Volume 37 Number 1 | February 2023

Stacy Walz, PhD, MLS(ASCP), ASCLS Patient Safety Committee

Courtney Shrader, MSHS, MLS(ASCP)CM, CPHQ, ASCLS Patient Safety Committee

Stacy WalzCourtney ShraderThe U.S. Census in 2020 estimated that approximately 11.3 million citizens are Indigenous Peoples1. Of those, 9.7 million are American Indian and Alaskan Native (AI/AN) and 1.6 million are Native Hawaiian or other Pacific Islander1. Indigenous people face many healthcare disparities. They have a life expectancy of 5.5 years less than the overall U.S. population2. Historically, indigenous people have been forced from their native lands, rendering their agriculture and stewardship practices useless2. They involuntarily became dependent on a federal supply of canned and processed foods leading to poor nutrition and a 3.2 times higher mortality rate due to diabetes2. Alcohol-induced mortality is 6.6 times higher and drug-induced mortality is 1.5 times higher in AI/AN populations compared to the rest of the U.S. population3. These disparities are due to a variety of reasons including poor nutrition; lack of access to healthcare, including mental health services; and socioeconomic inequities4.

There are three levels of autonomy in healthcare-related decision-making for indigenous people—individual, tribal, and self-sufficiency5. There are many examples whereby individual autonomy in healthcare decision-making has been taken away from indigenous people5. Between the years of 1970 and 1976 it is estimated that around 25 percent of AI/AN women were involuntarily sterilized as part of a federally funded program5,6. In the 1970s one third of AI/AN children were taken from their tribal community and forced into boarding school or adoption by white families5. These egregious historical events have led indigenous people to lack trust in healthcare professionals and organizations7.

“As laboratory professionals, we are protocol and process-driven, we enjoy learning about ourselves and others, and we can do our job better when we partner with other colleagues. As such, our profession is naturally poised to embrace a cultural safety approach.”

Tribal healthcare-related decision-making is another level of autonomy playing a role in providing healthcare to indigenous people5. The tribe has the ability to make decisions that could impact the health of the whole tribe. For example, during the SARS-CoV-2 pandemic, tribes made decisions on how people are let into the reservation to prevent the introduction and rapid spread of the virus5.

The third level of autonomy, self-sufficiency, is about providing care for your own5. Although the patient-provider correspondence and relationship are considered, self-sufficiency, tribal, and individual autonomy are more important when it comes to healthcare decision-making5.

With the strain on the relationship between healthcare providers and indigenous people from significant historical trauma, it is important that healthcare professionals use a modified approach in their interactions7. Healthcare professionals must preserve all levels of autonomy in the health decisions of indigenous people and empathize with the lack of trust in white people and healthcare they provide5,8. Listening and learning are vital when working with indigenous people, along with understanding that their approach to healthcare is more holistic, focusing on the mind, body, and spirit and in harmony with their community and environment. Indigenous people view healing as a sacred calling, including rituals and ceremonies8. Seeing multiple doctors, and being touched and asked a lot of probing questions is perceived as foreign and invasive8.

As laboratory professionals working in a behind-the-scenes capacity, we don’t often have the opportunity to directly interact with patients. In settings where we are involved in specimen collection or overseeing that activity, sensitivity to diverse cultures and awareness of our own prejudices are essential components of our interactions with indigenous people.

Typically, when considering how to better serve underrepresented or remotely located populations, we focus on physical access to care and services. We might expand our hours of operations, offer additional specimen collection satellite locations, or accompany other healthcare colleagues as they make house calls, to name a few examples of how clinical laboratories might try to improve a patient population’s access to our services.

However, as stated in a 2018 article by Horrill et. al.9, “accessing healthcare extends beyond physical accessibility to equally consider the influence of contextual factors, and the social, historical, and political barriers that must be navigated by patients.” These contextual factors significantly impact the professional relationship we establish with indigenous patients and, when taken into account, paint a very different “picture” for solutions to the problem. “Healthcare is understood as a form of social relationship, rather than strictly as a service”10. Our Code of Ethics and respect for persons, not to mention core principles of patient safety (equity and patient-centeredness in particular), implore us to consider a modified approach.

