A Word from NAMI If mental health is the foundation of a vibrant, productive society, then access to treatment must be its cornerstone. Yet, even here in the U.S., where resources for treatment far outstrip those of our counterparts across the globe, less than a third of those with mental illness seek treatment. And those Americans whose race, ethnicity, primary language, and/or economic status have pushed them to the margins of U.S. society face daunting barriers to the most basic health care. Nowhere are these inequities more evident than among American Indians and Alaska Natives (AI/AN) with mental illness, whose morbidity rates for various mental illnesses are astronomically higher (alcoholism, 770% higher; suicide, 190% higher) than those of their white peers. NAMI's commitment to reach out to AI/AN communities and other underserved populations was made an official priority on November 9, 2001. On this day NAMI's Board of Directors approved its new Strategic Plan. Goal # 3 of this Strategic Plan states: NAMI must actively reach out to diverse and priority populations. To improve access to services, NAMI must continue to build its grassroots advocacy movement by involving increasingly diverse groups. To accomplish this, NAMI must enlist leaders from diverse cultural communities in order to establish a dialogue with the communities they represent and to assure that NAMI adopts practices, messages, and methods that are "culturally competent". NAMI must develop targeted marketing and outreach strategies to successfully involve these groups. In addition, NAMI must continue to develop a culture of respect for increased diversity in its governance and membership. To achieve this goal NAMI created a Multicultural and International Outreach Center (NAMI MIO). NAMI MIO's goals are to: • More centrally involve members of diverse communities in education/advocacy efforts. • Develop and disseminate culturally competent direct service/support models in the field. • Decrease stigma through public education models that address specific racial and cultural barriers. • Improve mental health policy development at the local, state and national level by increasing grassroots participation. It is a serious decision to start an AI/AN outreach initiative. It requires a thoughtful planning process and real commitment. The purpose of this manual is to aid in this process by providing key information regarding the AI/AN communities, mental illnesses, outreach strategies, and available resources. This manual is designed as a tool to help NAMI state offices and affiliates to better understand what is involved in an AI/AN outreach campaign and aid in the creation of an outreach plan. This manual covers the following area: the need for AI/AN outreach, the importance of cultural competence and how to develop it, how to create AI/AN outreach plan (NAMI examples), how to evaluate your efforts, and how to share your experience with other NAMIs. Jim McNulty President NAMI Board of Directors Table Contents Chapter One Issues At A Glance: Assessments from the Indian Health Services Health Disparities Trends 6 Facts on Indian Health Disparities 7 Mental Health 8 Excerpts from the Surgeon General's Report, Mental Health: Culture, Race and Ethnicity Chapter 4- Mental Health Care for American Indians and Alaska Natives 9 Chapter 7- A Vision for the Future 35 Chapter Two Cultural Competency Working with American Indian and Alaska Native Communities 54 Cultural Competency: Notes for NAMI Chapters 56 Self Assessment Checklist 59 Examples: Healing Our Spirit Worldwide A Culturally congruent Mental Health Framework 64 Chapter Three Culturally Competent Outreach Part 1: 100 Questions for 500 Nations 66 Research: Exploring Issues Facing American Indians and Alaska Native Communities 80 American Indian and Alaska Native Mental Health Research The Journal of the National Center 81 Part 2: Formulating an Outreach Plan 108 Formulating Your Basic Plan 109 Funding For Your Outreach Efforts 111 Case Examples to Use in Outreach 113 Chapter Four Evaluating Your Outreach Efforts 127 Materials adapted from Outreach to African Americans and Hispanic Families: A Manual for NAMI Affiliates. Prepared by Judith A. Cook and Jesse Knox, 1993 Program Evaluations Satisfaction Survey Outcome Assessment 131 Conclusion 132 Resources Annotated Bibliography 134 Handbooks Popular Books Clinical Research NAMI Resources Multicultural and International Outreach Center (MIO) 135 MIO Partner Coalition 136 MIO Technical Assistance 138 Policy: Keys to Effective Lobbying 139 Family To Family Education Program Design: Multicultural Aspects 140 Frequently Asked Questions 141 Development Fundraising Tips for NAMI Affiliates 148 Planned Giving 152 Special Event Fundraising 153 Office of Consumer Affairs 154 Communications American Indian and Alaska Native Media Outlets 157 Chapter One Issues At A Glance: Assessments from the Indian Health Services Health Disparities Trends Facts on Indian Health Disparities Mental Health Excerpts from the Surgeon General's Report, Mental Health: Culture, Race and Ethnicity HEALTH DISPARITIES TRENDS ISSUE Specific intervention strategies are required to address the significant disparities that exist between the health of the American Indian and Alaska Native population and the general U.S. population. BACKGROUND The Indian population is diverse, geographically dispersed, and economically disadvantaged. Disease patterns among Indians are strongly associated with adverse consequences from poverty, limited access to health services, and