Challenging Dogma - Fall 2008

Thursday, December 18, 2008

Issues with Public Health Program Effectiveness in Native American Communities: a Critique of the STD & HIV/AIDS Educational Program Stop the Silence

- David Bohr

The control and treatment of sexually transmitted diseases (STDs) and HIV/AIDS is a major issue that needs to be addressed by all cultures, especially those in the Native American communities. STD and HIV/AIDS rates in Native American communities are exceptionally high. In 2006, Native Americans had the second highest rates of Gonorrhea and Chlamydia, 138.3 and 797.3 cases per 100,000 persons [1,2]. They also had the third highest rate of Syphyllis and HIV infections with 3.3 and 10.4 per 100,000 persons [3,4]. Though the total population of STD or HIV infected Native Americans is only 1% of the total population, the incidence rates are staggering [5]. Public health interventions using education and treatment plans are necessary to reduce these high incident rates. Native American communities also are some of the poorest in the country, making health interventions less common and providing them with less funding, which means programs have to be effective and efficient [6].
Stop the Silence
A media campaign created by the Red Talon Coalition in coordination with the Northwest Portland Area Indian Health Board for the people in the tribes in the northwestern tribes, located in Washington, Oregon and Idaho. The media campaign consists of a community website (, posters, location of testing facilities, public service announcements in newspapers, tip-sheets for adults on talking to teens about sex and STDs and magazines with STD and HIV information made appropriate for either young teens and older teens [7,8]. Statistics on STDs and HIV/AIDS, warning signs, methods to keep safe from transmission and a section on where to get tested for STDs and HIV/AIDS were provided [7,8]. A lower incidence of transmission is expected through educating the Native American Community. However, there are lingering issues with this program that may keep it from achieving this goal. Native Americans has had history of not trusting the government due to long-term mistreatment.
“…history of disenfranchisement; extermination of tradition, language, and land rights; broken treaties; sterilization of Native American women; placement of Indian children in Indian boarding schools; and other experiences of oppression have established deep- rooted intergenerational anger and grief, as well as a mistrust of government that persists to this day”[9]

Through studying social sciences such as linguistics, history and anthropology and behavioral models such as the Theory of Reasoned Action and the Social Cognitive Model, the weaknesses of this program that have been ingrained from mistreatment can be drawn out and corrected to make a more effective program.
Social Structures affect on help
The Theory of Reasoned action suggests that a person will weigh the costs, benefits and the opinions of the surrounding social group and make a rational decision [10,11]. Native Americans exist in communities where this model is extremely relevant because decisions are often delineated by the community as a whole [12]. Therefore, an individual may feel one way towards a behavior but act differently in order to keep within the social constraints provided for him or her. When programs are created to influence a single type of member of the Native American community, the entire group may need convincing before a result is observed. Social structures in Native American cultures can be based on a range of things such as extended families, clans, moieties, bands and patriarchal or matriarchal structures [12]. Stop the Silence is geared towards children and parents from communities where they were supplied with little information about STDs and HIV. The program may provide adequate information to the groups targeted; however, other members of the community are disregarded. An example of this is the case of the two-spirit men, who are members of a tribe that fulfill a mixed gender role, that are the primary caregivers of the children of the tribe [12]. However, no information in this program is geared towards two-spirit persons as caregivers. For a program to be effective, suitable information needs to be produced and distributed to levels of a community's social structure where people are most likely to influence the target population. Through avoiding traditional social structures, Stop the Silence exemplifies the same criteria that has created the mistrust found today; extermination of Native American tradition.
The Ignoring of Cultural Practices: Language
The neglect of Native American language is a major fault of this intervention. Language is an important aspect of Native American culture.
“Language ... guides the way a community views the world and recognizes its place in it. Embedded in language are generations of wisdom that carry cultural values and help shape a person’s self-awareness, identity and interpersonal relationships. Language strengthens an individual’s sense of identity and self-esteem, which are critical aspects for creating a barrier against HIV/STD infection.”[12]

