COMMUNITY RESPONSE TO NEEDS ASSESSMENT 15

AN URBAN AMERICAN INDIAN HEALTH CLINIC’S RESPONSE TO A COMMUNITY NEEDS ASSESSMENT

Mary Kate Dennis, MSW, PhD, Sandra L. Momper, MSW, PhD, and the Circles of Care Project Team

Abstract: Utilizing community-based methods, we assessed the behavioral and physical health needs of a Detroit metropolitan Indian health clinic. The project goal was to identify health service needs for urban American Indians/Alaska Natives and develop the infrastructure for culturally competent and integrative behavioral and physical health care. We conducted 38 semi-structured interviews and 12 focus groups with service providers and community members. Interview and focus group data indicated a need for 1) more culturally competent services and providers, 2) more specialized health services, and 3) more transportation options. We then report on the Indian health clinic’s and community’s accomplish- ments in response to the needs assessment.

Major difficulties exist when attempting to identify the health service needs of urban

American Indians and Alaska Natives (AI/ANs) and develop the appropriate infrastructure for

care delivery. Of the 2.9 million people who identify solely as AI and/or AN, 67% live outside of

reservation or tribal lands (U.S. Census Bureau, 2012). Providing for the health service needs of

urban AI/ANs is imperative, as, compared to the general population they struggle with

disproportionate rates of obesity and chronic diseases and are more likely to smoke, less likely to

visit a dentist, more likely to report their health as poor or fair, and less likely to use primary care

services (Glasnapp, Butrick, Jamerson, & Spinoza, 2009; U.S. Commission on Civil Rights,

2004). Urban AI/ANs experience worse health outcomes than the general population as a result

of racial and social inequities; high unemployment rates; cultural and historical trauma; and

limited social, health, and cultural resources (Moy, Smith, Johansson, & Andrews, 2006;

Weaver, 2012).

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Urban programs also have the difficult task of providing culturally appropriate behavioral

and physical health care for AI/ANs who represent multiple tribal backgrounds and have varying

levels of knowledge regarding health care that utilizes traditional Native methods of healing

(Urban Indian Health Institute [UIHI], Seattle Indian Health Board [SIHB], 2012b).

Furthermore, urban AI/ANs have limited access to health care and fewer available health

professionals. A U.S. Commission on Civil Rights report (2004) notes that there were 101

mental health professionals available per 100,000 AIs, compared to 173 per 100,000 Whites. The

Detroit metropolitan area, where the clinic in this study is located, is a designated Health

Provider Shortage Area with a score of 17 out of 20 (higher scores indicate more shortages),

revealing the lack of providers throughout the health system (U.S. Department of Health and

Human Services [USDHHS], 2014). Another common barrier to providing the highest quality of

care lies in the significant gaps in behavioral health data for the AI/AN population. An analysis

of the 2006 National Health Disparities report indicated that only 50% of the data for AI/ANs

were available, data were unreliable, samples were too small to be statistically significant, and

only two-thirds of the utilization data were usable.

DETROIT METROPOLITAN INDIAN HEALTH CLINIC

Services Provided by the Indian Health Clinic

American Indian Health and Family Services of Southeast Michigan, Inc. (AIHFS or “the

center”) is funded by Indian Health Service (IHS). Like many urban Indian health clinics, it

receives little funding. For example, tribally run health services and IHS facilities received

approximately 53% and 43% of the 2010 IHS budget respectively, while urban programs

received only 1%, although the majority of AI/ANs reside in urban areas (USDHHS Fiscal Year

2010 Budget in Brief: IHS, as cited in UIHI, SIHB, 2012b.) AIHFS’ service area is composed of

seven counties in southeast Michigan where over 47,900 AI/AN people reside (U.S. Census

Bureau, 2010). AIHFS’ mission is to “empower and enhance the physical, spiritual, emotional,

and mental wellbeing of American Indian families and other underserved populations in SE MI

through culturally grounded health and family services” (AIHFS, 2014). AIHFS provides

medical care, women’s health care, maternal and child health care, diabetes management, dental

referrals, behavioral health care, substance abuse counseling and prevention, tobacco cessation

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COMMUNITY RESPONSE TO NEEDS ASSESSMENT 17

programs, youth programming, parent support programming, fitness programs, and traditional

healing ceremonies (e.g., sobriety lodge). AIHFS aspires to integrate traditional AI healing and

spiritual practices with contemporary Western medicine in both treatment and prevention

(AIHFS, 2014). AIHFS also hosts annual health fairs, celebrations, and other cultural events.

