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Rural Native American Veterans

"Even in those times of Vietnam, with the anti-war demonstrations, for veterans who returned to their own Native communities, there was not that kind of reception. It’s the warrior cultures. Warriors have always been in our presence and always will be … not only in times of conflict, but in times of peace as well. They became the leaders."
Robert Holden
~ Choctaw Chickasaw, Deputy Director NCAI ~

Basics

Quick Facts About Native American Populations

  • Native Americans (American Indians, Alaska Natives, Native Hawaiians, and Pacific Islanders) have rich diversity in tribal affiliations, cultural customs, and languages. As with any population, Native American individuals vary in the extent to which they identify with traditional culture and engage in culture-specific practices.
  • According to the 2010 US Census, 5.2 million American Indians and Alaska Natives and 1.2 Million Native Hawaiian and Pacific Islanders live in the U.S. and its territories.
  • Federally-recognized tribal governments are sovereign nations with rights to certain benefits, services and protections from the U.S. government. As of 2018, there are 567 federally recognized American Indian and Alaska Native tribes in the U.S. In addition, there could be as many as 400 non-federally recognized tribes.
  • Among persons at least 5-years-old, who identify as (1) American Indian and Alaska Native alone or (2) Native Hawaiian or other Pacific Islander alone, 29% and 43% respectively speak a language other than English at home.

Quick Facts about Our Nation’s Native American Veterans

  • Looking across 2011-2015, approximately 334,000 Veterans endorsed American Indian and Alaska Native alone or in combination with other races. Approximately 62,000 Veterans endorsed Native Hawaiian and Pacific Islander alone or in combination with other races.
  • Veterans from American Indian, Alaska Native, Native Hawaiian, and Other Pacific Islander populations have an exemplary tradition of military service and sacrifice, serving at the highest rate per capita of any ethnic minority group (representing 3.6% of minority Veterans vs. 2.1% of minority non-Veterans).
  • Native American Vietnam Veterans are more likely than other Veterans to have served in hazardous combat missions, and as a consequence disproportionately withstand higher rates of disorders related to warzone trauma (e.g., posttraumatic stress disorder).1
  • Compared with non-Native American Veterans, Native American Veterans are younger (median age 59 vs 64 years), are more likely to have some college (42.9% vs. 37.1%), are more likely to be female (11.7% vs 8.4%), and earn less income ($27,943 vs. $36,382 annually).2
  • Native American Veterans face increased barriers to health care relative to other Veterans. They are less likely to be insured, more likely to have transportation problems, and less likely to reach a care provider via telephone or obtain a timely appointment.
    • American Indian and Alaska Native American Veterans are the most rural of Veterans (approximately 37% vs. 24% of the U.S. Veteran population, 2016 American Community Survey 5-year estimates, Table S2101). They often must travel long distances, with few transportation options, to receive health care.
    • Many Native Hawaiians and other Pacific Islander Veterans reside on remote islands.3  These Veterans are often far from health care services, with distances exacerbated by bodies of water. Obtaining specialty care often entails costly air travel between islands.

1 Beals J, Manson SM, Shore JH, Friedman M, Ashcraft M, Fairbank JA, Schlenger WE. The prevalence of posttraumatic stress disorder among American Indian Vietnam veterans: disparities and context. Journal of Traumatic Stress. 2002 Apr;15(2):89-97.

2 U.S. Department of Veterans Affairs. American Indian and Alaska Native Veterans: 2015 American Community Survey. August 2017. https://www.va.gov/vetdata/docs/SpecialReports/AIANReport.pdf

3 "DP02. Selected Social Characteristics in the United States - Race or Ethnic Group: Native Hawaiian and Other Pacific Islander alone or in combination with one or more other races - Hawaii." Data Set: 2011-2015 American Community Survey Selected Population Tables. Available at American FactFinder (Census Bureau), https://factfinder.census.gov; Accessed 6/21/2018.

