摘要：Objectives. We conducted an exploratory study to determine what organizational characteristics predict the provision of culturally competent services for American Indian and Alaska Native (AI/AN) veterans in Department of Veterans Affairs (VA) health facilities. Methods. In 2011 to 2012, we adapted the Organizational Readiness to Change Assessment (ORCA) for a survey of 27 VA facilities in the Western Region to assess organizational readiness and capacity to adopt and implement native-specific services and to profile the availability of AI/AN veteran programs and interest in and resources for such programs. Results. Several ORCA subscales (Program Needs, Leader’s Practices, and Communication) statistically significantly predicted whether VA staff perceived that their facilities were meeting the needs of AI/AN veterans. However, none predicted greater implementation of native-specific services. Conclusions. Our findings may aid in developing strategies for adopting and implementing promising native-specific programs and services for AI/AN veterans, and may be generalizable for other veteran groups. Limited data available indicate significant disparities in health status and health care between American Indian and Alaska Native (AI/AN) veterans and other populations. AI/AN veterans often live in rural areas; roughly 40% live on geographically dispersed reservations and tribal lands. Many of these areas are remote and isolated, making delivery of health care a significant challenge. 1,2 AI/AN veterans rank poorly on several important dimensions of quality of life, including educational attainment, income, home ownership, and employment. 2–4 In addition to transportation difficulties and distance to care, they face several other access barriers, including lack of appropriate diagnostic services and specialty care. 2–4 AI/AN veterans are significantly more likely than White veterans to delay care because they have difficulty getting timely appointments, locating and accessing specialty care, and reaching providers by phone. 2–5 AI/AN veterans have higher incidences of mental health problems 3,5 and are 4 times as likely as White veterans to report unmet health care needs. 6,7 AI/AN veterans often report impersonal care, limited knowledge about Department of Veterans Affairs (VA) services and eligibility, lack of understanding within the VA regarding their culture and their needs, a preference to obtain mental health services from traditional healers from within their own tribal culture, and dissatisfaction with the VA as barriers to obtaining VA care. 8 The VA is committed to delivering high-quality, equitable care and to eliminating racial and ethnic disparities in health care. Proposed strategies to address health and health care disparities among minorities include a stronger focus on patient-centered care and a more culturally congruent health care environment. 9 Culturally congruent, patient-centered care aims to improve health outcomes by empowering patients to participate in the health care decision-making process and by increasing trust, reducing skepticism, and enhancing acceptability of care. 9,10 Patient-centered health care encompasses (1) respect for patients, (2) collaborative communication strategies, (3) knowledge sharing between patients and their health care providers, and (4) sociocultural competence. Cultural competence encompasses understanding and consideration of culture, economic and educational status, health literacy level, family patterns and situations, and traditions (including alternative and folk remedies), as well as communication at a level that the patient understands. 10 Cultural competence in health care involves understanding of and respect for culturally different patient groups, ideally resulting in health care tailored to accommodate cultural differences in health-related values and beliefs. Cultural competency is a key part of delivering patient-centered care because both concepts stress respect for the patient, clear communication, shared decision-making, and building strong doctor–patient relationships. 10 Patient centeredness and cultural competence are important elements of delivering quality care to AI/AN veterans and may help reduce health care disparities among this special population. AI/AN peoples have their own long tradition of medicine and healing. The literature contains several arguments for the incorporation of traditional healing practices into health care for native groups. Some authors advocate individualized medicine that is culturally and linguistically appropriate. 11–13 Others argue that the holistic approach of traditional healing in understanding the mind, body, and spirit is particularly relevant in the treatment of disorders related to trauma 13 and may be especially relevant for AI/AN veterans, who have a high prevalence of traumatic disorders. 14 One study found that although most AI/AN veterans were generally satisfied with the quality of care received in VA facilities, they considered that the care they received was not fully culturally competent regarding AI/AN health beliefs and behaviors. 7 However, efforts by the VA, including the newly revised VA–Indian Health Service Memorandum of Understanding , 15 as well as VA contracting agreements, have renewed the focus on improving care to these veterans.