Indian Health Clinic Service Needs and Response

At the time of this study, AIHFS served 2,304 clients, approximately 10% of whom were

receiving behavioral health services. Identifying and recruiting specialized providers (e.g., in

behavioral health) who are AI/AN is challenging. The behavioral health program was not able to

provide services to all of the clients in need of those services.

In response, AIHFS recognized that a needs assessment was necessary to increase

organizational capacity and build an infrastructure that could better provide for the health care

needs of the AI/AN population in its service area. A Substance Abuse and Mental Health

Services Administration Circles of Care Infrastructure Development grant funded AIHFS to plan

and perform an in-depth needs assessment of the systems of care impacting the physical and

mental health and wellness of AI/AN children, youth, and their families. The specific purpose

was to assess, plan, and design a culturally appropriate integrative system of behavioral and

physical health care that incorporated traditional healing.

In this paper, we present needs assessment data from AIHFS’ 2008-2011 community

project entitled Gda’shkitoomi (“We are Able”). The data reported here were collected between

April of 2008 and October of 2009. Additionally, we report on the AIHFS’ and the community’s

response to the needs assessment data. This community-based project posed the following

questions: 1) Are health services in general available, accessible, and appropriate? and 2) What

are the culturally appropriate health services needed in the Detroit metropolitan area?

METHODS

Study Purpose

Between April of 2008 and October of 2009, the team conducted 38 semi-structured

interviews with 27 community members and 11 service providers, and also conducted 12 focus

groups, 10 with just community members and 2 with just service providers. We chose these

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qualitative data methods as we felt they would elicit richer data. Data saturation, community and

staff composition, and cost were considered when choosing the number of interviews and focus

groups. The purpose was to collect information from a diverse group of people who could

provide insight into the nature of the health issues (e.g., availability, accessibility, and

appropriateness of treatment; cultural and spiritual relevance of services), recommend solutions,

and provide guidance about integrating behavioral and physical health services. We determined

that it was important to get the views of community members, as they receive the services and

are aware of service improvement needs and preferences, and the views of service providers, as

they were more knowledgeable about currently provided services.

Research Design

Study Team and Advisory Council The study team was composed of the second author/evaluator, a research assistant, the

project manager, and AIHFS staff members. The team collaboratively designed, developed, and

conducted this community-based study. An advisory council was formed by recruiting

community members via telephone calls, flyers posted at the center, notices in the center

newsletter, and word of mouth. The advisory council met once a month (in the evening, to

accommodate participants’ work and school schedules). Attendance varied from 15 to 22

members. The council was composed of tribal elders and leaders, parents, youth, AIHFS staff

members from various departments, and representatives from local organizations interested in

developing programs to support the community. This group reviewed the study processes and

offered oversight on cultural appropriateness and viability of the project. This study was

approved by AIHFS and the University of Michigan Institutional Review Board.

Recruitment and Consent Interview and focus group participants were recruited via face-to-face discussions, flyers

posted at the center and at local community events, and at AIHFS. The interviews and talking

circles occurred at AIHFS, at other Indian centers in the Detroit metropolitan area, and at

community venues. All participants signed consent forms, and parental consent was obtained for

youth under the age of 18 years.

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COMMUNITY RESPONSE TO NEEDS ASSESSMENT 19

Data Collection We conducted both individual interviews and focus groups in order to tailor the venues

toward the comfort of the participants, as we thought some might be more apt to share in a

private setting and others might need group interactions to elicit detailed perspectives. The

interviews were conducted in private areas of the venues and/or in interviewee homes. The focus

groups took place in a private area of the center. Interviews and focus groups were digitally

recorded and lasted between 45 and 75 minutes. Community member participants filled out a

demographic survey and were provided transportation, child care, a meal, and a $20 gift card.

Service provider participants filled out a different demographic survey (asking for less

identifying information) that included questions on individual service provision, role, and length

of time in this role at AIHFS and elsewhere.

Talking Circles The focus groups were conducted as talking circles, a traditional method of group

communication in Indian country (Becker, Affonso, & Blue Horse Beard, 2006; Montejo, 1994).

In typical focus groups, the moderator plays an active role in eliciting information; in talking

circles, the moderator defers to elders. If an elder is speaking, it is inappropriate for anyone to

interrupt. The team began the talking circle by sharing a meal, and an elder (or other participant,

if no elder was present) offered a brief prayer. Everyone sat in a circle and the moderator passed

around a shell which a participant held while only he/she was talking. When the speaker was

finished, he/she then passed it to another person; then, only that person could speak. Everyone

was given the opportunity to talk, and no one was interrupted. If a person did not want to talk

he/she passed the shell to the next participant. The shell was passed multiple times for each

question to ensure that everyone was able to share his/her views.