Educational Materials

Educational Materials

  • The SAMHSA Culture Card was designed by Public Health Service Officers, tribal community members, and American Indian and Alaska Native behavioral health professionals to enhance cultural competence while serving American Indian and Alaska Native (AI/AN) communities. Content includes roles of Veterans and Elders, strengths in AI/AN communities, wellness challenges, and self-awareness and etiquette.
  • The Department of Health and Human Services (HHS) Administration for Native Americans presents Storytelling for Healing, featuring Native American Veterans from World War II, Vietnam, the Gulf War and Operation Iraqi Freedom. This website covers many topics important to Native American Veterans, and streams interviews with individual Veterans telling their experience of service and issues they face today.
  • The Office of Rural Health strives to improve access to care for Veterans living in rural and remote communities who rely on VA for health care.  Their website includes video resources (e.g., a caregiver video series) for all rural Veterans as well as information about programs for rural Native American Veterans, and brief explanations of promising practices promoting the health of all rural Veterans.
    • Telemental Health Clinics for Rural Native American Veterans are one of the Office of Rural Health’s Promising Practices.  Serving tribes in Montana, Wyoming and Oklahoma, these clinics strive to provide holistic, person-centered telemental health care through VA-tribal-academic partnerships. Clinics are currently run by the VA Montana Health Care System.
    • Native American Veteran Homelessness Toolkit – Homelessness among rural Native American Veterans poses unique challenges. This toolkit provides detailed information for individuals and organizations working to solve homelessness among Native American Veterans who live on reservations or in Alaska Native Villages.  
    • Fact Sheet: Tribal Colleges and Universities – Tribal Colleges and Universities (TCUs), located on tribal lands, provide post-secondary education opportunities for American Indian and Alaska Native populations. This fact sheet explains how TCUs are relevant to Veterans, especially those who served in recent conflicts. It also provides resources pertaining to higher education.
  • The National Indian Health Board (NIHB) “seeks to reinforce Tribal sovereignty, strengthen Tribal health systems, secure resources, and build capacity to achieve the highest level of health and well-being” for American Indian and Alaska Native People. NIHB provides resources on behavioral health, including alerts, current projects, toolkits, strategies on prescription drug abuse prevention, and related agencies and organizations. 
  • Like NIHB, other offices and organizations encourage policies and programs to support Native American Veterans:
    • Office of Tribal Government Relations – This VA Office supports government-to-government relations between tribal governments and the VA, including facilitating policies to improve the health and well-being of Veterans living in tribal lands. Its website also features a selection of upcoming events in tribal areas.
    • National Congress of American Indians – “proudly seeks fair and dignified treatment of all veterans and also advocates for federal support and funding for American Indian and Alaska Native veteran programs and services.”
  • Other institutions support research, treatment and education programs for Native American Veterans. The Pacific Health Research and Education Institute “conducts health research and education that improves the health and well-being of veterans and all people in Hawaii, central California, the Pacific region, and throughout the U.S.” The Centers for American Indian and Alaska Native Health (CAIANH) conducted the Matsunaga Vietnam Veterans Project in conjunction with the National Center for Post-Traumatic Stress Disorder, collaborates with the VA on Telemental Health Clinics for American Indian Veterans, and houses the journal American Indian and Alaska Native Mental Health Research, which disseminates many articles on Native American Veterans.
  • For more information about American Indian and Alaska Native tribes, Native American Veterans, and VA Services for Native American Veterans, please see our FAQ).

Health Care Considerations

Health Care Considerations

  • The majority of American Indian and Alaska Native VHA users live in rural settings (54%).  Although rural Native American Veterans had fewer diagnoses on average, they were more likely to have served in combat areas and to have higher levels of service-connected disability compared with other rural Veterans.
  • Native American Veterans’ experience during military service often differed from their peers in other ways as well.  Their reports of being mistaken for the enemy, of identifying with the enemy in terms of appearance or plight, and of being mistreated due to resemblance to the enemy could cause additional health complications.
  • The largest study of Native American Veterans, the Matsunaga Vietnam Veterans Project examined the readjustment experience among Native Hawaiian and rural American Indian Vietnam Veterans. Lifetime prevalence of PTSD was higher for American Indian (59%) and Hawaiian Veterans (38%) than for White Veterans (24%).  Rural American Indian Vietnam Veterans also had significantly higher alcohol abuse and dependence (72% current, 84% lifetime) prevalence than other ethnic groups (White Veterans 11% current, 40% lifetime)*.