cultural dislocation. Inadequate education, high rates of unemployment, discrimination, and cultural differences all contribute to unhealthy lifestyles and disparities in access to health care for many Indian people. • 32% fall below poverty standard • Unemployment is 2.5 times higher • Many live in remote places • 55% rely on IHS as the only source of health care Indians experience disproportionately high mortality compared to other Americans from: • Alcoholism 740% higher • Tuberculosis 500% higher • Diabetes 390% higher • Injuries 340% higher • Suicide 190%higher • Homicide 180% higher SITUATION Tribal leaders cite diabetes, unintentional injuries, and alcoholism and substance abuse as rising to crisis proportions in Indian communities. They are concerned that Indian health resources may not be adequate to deal with the enormous needs—a concern consistent with a recent actuarial study that found IHS funding for personal health services at 60% compared to mainstream employer-provided plans such as the Federal Employees Health Benefit Plan. Efforts to address these health problems cannot be expected to yield quick results. The most serious health problems are long-term, intractable issues that will be greatly affected by social-economic conditions in Indian communities and the resources available to respond to them. OPTIONS/PLANS The IHS employs a formal consultation process with tribal and urban Indian leaders to identify leading health priorities. The IHS will continue to assist tribes and urban Indian health programs in developing local and community level approaches to their health issues. ADDITIONAL INFORMATION For referral to the appropriate spokesperson, contact the IHS Public Affairs Staff at 301-443-3593. This issue summary should be used in conjunction with the IHS “Heritage and Health” and “IHS Profile” documents, available at http://info.ihs.gov February 2001 Indian Health Service “The elimination of health disparities is an important step in accomplishing the mission of the Facts on Indian Indian Health Service – to raise the health status of American Indian and Alaska Native people.” H ealth Disparities Charles W. Grim, D.D.S., M.H.S.A. Assistant Surgeon General Director, Indian Health Service Members of more than 560 federally recognized American Indian and Alaska Native tribes and their descendants are eligible for services provided by the Indian Health Service (IHS). The IHS is an agency within the Department of Health and Human Services that provides a comprehensive health service delivery system for approximately 1.6 million of the nation’s estimated 2.6 million American Indians and Alaska Natives. Its annual appropriation is approximately $2.8 billion. The IHS strives for maximum tribal involvement in meeting the health needs of its service population, who live mainly on or near reservations and in rural communities in 35 states, mostly in the western United States and Alaska. (cid:137) Approximately 60% of American Indians and Alaska Natives living in the United States rely on the IHS to provide access to health care services in 49 hospitals and over 500 other facilities operated by the IHS, by tribes, by Alaska Native corporations, or purchased from private providers. (cid:137) The American Indian and Alaska Native people have long experienced lower health status when compared with other Americans. Lower life expectancy and the disproportionate disease burden exist perhaps because of inadequate education, disproportionate poverty, discrimination in the delivery of health services, and cultural differences. These are broad quality of life issues rooted in economic adversity and poor social conditions. (cid:137) American Indians and Alaska Natives born today have a life expectancy that is almost 6 years less than the U.S. all races population (70.6 years to 76.5 years, respectively; 1996-98 rates). American Indian and Alaska Native infants die at a rate of 8.9 per every 1,000 live births, as compared to 7.2 per 1,000 for the U.S. all races population (1996-98 rates). (cid:137) American Indians and Alaska Natives die at higher rates than other Americans from alcoholism (770%), tuberculosis (750%), diabetes (420%), accidents (280%), suicide (190%), and homicide (210%). (Rates adjusted for miscoding of Indian race on state death certificates; 1997-99 rates.) (cid:137) Safe and adequate water supply and waste disposal facilities are lacking in approximately 7.5% of American Indian and Alaska Native homes, compared to 1% of the homes for the U.S. general population. (cid:137) Given the higher health status enjoyed by most Americans, the lingering health disparities of American Indians and Alaska Natives are troubling. In trying to account for the disparities, health care experts, policymakers, and tribal leaders are looking at many factors that impact upon the health of Indian people, including the adequacy of funding for the Indian health care delivery system. (cid:137) The American Indian and Alaska Native population has several characteristics different from the U.S. all races population that would impact upon assessing the cost for providing similar health services enjoyed by most Americans. The Indian population is younger, because of higher mortality, than the U.S. all races. The IHS service population is predominately rural, which should suggest lower costs; however, the disproportionate incidence of disease and medical conditions experienced by the Indian population raises the costs, which almost obliterates the lower cost offsets. (cid:137) A