Interview and Focus Group Questions Three major topics were addressed: 1) availability of, access to, and appropriateness of

treatment; 2) culturally and spiritually appropriate services; and 3) gaps or limitations in current

services. The questions posed in both the interviews and the talking circles were: 1) What do you

think about the way health care is provided for American Indians in general? 2) What do you

think about the appropriateness (cultural and spiritual) of services for American Indians in our

community? and 3) What do you think about the availability and accessibility of health services

for American Indians in our community?

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Analyses The interview and talking circle data were transcribed verbatim and reviewed by the

study team for accuracy. Then, the team utilized a content analysis approach whereby three

project staff members became familiar with the data by reading through the transcripts (Tutty,

Rothery, & Grinnell, 1996). We used this approach so we could analyze the text to define

common themes in participants’ views of community needs (Berg, 1989; 2004). During the first

stage of coding, the staff members re-read the transcripts to define categories from repeating

ideas. The team met to review the independently coded data, and then organized it into broad

categories that highlighted the specific themes reported in this paper. Themes identified by

participants were very consistent throughout the interviews, and were repeated in the talking

circles. Therefore, themes from the interviews and talking circles were combined and

subsequently catalogued using taxonomic method and arranged into a matrix format (Berg,

2004). All results were reported to the AIHFS advisory council at their meetings and to the

AIHFS community at large community events. Dissemination methods included PowerPoint

presentations, posters, and discussions.

RESULTS Select Characteristics of the Participants

Interview Participants Of the 27 community member interviewees, 18 were women; the age range was 12 to 82

years, and 25 were tribally affiliated (many urban AI/ANs identify as affiliated, but are not

enrolled in a tribe). Of the 11 service provider interviewees, 6 were women; the age range was

26 to 70 years, and 5 were tribally affiliated. The services they provided were mental health (n =

5), physical health (n = 2), administrative (n = 1), and support (n = 3).

Talking Circle Participants Twelve talking circles were conducted, 10 with community member participants and 2

with service provider participants. The groups were organized by gender or age. Some groups

were composed solely of women or men, some of only youth, and some of elders of both

genders. Of the 73 community members, 37 were women; the age range was 12 to 77 years, and

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COMMUNITY RESPONSE TO NEEDS ASSESSMENT 21

62 were tribally affiliated. Of the 10 service providers, 8 were women; the age range was 21 to

70 years, and 1 was tribally affiliated. The services they provided were behavioral health (n = 6),

physical health (n = 3), and support (n = 1).

Participants shared feedback regarding the services that currently are provided in the

Detroit metropolitan area. The themes that emerged were needs for 1) more culturally competent

services and providers, 2) more specialized health services, and 3) more transportation options.

Need for More Culturally Competent Services and Providers

Community member participants requested more services tailored to their cultural needs:

more traditional healing; more cultural programming; more marketing of provided services

(especially traditional services); AI/AN and/or culturally competent providers, both at AIHFS

and offsite; service integration so the whole body and mind could be served; and collaboration

between providers and community members.

A community member interviewee (#26) stated, “I have more faith in Indigenous healing

now than I have in any other.” Another community member interviewee (#2) stated:

I think [traditional healing] is better than [Western medicine] because they deal

with the spirituality, they deal with the mind and the mind has a lot of control

over the body, where the Western medicine they don’t consider the mind, and it’s

just the physical but that’s not what it is.

Talking circles where people can gather to share wisdom and knowledge, support one another,

and experience the cultural components of prayer were important for participants. When a

community member interviewee (#39) was asked what kind of mental health services she would

like to see the center provide, the response was, “Talking circles…like bringing in more like

Native teachers, like elders, community members that could like lead a talking circle or share a

teaching.” Another participant, in the male community member talking circle (#2), shared:

You know, myself, sometimes I wish I had somebody to talk to. You know what I

mean? I am 49 years old and sometimes I wish I just had somebody to open up

to. A lot of people hold stress inside of them…A lot of people just do not know

where to turn, you know. Or a lot of people do not trust people to talk to. You

know. You have got to be around somebody that you can trust, somebody you can

open up to.

