Use of Biomedical Services and Traditional Healing OptionsAmong American Indians
Sociodemographic Correlates, Spirituality, and Ethnic Identity
Douglas K. Novins, MD,* Janette Beals, PhD,* Laurie A. Moore, MPH,† Paul Spicer, PhD,*Spero M. Manson, PhD,* and the AI-SUPERPFP Team
Objective: The objective of this study was to describe the use ofbiomedical services and traditional healing options among a reser-vation-based sample of American Indians from 2 culturally distincttribesMethods: Participants were 2595 American Indian adolescents andadults ages 15 to 57 randomly selected to represent 2 tribes living onor near their rural reservations. First, we examined the prevalenceand correlates of use of biomedical services and traditional healingfor both physical health and psychiatric problems. Second, wedeveloped logistic regression models predicting the independent andcombined use of biomedical services and traditional healingResults: The prevalence of combined and independent use ofbiomedical services and traditional healing varied by tribe. Theprevalence of biomedical service use ranged from 40.9% to 59.1%for physical health problems and 6.4% to 6.8% for psychiatricproblems. The prevalence of the use of traditional healing rangedfrom 8.4% to 22.9% for physical health problems and 3.2% to 7.8%for psychiatric problems. Although combined use of both types ofservices was common (10.4–22.6% of service users), many usedonly traditional healing (3.5–40.0%). Correlates of service useincluded age, educational level, and ethnic identity. For example,use of traditional healing was correlated with higher scores on ascale measuring identification with American Indian cultureConclusions: Both biomedical services and traditional healing areimportant sources of care in American Indian communities, and areused both independently and in combination with one another.
Key Words: American Indian, North American, serviceutilization, traditional healing, alternative and complementarymedicine
(Med Care 2004;42: 670–679)
The health service ecology for American Indian popula-tions is notable for the wide variety of traditional healing
options that coexist with biomedical health services.1,2 Stud-ies in rural, reservation, and urban communities have found ahigh prevalence of use of traditional healing among AmericanIndians receiving biomedical services,3–11 with estimates ofregular use ranging from 38% to 70%. Sociodemographic andpsychosocial correlates of the use of traditional healers in-clude male gender,6 having greater than a high school edu-cation,6 religious affiliation,7 and report of living by the“native way of life” and not by the “white way of life.”3
These studies provide important insights into the use oftraditional healers among American Indians, but have fo-cused only on individuals receiving biomedical services andare each limited to 1 community/treatment setting. Commu-nity-based studies are important because we cannot assumethat all users of traditional healers use biomedical services,whereas studies of more than 1 tribe are valuable because ofthe diversity of traditional healing practices across Indiantribes as well as variation in the availability and accessibilityof these practices after long periods of repression.1,2,12 Theseissues are highlighted by Gurley et al.’s study of the use ofbiomedical services and traditional healing among 621 Amer-ican Indian Vietnam veterans from 2 tribes—the only com-munity-based study of this nature to date.13 In this study, useof traditional healing was more common among veteransfrom a Southwest tribe than a Northern Plains tribe for bothphysical health (17.1% and 4.7%) and psychiatric (18.5% and5.0%) problems, respectively. The majority, but by no meansall, of the users of traditional healing also sought biomedicalcare (59.6–88.0%, varying by tribe and problem type).
AI-SUPERPFP Team: Cecelia K. Big Crow, Dedra Buchwald, Buck Cham-bers, Michelle L. Christensen, Denise A. Dillard, Karen DuBray, PaulaA. Espinoza, Candace M. Fleming, Ann Wilson Frederick, Joseph Gone,Diana Gurley, Lori L. Jervis, Shirlene M. Jim, Carol E. Kaufman, EllenM. Keane, Suzell A. Klein, Denise Lee, Monica C. McNulty, Denise L.Middlebrook, Christina M. Mitchell, Laurie A. Moore, Tilda D. Nez,Ilena M. Norton, Theresa O’Nell, Heather D. Orton, Carlette J. Randall,Angela Sam, James H. Shore, Sylvia G. Simpson, and Lorette L. Yazzie.
Reprints: Douglas Novins, MD, American Indian and Alaska Native Pro-grams, UCHSC, Mail Stop F800, P.O. Box 6508, Aurora CO 80045.E-mail: [email protected].
