Question: Diversity and Health Assessments

Caring for patients in healthcare today, providers will encounter many different patient populations that come from a diverse set of cultures, lifestyles, and backgrounds that have beliefs and practices regarding health and illness which may be different from the provider. Providers must first examine their own beliefs, values, and culture for self-awareness and to examine for potential bias. Approaching individuals from a variety of cultures and backgrounds also requires flexibility and the ability to adapt the health history and physical exam to the patients' needs or culture. Having an understanding of the patient's beliefs, lifestyle, culture, and background and how they impact the patient is necessary for providers to provide culturally competent care.

The patient selected for this discussion is MR, a 23-year-old male patient, complaining of anxiety.

Identifying Information: MR is a 23-year-old Native American male seen in the office on September 5, 2018. The history is obtained from both a written questionnaire filled out before the visit and from the patient, and he is considered a reliable historian.

Chief Complaint-"I've been anxious lately and used both pot and alcohol to help me feel better" and is concerned about "not getting into heaven."

History of Present Illness: a 23-year-old male patient that uses both marijuana and alcohol for anxiety symptoms. MR describes the anxiety as starting when he lost his job one month ago. MR describes the anxiety occurring on 4-5 days during the week, and MR describes it as a "feeling of fear about providing for my family," and on 4-6 days/per week he uses alcohol and smoking "pot" to "feel better."

Current Medications-None

Family History- Diabetes-Father, Hypertension-Mother, and Alcoholism-Father.

Social History-smokes marijuana -per patient written questionnaire: typical amount described as 1 "joint"; with use of 6-7 times per month. Drinks alcohol, described as beer; amount varies from 36-64 ounces 3-6 times per week. Occasional use of liquor; the typical amount is 3-8 ounces per week usually with beer. Smokes cigarettes with a six pack year history.

Questions to ask MR:

1. Do you use any herbs for spiritual practices?

2. What is your spiritual or religious heritage?

3. Do your beliefs help you handle stress?

4. What do you consider drugs?

5. What practices prevent admission to heaven?

6. How long have you been drinking alcohol? Smoking marijuana?

7. When did you begin feeling this way?

8. How have you been sleeping?

9. Do you have thoughts to harm yourself?

10. What worries you?

11. How are things at home? Work?

12. How would you like me to help you with your anxiety?

Native American patients may have a lower socioeconomic status with the median annual household income is $ 37,353 for Native American households compared to $ 56,565 for non-Hispanic whites (US Department of Health and Human Services [HHS], Office of Minority Health [OMH], 2018). Patients with lower socioeconomic status may not seek medical care due to lack of insurance, ability to pay insurance premiums, have transportation issues, not fill prescription medications, or take prescribed medications sparingly with the belief to "make the medication last longer."

Native American patients' spirituality is also a cultural factor that requires cultural competence for the practitioner to understand how the patients' spiritual practices influence his care and how the provider can assist the patient. The practitioner must have an understanding of the relationship between spiritual beliefs and health practices and how beliefs relate to illness, health, family, symbols, and taboos (Sullivan, 2012). The patient's spiritual belief may include that mental health issues are viewed as spiritual punishment that is unable to be healed.

Native American patients have twice the rate of diabetes than non-Hispanic white patients (HHS, OMH, 2018). The influence of both smoking cigarettes, marijuana and a family history of diabetes and hypertension concerns for the development of diabetes and hypertension in the future.

The Native American culture has undergone a significant shift in the past 30 years. Nearly 60% of Native Americans now live in major metropolitan areas, and 22% still live on reservations (HHS, OMH, 2018). This shift from reservations to metropolitan areas has changed the Native American lifestyle and culture which strives to find harmony and live with nature (Ball, Dains, Flynn, Solomon & Stewart, 2015). Native Americans have higher rates of alcoholism, and chronic liver disease either from alcoholism, obesity, and exposure to hepatitis B and C virus is the leading cause of death (HHS, OMH, 2018).