INTRODUCTION 2001 1994 2001 2000 2004 2000 The purpose of this study is to examine factors that influence the choice between traditional cultural and western mental health and substance use associated care among American Indians from reservations in the northern Midwest. Specifically, we examine preference in terms of perceived effectiveness and actual utilization of traditional vs. Western-based service outlets. Barriers to Health Services 1998 2004 2002 2004 2003 2002 2002 1994 Traditional Help Seeking 1998 2004 1998 1998 2000 2000 2000 1998 2000 2004 2001 2004 1997 2000 1996 1997 2000 Hypotheses 2000 1996 2004 2004 METHODS Sample These data were collected as part of the “Healing Pathways Project,” a 3-year lagged sequential study currently underway on four American Indian reservations in the Northern Midwest and five Canadian First Nation reserves. Because of national differences in health care systems, the data presented here includes only that from U.S. reservations. The data are from wave one of the study collected on two U.S. reservations from February through October 2002, and wave one on a second pair of U.S. reservations collected from February through October 2003. The reservations share a common cultural tradition and language with minor regional variations in dialects. The sample represents one the most populous Native cultures in the United States and Canada. The project was designed in partnership with the participating reservations and reserves. Prior to the application funding, the research team was invited to work on these reservations, and tribal resolutions were obtained. As part of this agreement, the researchers promised that participating reservation names would be kept confidential in published reports. An advisory board was appointed by the tribal council at each participating reservation and is responsible for advising on difficult personnel problems, questionnaire development, reading reports for respectful writing, and assuring that published reports protected the identity of the respondents and the culture. Upon advisory board approval of the questionnaires, the study procedures and questionnaires were submitted for review and approved by an Institutional Review Board. All participating staff on the reservations were approved by the advisory board and were either tribal members themselves or non-members who are spouses of tribal members. To ensure quality of data collection, all interviewers underwent special training for conducting pencil-and-paper and computer-assisted personal interviewing for diagnostic measures, including feedback sessions. In addition, all of the interviewers completed a required human subject’s protection training that emphasized the importance of confidentiality and taught procedures to maintain the confidentiality of data. Each tribe provided lists of families of enrolled children aged 10–12 years who lived on or proximate to (within 50 miles) the reservation or reserve. We attempted to contact all families with a target child within the specified age range. Families were recruited via personal visits from Native interviewers during which they were given an explanation of the project, a gift of wild rice, and an invitation to participate. After agreement to participate and later completion of interviews, each participating family member received $40 for their time. This recruitment procedure resulted in an overall response rate of 79.4%. Sample Characteristics The sample for this analysis is made up individuals from the U.S. reservations only and consisted of 865 parents/caretakers (264 males and 601 females) of tribally enrolled children aged 10–12 years. Fathers/male caretakers ranged in age from 21 to 70 years with an average age of 42 years; mothers/female caretakers ranged in age from 17 to 78 years with an average of 39 years. Measurement To assess the perceived effectiveness of health service providers, respondents were given a series of questions asking them how effective various service outlets would be if ever there were to have (1) an emotional problem, or (2) a substance abuse problem. The response categories range from not at all effective to extremely effective. Traditional/informal services include family, talking to an elder, sweat lodge, pipe ceremony, offering tobacco, traditional healer, traditional ceremony, and healing circle. Formal services include Indian Health Service (IHS), doctor, psychologist, social worker, counselor, psychiatrist, chemical dependency counselor, and nurse. Respondents were asked to evaluate the perceived effectiveness of formal services both on and off the reservation. For multivariate analysis a mean effectiveness score was computed for three categories of services: (1) traditional, (2) formal on reservation, and (3) formal off reservation, all within each realm of service need (emotional and substance abuse). Each mean score has a range from 1 to 5, with higher scores indicating greater perceived effectiveness. Enculturation 1997 2002 Perceived discrimination Social support Health status Gender Education Employment on and off the reservation RESULTS Descriptive Characteristics The adults who comprised this sample had an average educational level falling between a high school diploma and at least some secondary school experience (mean = 2.4; SD = .87), and more than half (57%) were employed full-time. Very few of the adults lived off of the reservation (12%) at the time of our interviews. The self-reported health status of the adults in our sample averaged between ‘good’ and ‘very good’ (mean = 3.3; SD = 1.0), and the overall level of reported social support in the communities was 8.4 (SD = 4.1). Enculturation is a standardized variable in these analyses (mean = 0; SD = 1), while the mean level of perceived discrimination was 1.5 (SD = .69), indicating that the average response across all of the discrimination questions fell between ‘never’ and ‘a few times.’ Among the dependent variables concerning service preferences among respondents, the highest mean scores were found for informal/traditional services for both mental health (mean = 3.06; SD = 1.06) and substance use (mean = 3.09; SD = 1.15) related issues. Next highest were mean preference scores for on-reservation formal services (mental health = 2.51; SD = 1.01; substance use = 2.53; SD = 1.09), followed lastly by mean preference ratings for formal off-reservation care (mental health = 2.32; SD = 1.03; substance use = 2.34; SD = 1.09). Perceived Effectiveness of Services 1 FIGURE 1 Perceived Effectiveness of Services  Use of Informal and Formal Services 1 p p p p p p p p p p TABLE 1 OLS Regression Models Predicting Perceived Effectiveness (Preferences) of Mental Health and Substance Use Related Services  Mental Health Substance Use 1A 2A 3A 1B 2B 3B Informal Formal (on res.) Formal (off res.) Informal Formal (on res.) Formal (off res.) B β B β B β B β B β B β Age  − 0.003  − 0.03 0.01 0.05  − 0.002  − 0.02 0.001 0.01 0.01 0.07 + 0.00 0.003 Gender (female = 1) 0.15 0.06* 0.13 0.06 + 0.04 0.02 0.13 0.05 + 0.05 0.002  − 0.03  − 0.01 Education 0.04 0.03 0.14 0.12** 0.21 0.18*** 0.04 0.03 0.17 0.13*** 0.19 0.15*** Employment 0.14 0.07* 0.08 0.04  − 0.01  − 0.01 0.15 0.07* 0.02 0.01  − 0.06  − 0.03 Live off reservation 0.17 0.05 0.18 0.06 0.28 0.09* 0.07 0.02 0.27 0.08* 0.47 0.14*** Physical health status 0.01 0.01 0.03 0.03 0.02 0.02  − 0.02  − .01 0.02 0.01 0.01 0.01 Social support 0.03 0.13*** 0.03 0.13*** 0.02 0.08* 0.04 0.13*** 0.05 0.17*** 0.02 0.09*** Enculturation 0.52 0.49***  − 0.05  − 0.05  − 0.05  − 0.05 0.51 0.44***  − 0.05  − 0.05  − 0.08 -.07* Discrimination 0.14 0.09** 0.11 0.07 +  − 0.07  − 0.05 0.19 0.11** 0.17 0.1**  − 0.09  − 0.06 Constant 2.37 1.28 1.73   1.10 1.77 R 2 0.29 0.05 0.06 0.25 0.06 0.07 R 2 0.28 0.04 0.05 0.24 0.05 0.06 + p p p p n n p p p p p p p p p p p p p p p 1 R 2 DISCUSSION 1998 1990–1991 1987 1999 1996 on 1994 1995 1 2004 Limitations Although we interviewed a broad range of American Indian adults on multiple reservations that are dispersed geographically across two Midwestern states, these results pertain to a single culture and capture variations within this culture. We believe the findings represent the culture well, but they cannot be generalized to other Native cultures. A second caution regarding the sample is that it is made up of parents and caretakers of children aged 10–12 years. This could reflect a selection bias in that parents/caretakers may be more likely to utilize services and to be currently mentally healthy and alcohol and drug free than individuals with no children. Finally, all of our measures are based on self-reports. We did not have access to service utilization rates from local clinics or reports of services use from traditional healers. Policy Implications These findings have important policy implications for those who provide health services to American Indian people. Cultural traditions are very much alive on U.S. reservations and are preferred methods of healing for mental health or substance abuse problems. This should be taken into account when designing health services systems either by providing alternative services onsite or through creatively engaging informal traditional services. Simply acknowledging informal service providers by asking the patient if they have seen a traditional healer and then contacting him or her for an opinion would be an important step. Health providers could include key community spiritual leaders and healers on health advisory boards or create health partnerships that would encourage mutual referrals. Perhaps the place to begin would be to respectfully seek the advice of elders on decreasing barriers between the two. 1998 1998 2000 Changing the current short comings in mental health delivery first involves acknowledging that parallel systems exist in some cultures. The impetus for change may have to come from formal services providers who should demonstrate respect for traditional healers, invite their advice, and consult with them if patient’s give permission. Clinicians may need to be proactive in offering their patients this option rather than waiting for the patient to request it. Creating this sensitivity may require specialized training for services providers on American Indian reservations. Grant funding groups may want to consider supporting model programs that bring together the two healing modalities. Future Research There is much to be done to increase American Indians’ confidence in health services systems. One avenue for this would be to work more closely with informal traditional services that are trusted. We need control group trials of innovative services models that cross over between formal medical services and traditional approaches to healing to assess the efficacy of combining the approaches. Continued failure to acknowledge the strong preferences for traditional ways is to ignore a valuable health resource.