Cultural Competence in Caring for American Indians and Alaska Natives

Ahmed Nahian; Naveen Sharma; Natasha Jouk

Cultural Competence in Caring for American Indians and Alaska Natives

Author: Ahmed Nahian Author: Naveen P. Sharma Editor: Natasha Jouk Updated: 5/17/2026 11:08:29 PM

Introduction

Culturally competent care is essential for addressing health disparities in certain populations, including American Indians and Alaska Natives. This approach requires integrating individual needs with broader contextual factors, including race, culture, and gender. For example, patients who are American Indians and Alaska Natives are less likely to have a personal clinician or health care professional than other populations (63.1% of patients who are American Indians and Alaska Natives, compared with 72.8% of White patients, according to results from 1 study).[1] This trend underscores the urgent need for enhanced surveillance and screening, culturally competent preventive measures, and improved access to health care for American Indian and Alaska Native patients to reduce health care inequities. This course reviews critical clinical data on American Indian and Alaska Native individuals to highlight patient needs that can improve health care practices and outcomes for American Indian and Alaska Native patients. This course also provides insights into inclusive practices applicable to the care of various groups.[2][3][4]

Function

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Function

Cultural competence in the healthcare setting is foundational to compassionate care. An understanding of historical influences, cultural differences, and group trends facilitates better individualized care.[5] For example, understanding that racial and ethnic minority populations, such as American Indian and Alaska Native individuals, are more likely to develop chronic health conditions can improve screening for common medical conditions during a routine health visit.

Because each individual may identify to varying degrees with their cultural heritage, cultural competence does not require healthcare professionals to presume that a group's cultural beliefs apply to every individual in that group. Instead, the purpose of cultural competence is to inform healthcare interactions, facilitate rapport-building, patient involvement in care, and health behaviors.[6] Individual patients differ even within the same cultural heritage; therefore, a newer term, cultural humility, has been proposed to indicate the clinician’s stance of learning from the patient rather than learning before the patient.[7][8]

The American College of Obstetricians and Gynecologists states that cultural competence “conveys a sense of knowing or mastery that feels finite and may lend itself to narrow, one-size-fits-all notions,” while cultural humility “assumes a posture of ‘not-knowing’ and requires constant recognition of one's inability to even begin to understand any given patient's cultural or lived experiences without engaging.” [ACOG. Effective Patient-Physician Communication. For example, cultural competence may help inform clinicians to screen for chronic health conditions in racial and ethnic minority populations, such as American Indian and Alaska Native individuals, because they are more likely to develop them. In addition, closer monitoring and additional support may be indicated because individuals with more chronic health conditions are more likely to present to healthcare facilities.

Cultural competency can also enhance communication between clinicians and patients. Patients from racial and ethnic minority populations have previously reported reduced rapport with their clinicians, limited involvement in medical decisions, and overall lower levels of satisfaction.[9] For patients who are American Indian or Alaska Native, systemic racism within healthcare systems and a lack of culturally responsive care are factors shown to contribute to higher rates of cancer (including colorectal cancer), renal, liver, and cardiac disease.[10][11]

In addition, although American Indian and Alaska Native individuals nationally have a lower age-adjusted rate of suicide compared with both the United States population and non-Hispanic White individuals, specific American Indian and Alaska Native demographic groups experience substantially higher rates of suicide. For example, American Indian and Alaska Native individuals 25 years and younger have a 5.5 times higher rate (in Alaska) and a 4 times higher rate (in the Northern Plains) compared with White individuals in the respective regions and age groups. Acknowledging these nuances between and within individuals and groups and taking a stance of humility may facilitate more personalized and sensitive treatment planning.

Issues of Concern

Patients who are American Indian and Alaska Native often have a lower life expectancy than most other racial and ethnic groups.[12] Compared with White individuals, patients who are American Indian and Alaska Native are also more likely to face limited opportunities to pursue higher education. Higher educational attainment has been associated with a decreased lifetime risk of cardiovascular disease in the general US population.[13][14]

Similar trends have been observed among American Indian and Alaska Native populations when examining employment opportunities. However, this association is less pronounced than in the general United States population.[15] For example, results from 1 study showed that Alaska Native Yup'ik individuals who participated in their culture had improved adiposity, improved blood pressure, and a lower prevalence of diabetes mellitus.[16]

Decreased educational attainment and limited employment opportunities increase vulnerability to chronic conditions and reduce quality of life. Findings from a survey-based analysis indicate that patients who are American Indian and Alaska Native are more likely to consume sugar-sweetened beverages, which can contribute to obesity and subsequently predispose individuals to hypertension and diabetes mellitus. Additionally, a sedentary lifestyle and limited physical activity in residential settings are commonly reported in this population, and these factors are associated with poorer outcomes.