The Stop the Silence campaign did not translate their material from English to any of the indigenous languages of the tribes of the Northwest area. Without recognizing the importance of language, the campaign did not get in touch with each community, refusing to acknowledge each tribe’s individuality. This is leaving a very valuable resource untapped. Whereas, if language were accounted for, tribes may feel that this program is in tune with the wisdom of previous generations. In addition, it would improve their sense of identity and ability to be screened or tested for an STD.
Another issue with neglecting language is that older tribe members may not be able to read posters or informational pamphlets provided; not allowing for parents or community members to communicate with the youth to help them understand. Respect is a key component of Native American culture, and if parents don’t approve of the messages being taught to children, then these programs are most likely to be ignored. Some of the languages spoken in the tribes in the Washington, Idaho and Oregon region are Wakashan, Chinook, Wishram-Wasco, Spokane Salish, Coeur d’Alene, Klallam and Lushootsee [13]. Perhaps by translating information into these languages and distributing them accordingly, the messages that previously failed to be understood could be processed and accepted by elders. This would provide children with the capability of being tested for an STD without disrespecting his or her elders.
The Ignoring of Cultural Practices: Traditional Health Care
Before colonization, Native Americans had their own understanding of illness and ways to treat them such as with sweat baths, poultices, and mineral wraps [12]. The isolation of some tribes required them to create independent medical care in order to survive. Currently, many Native Americans agree with modern medicine's ability to treat diseases. However, they still believe in a combined effort of modern medicine and traditional medicine. Their deep rooted belief in their tribes healers and spiritual leaders suggests that the only way a public health intervention can motivate these people, is through a cooperative medical treatment involving modern and traditional techniques.
Stop the Silence provided literature on methods for STD and HIV prevention as well as the processes used to treat specific STDs. The processes provided only suggest modern medicines process in treating STDs with no mention of traditional treatments that could be used with modern medicine. The lack of sensitivity towards Native American’s traditional medicine could exhibit disrespect to members of the community, especially spiritual leaders whose influence might be great. By not being sensitive to these beliefs, a community's obligation to a disrespected spiritual leader might sway them to not want to be treated.