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Overwhelmingly, participants wanted AIHFS to provide both Western medicine and

cultural and social programming that includes education and activities that teach language,

culture, spirituality, and traditional ways of life. AIHFS does incorporate cultural activities into

its programming, but this study highlighted the gap between what is offered and what the

participants expressed as their cultural needs. Participants also noted that there are many AI/AN

community members who want more traditional healing and cultural knowledge, but do not

know what these might look like. Many times, the ceremonies and spiritual beliefs that the

participants wanted were not passed down as a result of cultural trauma, family dysfunction,

intermarriage, or shame. Many AI/AN children are being raised by non-AI/AN family

members/caregivers who may need assistance to learn about AI/AN cultures and teach them to

their children. Youth who receive cultural programming via AIHFS’ after-school program, are

aware of the need for their caregivers (both AI/AN and non-AI/AN) to be involved in cultural

programming tailored to their needs. One youth talking circle participant (#2) observed: “But not

just the children need to know, I think they should, you know? … More Native parents should be

involved in learning as well, not just the children.” Youth revealed that they are struggling at

home, struggling as adolescents, and struggling over school pressures. One youth (#1) remarked

in a talking circle that, “For me, it’s kind of hard to keep seeing my family like one unit… my

dad is going through depression and he’s using it through alcohol, and getting drunk, coming

home at two o’clock in the morning.” Many shared stories of challenging home environments

and the benefit of connecting and sharing with others to alleviate their stress at events at the

center (e.g., the Dreamseekers traditional youth after-school program). Community awareness of services—or the lack of marketing of services—was a dominant theme throughout, appearing in all the interviews and talking circles. A community member interviewee (# 27) stated:

Um, I wasn’t aware there was a clinic here. You know, I have been without

insurance for a long time, struggling, and, um, I didn’t know that you guys offered

any service, because I was not aware that the clinic was here. So it should be like

more advertisement around our city.

The service providers also acknowledged their responsibility to the community and their

shortcomings in providing information about available services. For example, a service provider

interviewee (#6) stated, “…Just getting the word out is what we really need, as well as more

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COMMUNITY RESPONSE TO NEEDS ASSESSMENT 23

transparency where people [service providers] are open, honest, accountable, and communicate

well.” One service provider shared that AIHFS has AI staff, including behavioral and physical

health specialists, paraprofessionals, and programming staff members; however, many of the

participants were unaware of their existence (e.g., that AIHFS has an AI physician in the health

clinic).

Community member and service provider participants discussed culturally competent

service and practice as it relates to interactions with health care providers. Participants wanted

both AI/AN physicians and service providers at the clinic, as well as service providers at non-

IHS clinics who are not AI/AN affiliated, to be more culturally competent (AIHFS’ employees,

as well as its service population, are diverse in terms of tribal affiliation, and level of cultural

competence). The desire for AI/AN service providers and for cultural competence reflects

participants’ need to be comfortable working with providers who understand that AI/ANs have

had historical, cultural, geographical, and social experiences that may differ from those of the

general population. An AI service provider (#8) shared in an interview: “I’m hoping that people

will get comfortable with being a community and see me as a resource when they need me.”

Participants often found themselves educating the service providers in non-IHS clinics about

their cultures. Participants stressed the need for building trust with their service providers, noting

that providers can help by considering their patients’ cultural needs. One service provider

interviewee (#4) said that “building a network of traditional people who can be consultants or

provide traditional services would increase the appropriateness of the services we offer.”

Participants advocated for the integration of services as an effective way to meet

community needs. One community member interviewee (#2) shared:

A lot of times with Native people they’re not going to tell you they have needs,

and by addressing both a counselor and a physical doctor at the same visit you

might be able to find out more of what they need.

AIHFS attempts to provide services that treat the whole person, and includes spiritual and

cultural aspects in services. Despite the existence of these services, the participants wanted more

integration of Western medicine and traditional medicine. A male community member in a

talking circle (#1) talked about what is important to him: “Reconnecting with tribal heritage…

going back to tribal practices and healing along with Western medicine.” The theme of culturally

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competent services and providers also included collaboration between staff and community

members. Collaboration is an AI/AN value and traditional way of interacting. A service provider

interviewee (#7) noted the importance of collaboration:

Having like really good communication about the changes, like with all the staff,

and…involving the staff in like creating the…programs so that everybody knows

how it’s going to work….asking the community’s opinion and feedback on it.

Need for More Specialized Health Services

Participants wanted more specialized services at AIHFS, as external providers were not

receptive to, or knowledgeable about, AI/AN cultures. They suggested that offering specialized

services in both the behavioral and medical health programs would help to build trust in AIHFS.

A service provider interviewee (#26) stated:

We provide here just a basic medical health…if they need any specialized

services, we have to refer them out for those services…if they need an internist, a

pulmonary specialist…any sort of specialist, we have to refer them out.

AIHFS provides a range of services, but some clients felt there were limitations that forced them

to go to more than one clinic, some non-IHS,