    *National Center for American Indian and Alaska Native Mental Health Research and National Center for Post-Traumatic Stress Disorder. (1997). Matsunaga Vietnam Veterans Project: Final report. White River Junction, VT: National Center for PTSD.
  • American Indian and Alaska Native American Veterans often qualify for services from both the Veterans Health Administration and the Indian Health Service. Misperception about care eligibility being “either/or” can result in Veterans being turned away for care.

    Focus groups with Veterans in tribal communities and their family members identified opportunities for improving care and services:
    • Challenges receiving services and benefits from the VA included:
      • Lack of culturally competent care
      • Transportation problems
      • Difficulties navigating the system
    • Family members, often main caregivers for American Indian Veterans, faced limited resources, including sources for information, support services, and financial means to procure adequate care.
    • Strengths included local leadership and a strong community commitment to improve care for Veterans.

 

Cultural Considerations

Cultural Considerations

  • Distrust of the U.S. Government stems from a history of genocide and relocation, and a more recent history of broken treaties, unjust reservation policies and boarding schools designed to eradicate Indian culture.
    • System transference happens when past experience with a system(s) (e.g., VA, Federal Government) influences current feelings and reactions to a system(s). Positive history with a system could engender trust and optimism toward the current system. Conversely, negative history could precipitate more distrust and pessimism.1
  • In systems where trust has been violated, trust must be earned over time. Some actions can help build trust with Native American Veterans:
    • Balanced and open acknowledgement of past issues and problems without making excuses, rationalization or blaming.
    • Making extra effort to listen.
    • Willingness to help address, facilitate and navigate current system issues.
    • Being realistic and avoiding overpromising.
    • Following through with any commitments and communicating back to the Veteran.
    • Understanding that actions speak louder than words.
    • Exploring and valuing the Veterans’ relationship with community.
    • Demonstrating interest in Veterans and their communities.
  • Traditional Healing and Spirituality
    • For many but not all Native American Veterans, spirituality of many kinds plays an important role in health and wellness.
    • Many Native Americans approach healing holistically (mind, body and spirit), and frequently incorporate traditional healing methods (e.g., ceremonial sweats, talking circles) with Western medicine. These methods are often facilitated by a healer and frequently involve investment of time and resources by the patient’s family.
    • Use of traditional healing services varies by tribe. For example, a study of two tribes found that among participants who sought services for psychiatric problems, 63% from the Southwest tribe used traditional healing alone or in conjunction with biomedical services, compared with 36% of participants from the Northern Plains tribe.
  • Environmental Factors
  • Clinical Assessments
    • Clinicians should consider, as appropriate, conducting a cultural history as part of an assessment, to render culturally appropriate care. A cultural history may include asking about:
      • Tribal enrollment, identity and affiliation
      • Traditional languages spoken
      • Engagement in traditional practices and activities
      • Kinship relations
      • Engagement in other systems of care, including Indian Health Service, Tribal Health Services, and traditional/spiritual care
    • The National Center for PTSD suggests additional steps to fulfil mental health service professionals’ responsibility to ethnic minority Veterans, over and above assessing combat exposure. For example, taking a step to assess a Veteran’s experience of being an ethnic minority service member can influence appropriate diagnosis, treatment, and compensation.

1 Shore JH, Savin DM, Novins D, Manson SM. Cultural aspects of telepsychiatry. Journal of telemedicine and telecare. 2006 Apr 1;12(3):116-21.

Treatment and Resources

Treatment and Resources

Useful Resources



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