Barriers to higher education limit access to employment opportunities, thereby restricting the ability to generate wealth. Wealth has been associated with improved health outcomes, including lower mortality, decreased risk of smoking and hypertension, and higher life expectancy.[17] Addressing these socioeconomic determinants of health is necessary to improve preventive measures and long-term outcomes.[18][19]

Economic challenges within American Indian and Alaska Native populations have also affected healthcare costs and access to care. In 2017, the poverty rate for American Indian and Alaska Native families was 21%, and the Standing Rock Sioux Tribe Reservation reported a poverty rate of 43.2% in 2012,[14] nearly triple the national rate. Many patients who are American Indian or Alaska Native rely on the Indian Health Service (IHS) for healthcare coverage, and this system faces many structural challenges.

Although the IHS provides access to medical care through federal clinics and hospitals, accessing specialist-level consultations outside the IHS system can be difficult.[20] Additionally, IHS facilities are often located in remote areas on reservations and may be difficult to access due to geographic or financial barriers, especially when individuals relocate for employment or education. Patients and families have also reported extended wait times, although the IHS has implemented standards to address this issue.[21][IHS. Patient Wait Times] Furthermore, language barriers may still occur within IHS facilities because of the diversity of languages within American Indian and Alaska Native populations.

Limitations in data collection and federal funding further affect care delivery within the IHS system. Obtaining specific data on American Indian health remains challenging because congressional mandates for performance tracking have been difficult to meet due to inadequate funding. These limitations may delay preventive measures and reduce clinician availability at facilities.[22][23][24] Results from a study surveying clinicians at IHS sites in October 2007 identified several barriers to care delivery:

Approximately 29% reported insufficient access to high-fidelity specialist care
Approximately 37% reported insufficient resources for nonemergency hospitalizations
Approximately 32% reported insufficient access to quality diagnostic imaging
Approximately 16% reported insufficient availability of high-quality mental health outpatient treatment services [23]

A significant proportion of primary care clinicians (59%) reported that the complexity of care provided without specialist support exceeded expectations. Additionally, 32% cited a shortage of nearby specialist services as a significant barrier, and 63% identified insufficient funding for the IHS as a very important barrier to subspecialist care.[23] Screening availability and preventive services vary across IHS sites.

In the same study, findings showed that 54% of primary care clinicians reported that screening mammography was almost always available, and 60% reported the same for diabetic eye examinations. Breast cancer screening rates varied across sites, with an interquartile range of 31% to 55%, and diabetic eye examination rates ranged from 44% to 58%. Health centers with greater availability of screening mammography had higher screening rates (46%) than those with lower availability (35%), and this difference was statistically significant at the health center level.[23]

Despite these limitations, the IHS provides essential services and has demonstrated measurable improvements in health outcomes. The IHS operates 43 hospitals and 383 clinics nationally, serving 1.7 to 1.9 million federally recognized tribal members and providing care at no cost. No-cost care has been associated with reduced cost-related avoidance of care, lower rates of medical debt, and increased healthcare use.[25] The IHS has also reduced the life expectancy gap between American Indian and Alaska Native populations and White Americans from 8 years to 5 years and improved metabolic measures, including a 20% reduction in low-density lipoprotein cholesterol levels and a 10% reduction in hemoglobin A1c levels.[26] Additionally, IHS care has improved perinatal outcomes for American Indian and Alaska Native mothers.[27]

The IHS also supports tribal sovereignty and self-determination in healthcare delivery. The Indian Self-Determination and Education Assistance Act of 1975 allows American Indian and Alaska Native tribes to assume control of IHS programs through a compacting process, enabling self-administration of healthcare services tailored to local needs.[28] Tribes now administer more than 60% of IHS funds, allowing communities to address specific health concerns and historical trauma in culturally appropriate ways.[29]

