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Designing Culturally Relevant Healthcare to Meet Community Needs

A Consumer-Centered Health System Story December 8, 2022

Aligned with the growing awareness of health inequities, healthcare organizations are exploring innovative ways to create access to care and services that better meet the distinctive needs of the people they serve. Often, this involves partnering with stakeholders from specific diverse communities to understand cultural nuances and using these insights to develop consumer-centered initiatives that are a good fit for the members of those communities.

Interventions for Indigenous Communities

According to the U.S. Department of Health and Human Services’ Indian Health Service, American Indian/Alaska Native (AI/AN) people have a lower life expectancy than other groups of people in the U.S. and are disproportionately impacted by disease. Such challenges present opportunities for health systems to address these gaps through focused interventions that incorporate AI/AN values and beliefs, according to Donald Warne, MD, MPH, a member of the Oglala Lakota Tribe, and the Associate Dean of Diversity, Equity, and Inclusion at the University of North Dakota (UND). He serves as the Director of the Indians into Medicine (INMED) and Public Health programs at UND; he is also Professor of Family and Community Medicine at UND’s School of Medicine and Health Sciences.

The Center for Indigenous Health at the Johns Hopkins Bloomberg School of Public Health is one organization making strides in health and wellness programs and educational resources in collaboration with Native American communities. The Center partners with tribal and urban Native communities across the U.S. to address common and pressing health priorities of AI/AN people, such as maternal and child health, mental health concerns, substance use disorder, and suicide. Programs emphasize diverse tribal knowledge and traditions, such as storytelling and elevation of elders’ voices to promote public health.

By working together closely on these initiatives, tribal communities are empowered to promote wellness across the individual, family, and community levels, explained Victoria M. O’Keefe, PhD, a member of the Cherokee and Seminole Nations, and Associate Director of the Center. O’Keefe also serves as the Mathuram Santosham Endowed Chair in Native American Health at Johns Hopkins University.

Family Spirit is an early childhood home-visiting program designed by Native Americans from the Navajo, White Mountain Apache, and San Carlos Apache Tribes in partnership with the Center. It employs local paraprofessional home visitors from Indigenous communities to help young Indigenous parents to achieve the best possible health and well-being for their children, themselves, and their families for three years after giving birth. The program encourages new mothers to reach out to extended family and support systems within the tribal community and helps them to develop and adopt strategies to manage stress, manage substance use, and focus on parenting skills that reflect Native American values. Educational materials include graphics, stories, and prompts to discuss cultural practices around child-rearing.

A study published in the American Journal of Psychiatry showed that adolescent mothers who received support through Family Spirit had less substance use, less depression, improved parenting knowledge, and reduced stress, and their children had better social, emotional, and behavioral development through age three than those who did not receive home interventions. This model has been so successful it has been implemented in 150 tribal communities across the country.

Aligning with Cultural Traditions to Address Suicide Risk in Tribal Communities

Bloomberg’s Center for Indigenous Health also supports an innovative suicide prevention and surveillance program developed by the White Mountain Apache Tribe in Arizona. It includes a tribal mandate passed by the White Mountain Apache Tribe to identify high-risk behaviors more consistently and accurately among residents of the area, in order to guide more effective community education, resources, and support. Further, it taps into local traditions by involving highly respected elders to promote strengths, identity, and connectedness among young people.

According to an article published in the American Journal of Public Health, following the program’s introduction a decade ago, the suicide rate decreased by close to 40% among White Mountain Apache Tribal members overall. Embedding such efforts into the community in a way that aligns with local traditions and values increases the program’s effectiveness and makes essential care more accessible.

Creating an Audience-Specific Insomnia Intervention

Focused interventions to address health concerns can also benefit other groups facing healthcare disparities. Eric Zhou, PhD, an Assistant Professor of Pediatrics at Harvard Medical School and a psychologist with the Division of Sleep Medicine at the Dana-Farber Cancer Institute, worked with colleagues at Boston University and the University of Virginia to adapt SHUTi (Sleep Healthy Using the Internet), a digital cognitive behavioral therapy for insomnia (CBT-I) intervention. Their efforts were prompted by high rates of insomnia among Black women in the U.S., with the goal of improving their sleep health.

While such online efforts delivering CBT-I have proven to be a cost-effective approach to improving sleep, engaging in these programs has been more challenging for Black women.  Over the course of a year Zhou’s team worked with Black women, a sleep physician who practiced at a hospital with a high number of minority patients, and a sleep researcher to tailor the standard SHUTi program for Black women. The resulting model incorporates Black characters into the program’s storylines and addresses common cultural factors that may affect sleep quality.

Zhou and the other researchers tested the effectiveness of the revised program by conducting a randomized clinical trial with 333 Black women participants from around the country. They compared the results of the standard version of SHUTi, to the culturally tailored version, and to sleep hygiene education alone. The findings were published in JAMA Psychiatry.

While the study revealed the standard or tailored online programs proved far more effective than providing sleep hygiene education alone, Black women who used the tailored intervention were about 13% more likely to complete the customized program. Completion of the online intervention is directly linked to better success in addressing insomnia.

“At the population level, [culturally tailored interventions such as this] can have big implications for societal health,” Zhou stressed. “The better we represent our diverse communities in the programming we deliver, the more likely it is that there will be better uptake for these evidence-based interventions.”

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