use of media technologies by native American teens and young adults in the Pacific northwest: Exploring their utility for designing culturally appropriate technology-based health interventions. J Prim Prev 2011;32:135?145.

To order reprints of this article, e-mail Karen Ballen at: Kballen@ or call (914) 740-2100.

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