The National Indian Health Board emphasized the importance of this approach in a 2025 health equity report and recommended strengthening partnerships between federal and tribal governments while avoiding classification of American Indian and Alaska Native populations solely as racial or ethnic minority groups.[30] Ongoing efforts are required to reduce health disparities and improve outcomes for American Indian and Alaska Native populations. Continued disparities in health care access and outcomes persist between American Indian and Alaska Native populations and the broader United States population, and addressing chronic underfunding of the IHS remains a critical priority.[31]

Clinical Significance

Cardiovascular disease is the leading cause of mortality among patients who are American Indian and Alaska Native.[14][HHS. American Indian and Alaska Native Health] Elevated cardiovascular risk in American Indian and Alaska Native populations is closely linked to the high prevalence and earlier onset of diabetes mellitus. Compared with other populations, patients who are American Indian or Alaska Native may develop diabetes mellitus at a younger age, which contributes to earlier progression of cardiovascular disease and higher mortality rates. Genetic contributors have also been identified, including associations with type 2 diabetes mellitus, early-onset obesity, lithogenic bile, and middle-digestive tract cancers.[32]

Alcohol use disorder has been reported at high rates in certain American Indian and Alaska Native populations. However, alcohol use patterns vary significantly across the more than 570 American Indian and Alaska Native communities, and broad generalizations are inappropriate. Earlier studies reported high lifetime prevalence rates, including 72.8% in men from a single community.[33]

Findings from the 2013 National Epidemiologic Survey on Alcohol and Related Conditions III have suggested that the lifetime prevalence of alcohol use disorder is 43.4% in American Indian and Alaska Native patients, compared with 32.6% in White individuals.[34] Conversely, results from other reports have shown lower overall drinking rates in American Indian and Alaska Native populations compared with White Americans (34% versus 56%).[35] Historical context, including the introduction of alcohol during colonization and its use in exploitative trade practices, contributes to current disparities.[36] Genetic susceptibility has also been linked to loci on chromosomes 4 and 11 in specific communities.[32]

Genetic and environmental factors both contribute to cardiovascular disease risk in American Indian and Alaska Native populations. The Strong Heart Study and the Genetics of Coronary Artery Disease in Alaska Natives (GOCADAN) study have identified hereditary contributions to 20% to 50% of cardiovascular risk phenotypes, including diabetes mellitus, hypertension, obesity, and dyslipidemia. The GOCADAN study similarly suggested that low-density lipoprotein particle size and obesity may be modulated by a single set of genes.[14]

Social determinants of health, structural inequities, and cultural factors play a central role in disease prevalence. Research consistently highlights the influence of cultural norms, historical trauma, structural racism, and socioeconomic conditions on the prevalence of diabetes mellitus and cardiovascular disease in American Indian and Alaska Native populations, beyond biologic factors alone.[37][38] Consequently, preventive programs must incorporate cultural, economic, and regional considerations to be effective.[39] According to the 2020 American Heart Association scientific statement and the Indian Health Service Special Diabetes Program toolkit, effective prevention programs should include the following elements:

Obtaining tribal and organizational support
Evaluating individual barriers to care and identifying resources
Developing relationships with the community
Identifying the professional team, including the program coordinator, case manager, health educator, and clinicians
Creating a means of public communication
Monitoring progress with an action plan [14]

The Special Diabetes Program for Indians has demonstrated measurable improvements in clinical outcomes. Since its congressional funding in 1998, the program has reduced average blood glucose levels by 10% from 1996 to 2019 and decreased the incidence of diabetes mellitus by 4% per year at 3 years after lifestyle intervention, compared with 11% per year with placebo.[40] Culturally appropriate interventions further enhance prevention and treatment efforts. Integrating traditional foods and promoting food sovereignty have shown benefits in reducing chronic disease while preserving cultural identity.[41] Together Overcoming Diabetes, a family-based and culturally centered prevention program developed within American Indian and Alaska Native communities, has demonstrated preliminary effectiveness in reducing body mass index and symptoms of depression.