One recommendation is to adopt a cultural safety approach to care of patients. Cultural safety is on the far positive end of a continuum, where cultural awareness and cultural competence come before it. Although this approach is not something that can be mastered overnight, it is certainly worth pursuing over time. One does not need to become an expert in every culture’s norms, behaviors, and beliefs. Rather, it asks the individual to perform guided self-reflection, exploring the roots of one’s values and assumptions, and social and cultural positioning, to better understand and connect with patients11. A scholar in this area, Jessica Ball, describes five principles of cultural safety: protocols, personal knowledge, process, positive purpose, and partnerships. As laboratory professionals, we are protocol and process-driven, we enjoy learning about ourselves and others, and we can do our job better when we partner with other colleagues. As such, our profession is naturally poised to embrace a cultural safety approach.

In summary, traditional solutions to improve access to clinical laboratory services for remotely located or underserved populations should be considered alongside a cultural safety approach, particularly when caring for indigenous peoples.

  1. United States Census Bureau. (2021, August 12). Race and Ethnicity in the United States: 2010 Census and 2020 Census. Retrieved from United States Census Bureau: https://www.census.gov/library/visualizations/interactive/race-andethnicity-in-the-united-state-2010-and-2020-census.html
  2. Kao, A. (2020). Health of the First American. AMA Journal of Ethics, 22(10), E833-836.
  3. Indian Health Service. (2019, October). Disparities. Retrieved from Indian Health Service: https://www.ihs.gov/newsroom/factsheets/disparities/
  4. Adakai M, Sandoval-Rosario M, Xu F, et al. Health Disparities Among American Indians/Alaska Natives — Arizona, 2017. MMWR Morb Mortal Wkly Rep 2018;67:1314–1318. DOI: http://dx.doi.org/10.15585/mmwr.mm6747a4
  5. Wescott, S., & Mittelstet, B. (2020). Three Levels of Autonomy and One Long-Term Solution for Native American Health Care. AMA Journal of Ethics, 22(10), E856-861.
  6. Cordova-Marks, F., Fennimore, N., Bruegl, A., & Edrich, J. (2020). What Should Physicians Consider About American Indian/Alaska Native Women’s Reproductive Freedom? AMA Journal of Ethics, 22(10), E845-850.
  7. Edrich, J., & Gonzales, C. (2020). How Should Health Professions Schools Partner With AI/AN Communities? AMA Journal of Ethics, 22(10), E851-855.
  8. Montgomery, S. (2021, October 7). Sacred Healers: Looking at Healthcare Needs of America’s Indigenous Peoples. Retrieved from Critical Values: https://criticalvalues.org/news/item/2021/10/07/sacred-healers-looking-at-healthcare-needsof-america-s-indigenous-peoples
  9. Horrill T, McMillan DE, Schultz ASH, Thompson G. Understanding access to healthcare among Indigenous peoples: A comparative analysis of biomedical and postcolonial perspectives. Nurs Inq. 2018 Jul;25(3):e12237. doi: 10.1111/nin.12237. Epub 2018 Mar 25. PMID: 29575412; PMCID: PMC6055798.
  10. Tang, S.Y., Browne, A.J., Mussell, B., Smye, V.L. and Rodney, P. (2015), ‘Underclassism’ and access to healthcare in urban centres. Sociol Health Illn, 37: 698-714. https://doi.org/10.1111/1467-9566.12236
  11. Brascoupé, S., & Waters, Catherine, B.A., M.A. (2009). Cultural safety: Exploring the applicability of the concept of cultural safety to aboriginal health and community wellness. Journal of Aboriginal Health, 5(2), 6-41.

Stacy Walz works at Arkansas State University as the Department Chair of Clinical Laboratory Sciences and Program Director for both the MLT and MLS degree programs.

Courtney Shrader is a Clinical Laboratory Quality Assurance Specialist at Exact Sciences Laboratories in Madison, Wisconsin.