Although American Indian traditional healing practicesare often classified as a form of “complementary and alternativemedicine,”14,15 studies of the use of complementary and alter-native medicine among the U.S. and Canadian general popula-tions have not included enough American Indians to examinethe use of traditional healing in this diverse cultural popula-tion.15–19 Thus, many important insights regarding the correlatesof complementary and alternative medicine use among non-American Indians such as female gender,15–17 specific ageranges (eg, 35–49 years),15–17 being divorced or separated,15
having a college education,15–17 annual incomes above$50,000,15–17 and beliefs in the importance of spirituality19 havenever been examined in American Indian populations.
We examine the use of biomedical and traditional healingamong American Indians ages 15 to 57 from 2 tribes thatparticipated in a large-scale, community-based study. Morespecifically, the goal of this study was to describe the preva-lence, patterns, and correlates of the use of biomedical andtraditional healing among American Indians from these 2 tribes.
METHODS
Study Design and SampleData for this study was drawn from the American
Indian Service Utilization and Psychiatric Epidemiology Riskand Protective Factors Project (AI-SUPERPFP). These meth-ods are described in greater detail elsewhere.20,21 The 2populations of inference were enrolled members of a North-ern Plains or a Southwest tribe who were 15 to 54 years oldat the time of development of the sample frame (1997) andwho lived on or within 20 miles of their reservations. Thesample was identified using stratified random sampling pro-cedures (by age and gender)22 from tribal rolls. Because ofthe importance of community confidentiality in work withAmerican Indian groups, general cultural descriptors are usedin this article rather than specific tribal names.23
The 2 participating tribes are among the larger tribes inthe United States and represent both the diversity and com-mon experiences of this population. The 2 tribes belong todifferent linguistic families, have different histories of migra-tion, subscribe to different principles for reckoning kinshipand residence, and have historically pursued different formsof subsistence. They share similar histories of colonization,including dramatic military resistance and externally imposedforms of governance. Unemployment and poverty are wide-spread, but both tribes vary considerably in acculturation,education, and income.
Data were collected between 1997 and 1999. Oncelocated and found to be eligible, 73.7% and 76.8% agreed toparticipate from the Southwest (n � 1446) and NorthernPlains (n � 1638) tribes, respectively.
Only those participants who had a complete set of datawere included in these analyses, resulting in the exclusion of 489
participants because of missing data, primarily because of an-swering “don’t know” to the income questions critical to mea-suring poverty status (n � 298) and/or missing data on thespirituality measure (n � 196). Data regarding income could bemissing because income could be particularly difficult to quan-tify in economies with substantial bartering. Missing data on thespirituality measure was the result of the placement of thesequestions near the end of the interview. Compared with thoseincluded in these analyses, those who were excluded differedfrom those included on 7 of the 19 variables (table availablefrom the authors). However, these 7 variables explained only2.5% of the variance of the missing data variable. The keydifference between those excluded from these analyses was thatthey were less likely to use biomedical services for physicalproblems than those who were included (30.9% vs. 40.6%).Participant characteristics are summarized in Table 1.
Service EcologiesThe Indian Health Service is the primary provider of
ambulatory and hospital-based care for physical health as well aspsychiatric problems among these 2 tribes. Such services areprovided without cost to users, pursuant to treaty-defined obli-gations on the part of the Federal government. Other providersof biomedical services include tribally operated facilities, theVeterans Administration, and other providers.24
American Indian tribes have a rich history of traditionalhealing through consultation with medicine people and ceremo-nies designed to intervene in the spiritual world to affect heal-ing.1,2 Traditional systems of healing are active in both tribesreported here, although the organization of traditional healing isquite different in each. Although specific aspects of these heal-ing systems cannot be discussed without violating communityconfidentiality, broad contrasts can be drawn in terms of theorganization and indications for ceremonial intervention in eachtribe. The Northern Plains tribe features a network of traditionalhealers that is informally organized and whose practices centeron a set of core ceremonies, any 1 of which could be indicatedfor multiple forms (and causes) of distress. In contrast, theSouthwest tribe features a formally organized network of tradi-tional healers who perform carefully scripted ceremonies thatoften have very specific indications based on the determinationof a specific spiritual cause of an individual’s distress.25 Al-though specialization is certainly a part of the Northern Plainssystem of traditional healing, it is much less elaborated than inthe Southwest, where practitioners specialize in specific diag-nostic practices and ceremonies.