Modifiable risk factors are important targets for reducing cardiovascular disease. Tobacco use, elevated cholesterol levels, diabetes mellitus, and hypertension are strongly associated with increased cardiovascular disease incidence in American Indian and Alaska Native populations.[42] An analysis of the Strong Heart Study outcome data of chronic heart disease has highlighted the following significant risk factors for chronic heart disease within this population:

Age
Sex
Lipid levels
Smoking
Albuminuria
Diabetes mellitus
Hypertension
Obesity
Underreporting of ethnicity
Toxic metal exposure
Socioeconomic status
Insurance access
Experiences of discrimination [14][43][44]

Findings from Behavioral Risk Factor Surveillance System interviews in Montana reservations (Blackfeet, Crow, Flathead, Fort Belknap, Fort Peck, Northern Cheyenne, and Rocky Boy's) showed that American Indian adults with and without diabetes mellitus had elevated rates of modifiable risk factors, including tobacco use, physical inactivity, obesity, and hypertension. Lifestyle interventions, including regular physical activity and weight reduction, have been shown to lower blood pressure, improve insulin sensitivity, delay the onset of type 2 diabetes mellitus, and reduce cardiovascular risk.[45][46][47]

Distinguishing traditional and commercial tobacco use is essential in this population. Traditional or ceremonial tobacco use holds cultural and spiritual significance, whereas commercial tobacco use drives health disparities. Results from the iCanQuit randomized controlled trial demonstrated improved smoking cessation outcomes, with 30% abstinence at 12 months among participants using the intervention, compared with 18% among participants using a control application.[24]

Mental health considerations are integral to comprehensive care. Indigenous populations often conceptualize mental health differently, and emotional distress may be expressed through physical symptoms rather than conventional psychiatric categories.[48][49] Additionally, Indigenous patients may be more likely to seek care from spiritual or traditional healers rather than clinicians.

Limited awareness of mental health conditions, along with shortages of culturally responsive programs and clinicians, can further reduce engagement with mental health services.[50][51] Comprehensive prevention strategies should address both medical and social factors. Key targets include weight reduction, increased physical activity, control of hypertension and diabetes mellitus, optimization of low-density and high-density lipoprotein cholesterol levels, monitoring renal function, promoting tobacco cessation, reducing alcohol use when present, encouraging a balanced diet, and strengthening community-based support systems for physical and mental health care.

Other Issues

The prevalence of reservation segregation, resource limitations, and isolation significantly contributes to the challenges faced by American Indian and Alaska Native tribal citizens and exacerbates disparities in mental health status. Despite the significant existing literature on the subject, interpreting research findings on the prevalence of mental health issues among patients who are American Indian and Alaska Native was challenging until recently.[52] Research interpretation has been complicated because external practitioners working in American Indian and Alaska Native contexts often seek to publish anecdotal observations, which can contribute to anxiety in American Indian and Alaska Native communities because of concerns about academic mischaracterization. Misrepresentation in research and concerns about data sovereignty have been frequently demonstrated. In addition, conducting controlled studies in American Indian and Alaska Native populations presents substantial challenges, including:

Limited sample sizes
Remote and isolated locations
Communication barriers
Cultural disparities
Distrust of Euro-American outsiders, including academic researchers
Need for community engagement and tribal approval [53]

European and Euro-American officials have extensively scrutinized American Indian and Alaska Native peoples for decades. Beginning in the late 19th and early 20th centuries, many characterizations of American Indian and Alaska Native peoples, often critical or denigrating in nature, were framed within the language and framework of mental health and psychopathology, coinciding with the emergence of the psychological sciences, including psychology and psychiatry, as a formal discipline.[54][55][56] For example, Emil Kraepelin, the principal designer of modern psychiatric nosology, conducted comparative studies with American Indian individuals in 1925.[57]

Applying Eurocentric psychiatric frameworks to Indigenous peoples has been described as psycholonization,[58][59] with the Diagnostic and Statistical Manual of Mental Disorders and psychologizing discourses characterized as cultural products born out of coloniality that contribute to the subjugation of Indigenous peoples. Psychology has been criticized as complicit in perpetrating epistemic violence and practices that continue ongoing transmissions of colonial oppression,[60] and resilience constructs are argued to be rooted in hierarchical and comparative systems historically used to dehumanize and disenfranchise racial and ethnic minority communities.[60] Gone (2021) describes how this problem frame recasts mental disorders as postcolonial pathologies and proposes an alter-Native psy-ence as a framework parallel to but distinctive from dominant psychiatric discourse.[61] Given that American Indian and Alaska Native individuals may prefer traditional healers, integrating traditional healing with evidence-based care can improve representation in mental health treatment.