Racism's affect on Native Americans willingness to get help
Native Americans have encountered racism since the arrival of the first European settlers. They experienced racism through sterilization, stealing of land and verbal abuse by the settlers [9,12]. Experiencing racism from the onset of European settlers only added insult to injury to the Native American people through the 16th to 19th centuries because the settlers brought with them diseases never encountered before by the Native Americans' immune systems. Today, Native Americans are well aware of this history and the unfair treatment they're receiving today by their health services because it is reminiscent of how their ancestors were treated. Racism has been reported at Indian Health Service facilities in the form of wait time, as believed by the Native Americans, to be determined by color of their skin. “Full-blood Indians” wait longer for help compared to “lighter skinned Indians."[9] In addition, reports have been made about providers at dental clinics commenting on the skin of Native American patients and revealing their lack of enthusiasm in providing care to them because the caregiver believes their skin is “dirty.”[9] Raymond Uses the Knife, the chair of the Cheyenne River Sioux Health Committee, stated that this type of discrimination came from non-Native staff members, who according to the Indian Health Service, constitute 64 percent of the health staff [9]. These harsh displays of discrimination have given Native Americans feelings of worthlessness and helplessness and their self-efficacy has diminished accordingly. This is made evident by their high levels of antisocial behaviors such as depression, suicidal tendencies, violence, promiscuity and alcohol abuse [9].
Albert Bandura’s idea of self-efficacy from the social cognitive model suggests that a person’s ability to start a certain behavior and their persistence in finishing a goal is dictated by a person’s opinion on whether that goal can be completed successfully [10,11,14]. Therefore, a person with feelings of helplessness and worthlessness might feel that they aren’t capable of doing any behavior correctly and therefore their self-efficacy will be low. People with low levels self-efficacy are less likely to acquire new habits [14]. Since low levels of self-efficacy are prevalent among Native Americans, health programs need to address this issue. Stop the Silence is a program that does not. Stop the Silence introduces Indian Health Service facilities and other health facilities as locations to visit if someone who wants to be tested or treated for STD or HIV/AIDS. Promoting this option is meaningless if Native Americans aren’t willing to try something new and get tested, treated or use preventative methods. Their feelings of worthlessness and helplessness may prevent them from following through with programs to keep their HIV under control or to keep them from establishing safe sex practices. A program like Stop the Silence needs to incorporate tactics to improve self-efficacy while promoting its agenda. Including real-life accounts of Native Americans going to health service facilities and participating in programs that are keeping them STD and HIV free might be an effective measure in raising awareness and self-efficacy.
Alternative Proposal
Through analyzing the weaknesses of Stop the Silence, new STD and HIV educational programs can be developed with improved effectiveness on Native American communities in the Northwestern United States. Though the history of mistreatment of Native Americans is impossible to reverse, public health educational programs can be tailored to not only provide pertinent information, but also to facilitate the practice of such information through improved self-efficacy and the utilizing of cultural practices and social structures. A new STD and HIV educational program could hypothetically be created in the same vein as Stop the Silence, providing a multifaceted media campaign identical to it, but with enhancements to the weaknesses discussed here. The program will potentially include a community website for each tribe, posters, public service announcements in newspapers, and tip-sheets on how to speak to high risk groups about STD and HIV. The campaign will potentially be titled: Our Tribe, Our Health.
Remitting Racism
The current display of discrimination by Indian Health Services workers toward Native Americans is reminiscent of the apparent racism that was directed at them nearly 500 years ago [9,12]. These ignorant presentations have negatively affected the already low self-efficacy of Native Americans and Our Tribe, Our Health will attempt to provide change [9]. One method of improving self-efficacy is to minimize the discrimination Native Americans are facing at Indian Health Service facilities. Individuals working at these facilities will be educated by Our Tribe, Our Health on cultural sensitivity and how to speak compassionately and with out ignorance towards Native Americans. In addition, new employees should be provided educational materials on cultural sensitivity before they are introduced into this ethnically diverse environment. Our Tribe, Our Health will provide a Native American elder to oversee cultural understanding within Indian Health Services. This should minimize the number of occurrences of discrimination and over the course of time, Native Americans will feel more comfortable attending one of these facilities with out being mistreated [10,11,14].
Another way that Our Tribe, Our Health will attempt to improve self-efficacy is by providing real-life accounts of Native Americans that have successfully remained STD free by following the safe sex ideas provided by Our Tribe, Our Health. Also, providing accounts of Native Americans attending Indian Health Service clinics and were successfully tested or treated for STDs would be helpful. This would improve the perceived effectiveness of health clinics and therefore improve self-efficacy. This will insist on Native Americans that they are capable of remaining STD and HIV free and that it is their choice to remain safe by following safe sex procedures or receive testing. With these improvements to self-efficacy, Native Americans may feel capable of acquiring the new habit of following the safe sex advice provided by Our Tribe, Our Health and hopefully STD and HIV incidence will diminish according [10,11,14].
Utilizing Cultural Practices: Language
Due to the importance of language in Native American communities, literature provided by Our Tribe, Our Health would be produced in the languages appropriate to the tribes of the Northwestern United States and distributed accordingly. Since language holds so much weight concerning individual’s self-awareness, identity and interpersonal relationships, the language used in the program will need to effectively tap into these sections of an individual’s life [12]. This can be accomplished by writing educational information on posters, websites and tip-sheets independent of each language. By not writing information in English and translating it directly, the program will be able to incorporate the individuality of each language [12].
An example of this is literature would be produced in the Wakashan language and distributed to the people of the Makah tribe who live on the coast of Washington state [8]. A meeting would be held between public health officials and English and Wakashan speaking members of the Makah tribe [8]. At this meeting, a cooperative effort would produce a language rich educational program that will provide information while displaying the importance of a tribe’s individuality. Through providing educational information in the native tongue of tribes, the members of the tribe will process the information in the same way they process cultural values that are passed down through time [12]. Potentially STD and HIV/AIDS education may permeate from generation to generation with other important cultural values.
In addition, by providing educational information in culturally appropriate language, non-English speaking members of a tribe will grasp the important health advice being provided. This is especially important because previously non English speakers may not have had any information on STD and HIV.
Utilizing Cultural Practices: Traditional Health Care
Our Tribe, Our Health will provide sensitivity towards traditional health care. This will be accomplished by providing a combined education of modern health care practices and traditional health care concerning STDs and HIV. Public health officials will work in collaboration with spiritual leaders from individual communities to create programs that will suggest a combination of modern and traditional treatments. An example of this may suggest that administering a traditional health procedure such as sweat baths combined with a modern health practice such as condom use will prevent the transmission of HIV [12]. Furthermore, when the combined effort is complete, spiritual leaders will disseminate the information aside from the media campaign. This will suggest that the information being provided is coming from a community respected source, not only a government agency that might not be held in the same regard [9,12]. With this combined effort of modern and traditional health education, public health information will circulate more effectively while avoiding the rejection of traditional Native American practices [12].
Employing Social Structures
The Social Structure in Native American communities is often complicated and including many individuals. Therefore, when health education programs are being developed, they need to account for the influence of social structure on an individual. Our Tribe, Our Health will attempt to use the social networks of Native American tribes to disseminate information. This will be accomplished by providing information geared toward active members of social networks with high-risk individuals, such as young adults [5]. Important individuals in a Native American young adult’s social network may include parents, siblings, extended family, community elders, teachers and two-spirit men [12]. Therefore, Our Tribe, Our Health will provide all of these members of the social network educational information directed towards their own life and their role as an influential figure in a young adult’s decision making. The opinions of the surrounding social group have a powerful impact on an individuals decision-making, therefore if the surrounding individuals are providing consistent, sound health advice, then the influence will positively impact the individual [10,11].
The information provided to members of the social network will not only provide information that is pertinent to STDs and HIV and how it relates to young adults but it will also include tip-sheets on how to speak to young adults about this subject matter. By this means, invaluable information such as how and where to receive testing for STDs and HIV has the ability to be provided by a numerous amount of resources, some that are integral parts of a young adults everyday life [12].
To be an effective educational program, each aspect of the program needs to be tailored to the specific culture it is being introduced. In this case, Stop the Silence provides pertinent information to communities of the Native American tribes in the northwest United States, however, it’s lacking awareness of cultural differences and history of mistreatment might suggest it will be ineffective. The shortcomings were discovered through studying behavioral models such as the Theory of Planned Action and the Social Cognitive Model and social sciences such as linguistics, anthropology and history. Future STD and HIV/AIDS awareness programs geared towards Native Americans need to provide salient information for distinct tribes and for each community member of their distinct social structure and provide tools to remedy the lasting effects of mistreatment. The hypothetical program Our Tribe, Our health provides a potential program that improves upon these lacking points and provides information accordingly. Through these improvements, Native Americans will benefit from enhanced health programs and their history of high STD and HIV/AIDS rates will reduce accordingly.


1. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2006 Supplement, Gonococcal Isolate Surveillance Project (GISP) Annual Report 2006. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, April 2008.
2. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2006 Supplement, Chlamydia Prevalence Monitoring Project Annual Report 2006. Rev ed Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; May 2008.
3. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2006 Supplement, Syphilis Surveillance Report. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, December 2007.
4. CDC. HIV/AIDS among American Indians and Alaska Natives, 2005. Atlanta: US Department of Health and Human Services, CDC; 2008.
5. CDC. HIV/AIDS Surveillance Report, 2006. Vol. 18. Atlanta: US Department of Health and Human Services, CDC; 2008.
6. US Department of Commerce. Bureau of the Census. Selected social and economic characteristics by race and Hispanic origin for the United States. American Indian population by tribe for the United States, regions, divisions, and states: 1990. Washington, DC: Government Printing Office; 1992. CPH-L-99.
7. Stop the Silence. Community Website, Red Talon Retrieved November 18, 2008:
8. Northwest Portland Area Indian Health Board. Retrieved November 18, 2008:
9. U.S. Commission on Civil Rights. Broken Promises: Evaluating the Native American Health Care System. Washington, DC: 2004
10. Salazar, M. (1991). Comparison of Four Behavioral Theories. AAOHN Journal, 39, 128-135
11. Edberg, M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Massachusetts: Jones and Bartlett; 2007.
12. Native Communities HIV/STD Prevention Guidelines Task Force. HIV/STD Prevention Guidelines for Native American Communities: American Indians, Alaska Natives, & Native Hawaiians. Bloomington, IN: Rural Center for HIV/STD Prevention; 2004.
13. Native American Languages, Retrieved: November 18, 2008 Web site:
14. Wikipedia. Self-Efficacy. Wikimedia Foundation Inc.

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