stakeholder workgroup has developed a model to estimate the costs of providing a package of personal health care services for Indian people based on mainstream health plan benefits enjoyed by many Americans. According to the workgroup’s cost model, the IHS appropriated funding provides only 59% of the necessary federal funding for providing mainstream personal health care services to American Indians and Alaska Natives using the system and only 54% for those living in the IHS service area of 35 States. Indian Health Service/Office of the Director/Public Affairs Staff September2002 MENTAL HEALTH ISSUE Greater than one-third of the demands made on health facilities in Indian country involve mental health and social service related concerns. BACKGROUND The Mental Health and Social Services program is a community oriented clinical and preventive service program whose activities are part of a broader, multidisciplinary behavioral health approach. Behavioral health teams are composed of psychologists, mental health counselors, psychiatrists, social workers, substance abuse counselors, and traditional healers. The composition of each team is tailored to the specific issue to be addressed. Substance abuse, trauma, and poverty often complicate the healing process for American Indians and Alaska Natives. Currently, Mental Health and Social Services programs promote the mental health of individuals, families, and communities by providing appropriate and culturally responsive intervention, treatment, and prevention services. SITUATION Considerable disparities exist in the psychological well being of American Indians and Alaska Natives. American Indians, compared to the general population, tend to underutilize services, experience higher therapy drop-out rates, are less likely to respond to treatment, and have negative opinions about non-Indian providers. The suicide rate for American Indians is 72% higher than the general population. The highest suicide rate is found in American Indians ages 15-34 compared to ages 74 and older for the general population. There is a significantly higher rate of poverty in American Indian and Alaska Native communities. Poverty often leads to a lack of housing and overcrowding in homes, as well as other socioeconomic, education, and health problems. Economic concerns are often related to domestic violence and childhood sexual abuse. The potential for mental health problems is evident. OPTIONS/PLANS Additional intervention and prevention strategies that meet specific needs of individuals, families, and communities are needed. Investing in inpatient, outpatient, home, and community services will have a dramatic effect on decreasing the need for direct health services to respond to the consequences of behavioral and mental health related issues. ADDITIONAL INFORMATION For referral to the appropriate spokesperson, contact the IHS Public Affairs Staff at 301-443-3593. This issue summary should be used in conjunction with the IHS “Heritage and Health” and “IHS Profile” documents, available at http://info.ihs.gov. February 2001 Need for American Indians and Alaska Native Outreach The Surgeon General's 1999 Report on Mental Health offered a singular recommendation: People should seek help if they have a mental health problem or if they think they have symptoms of a mental disorder. This simple statement belies the complex reality underlying it: access to mental health services is fraught with barriers, especially for consumers and families whose race, culture and class push them to the margins of U.S. health care systems. Understanding how issues of race and class create barriers to care is essential to addressing those barriers. Accordingly, this section of the American Indian and Alaska Native Resource Manual presents demographic information on the concentration and distribution of the American Indian and Alaska Native populations in the United States, as well as current research by the Surgeon General's Office on the state of mental health care for American Indians and Alaska Natives and a vision for the future. Surgeon General's Report Chapter 4- Mental Health Care for American Indians and Alaska Natives Mental Health: Culture, Race, and Ethnicity. A Supplement to Mental Health: A Report of the Surgeon General. U.S. Department of Health and Human Services: Introduction American Indian and Alaska Natives were self-governing people who thrived in North America long before Western Europeans came to the continent and Russians to the land that is now Alaska. American Indians and Alaska Natives occupy a special place in the history of our Nation: their very existence stands as a testament to the resilience of their collective and individual spirit. The U.S. Census Bureau estimates that 4.1 million American Indians and Alaska Natives lived in the United States in 2000. This represented less than 1.5 percent of the total U.S. population. (U.S. Census Bureau, 2001) The recorded population of this minority group increased by over 250 percent, largely due to better data collection by the Census Bureau, an increasing number of individuals who identify themselves as American Indians and Alaska Natives. Historical Context As members of federally recognized sovereign nations that exist within another country, American Indians are unique among minority groups in the United States. Ever since the European "discovery" and colonization of North America, the history of American Indians has been tied intimately to the influence of European settlers and to the policies of the U.S. Government.