Enhancing Healthcare Team Outcomes

Culturally responsive healthcare cannot be simplified into rigid formulas or prescriptions that yield a single definitive solution. Instead, culturally responsive healthcare requires a deep understanding of the fundamental principles of healthcare and how culture can influence them. Education can influence the health and healthcare experiences of individuals from diverse ethnic and cultural backgrounds. Since its inception, the growth, significance, and importance of multicultural health care have been pivotal. Within postgraduate clinical education, knowledge regarding community needs, traditions, and values should be integrated.[62] Clinicians should approach the care of diverse patients from multiple perspectives, including the following:

Establishing formal, coordinated advocacy or joint initiatives with organizations such as the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education. These initiatives should aim to significantly increase the representation of students and residents from American Indian and Alaska Native tribes in medical schools while also increasing their proportion in primary care, hospital medicine, and other medical specialties. Additional initiatives should increase the representation of learners from American Indian and Alaska Native tribes among allied health professionals, psychologists, nurses, pharmacists, case managers, social workers, and other professionals caring for children through older adults.
Gathering precise racial, ethnic, and gender data about American Indian and Alaska Native community members and exploring potential collaborations with the IHS to incorporate demographic considerations into survey tools for individual hospital compensation and productivity data. Furthermore, clinicians should oversee the Practice Study Committee, which is responsible for conducting ongoing demographic surveys of leadership. Clinicians should also explore formal expansion opportunities through the Accreditation Council for Graduate Medical Education.
Implementing a public relations initiative to highlight the underrepresentation of American Indian and Alaska Native hospitalists in leadership positions within health care systems and other employers. This initiative encourages purposeful efforts to increase diversity within these leadership ranks.
Establishing scholarships for hospitalists from underrepresented racial and ethnic groups, enabling them to attend Society of Hospital Medicine–sponsored leadership development programs, including the Academic Hospitalist Academy, Leadership Academy, and Quality and Safety Educators Academy. This initiative aims to enhance their representation in leadership positions in healthcare.
Implementing an educational pathway, mentorship program, or other developmental initiatives designed for aspiring medical leaders and those interested in enhancing their leadership capabilities.
Giving special attention to initiatives that increase the proportion of American Indian and Alaska Native medical professionals in leadership roles.
Assessing and reviewing existing Society of Hospital Medicine papers and position statements to ensure that discussions related to diversity, equity, and inclusion are incorporated across various aspects of hospital medicine, including staff and leadership, patient care, and efforts to eliminate health disparities. These findings should be broadened into the outpatient setting of medical care accordingly.
Establishing healthcare programs led by nonprofit organizations to address primary care and specialized healthcare requirements in remote American Indian and Alaska Native communities. Clinicians should advocate for federal funding and additional secondary funding sources.
Setting health priorities with local tribes and communities while understanding and integrating historical experiences and efforts that are already underway.
Implementing clinical guidelines for the treatment of patients who are American Indian or Alaska Native in a culturally competent way and emphasizing preventive measures, including:
- Nutritionists and dietitians support
- Annual glucose checkups
- Early screening for digestive and other types of cancer

Nursing, Allied Health, and Interprofessional Team Interventions

During training, nurses can effectively represent the diversity of United States society by broadening their understanding of racial, ethnic, and cultural commonalities and distinctions when interacting with individuals from various racial and ethnic backgrounds.[63] Increasing evidence suggests that diversity can enhance learning outcomes for all students in educational settings by improving the following skills:

Critical thinking
Academic involvement
Motivation
Essential social and civic skills, including empathy, as well as racial and cultural understanding

Educational institutions should view diversity as an institutional asset that enriches the educational and training experience of all health professions students, including physician assistants.[64][65] To address this priority, educational institutions should consider the following measures:

Prioritizing inclusion by implementing proactive initiatives
Engaging American Indian and Alaska Native men, women, and communities in formal or informal pipeline and recruitment activities, as recommended by leading organizations
Establishing allied healthcare programs to serve primary care needs in American Indian and Alaska Native communities without creating a financial burden on these communities

The literature also describes successful American Indian and Alaska Native–specific health education programs:

Wy'east Pathway: 86% of scholars in this program matriculated to medical school
Native American Research Internship: 88% completed bachelor's degrees, 20% matriculated to medical school
Medical School Applicant Workshop: Among participants who applied to medical school, 92% were offered acceptance [66]

Similar health education programs should be implemented across all health specialties. Forrest et al (2022) emphasize that American Indian and Alaska Native–specific programs that strategically integrate local tribal communities and cultural mentors into the program infrastructure have been shown to increase the number of American Indian and Alaska Native college graduates who successfully matriculate into medical school.[67]

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