Interview and MeasuresInterviews were conducted by tribal members who
underwent intensive training in research and interviewingprocedures. Questions were administered using a computer-assisted personal interview. Extensive quality control proce-dures verified that all portions of the location, recruitment,
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and interview procedures were conducted in a standardized,reliable manner.
Dependent VariablesService utilization was assessed using sets of questions
placed in an interview module devoted specifically to mea-suring service use, satisfaction with services, and barriers to
accessing care over the past year.26 Questions were problem-specific, focusing on service use for participants who reportedhaving a “physical health problem,” an “emotional problem,”or an “alcohol or drug problem.” Because of the relativelylow number of participants who endorsed service use foremotional (6.3%) and/or alcohol or drug problems (5.6%),
Percent of Life Spent on ReservationLess than 50 26.2% 1.3 26.1% 1.3*50 to 94.9 26.2% 1.3 34.3% 1.495 or more 47.6% 1.5 39.6% 1.4
Spirituality/Ethnic Identity ScalesImportance of spirituality (higher � greaterimportance of spirituality)
2.00 0.02 1.97 0.02
Indian identity (higher � greater identification withIndian culture)
2.09 0.02 2.17 0.02
White identity (higher � greater identification withWhite culture)
1.60 0.02 1.38 0.02*
*� p � .01.†Indeterminates included in nonpoor.‡Includes homemaker, looking for work, unemployed, retired, permanently disabled, other.§Includes living together as if married.%/mean � percent for categorical variables, mean for scaled variables. SE � standard error.Percentages reported are column percentages (eg, the percentage of participants from the Southwest tribe
who were male).
Novins et al Medical Care • Volume 42, Number 7, July 2004
service use for these 2 problem types was combined into asingle category: service use for psychiatric problems (10.7%).
Using these questions, 3 different dependent variableswere constructed separately for use of services for physical andpsychiatric problems (for a total of 6 dependent variables): 1)use of biomedical services; 2) use of traditional healing; and 3)a variable summarizing service use as use of biomedical servicesonly, use of traditional healing only, or use of both biomedicaland traditional services (combined services).
Independent VariablesIndependent variables were selected from the existing
literature on the use of traditional services,3–11,13 as well asthe complementary and alternative medicine literature regard-ing non-American Indians,15–19 and included the followingsociodemographic characteristics: tribe,13 gender,15–17 age atinterview (15–24, 25–34, 35–44, or 45–57),15–17 educationlevel (less than a high school education, high school diploma/GED, beyond high school)6,15–17; poverty status (poor—falling below the U.S. level of poverty, nonpoor)15–17; em-ployment (working for pay, student, not working for pay)15–17;marital status (married/living as married, not married);15 andpercent of life spent on a reservation (less than 50%, 51–95%,greater than 95%).3 Poverty status was used instead of in-come over $50,000 to adjust this measure to better reflect theincome range of participants (1% of this sample had anannual income over $50,000, whereas 45% were classified asnonpoor). Based on the existing literature, 3 additional scaledindependent variables were included.3,19 One scale measuredthe importance of spirituality in the individual’s life (Cron-bach’s alpha ���, a measure of internal consistency�0.80).19,27 Two additional scales measured each individu-al’s identification with American Indian (� � 0.73) and whitecultures (� � 0.70).3,28,29
Statistical MethodsAnalyses were conducted in STATA using sample and
nonresponse weights.30 First, we estimated the prevalence ofbiomedical and traditional service use for physical health andpsychiatric problems and conducted a series of univariateanalyses to describe the characteristics of participants whoused these services. These analyses were stratified initially bytribe as well as gender. However, we were unable to identifyany differences in characteristics of service users by gender,so we report these results stratified solely by tribe. Because ofmultiple comparisons, we discuss only differences at the levelof P �0.01 for these analyses.
Second, we estimated the prevalence of the combinedand independent use of biomedical and traditional servicesfor physical health and psychiatric problems among thoseparticipants who reported any service use. We then developed2 multinomial logistic regression models31 predicting thecombined and independent use of these services among study
participants who actually reported service use. Based on theexisting literature3,12,13,17,21 and key theories of service uti-lization,32,33 we tested for potential interactions of tribe,gender, and age with each of the independent variables in thefinal regression model to determine if these variables corre-lated differentially with the combined and independent use ofbiomedical and traditional services. Only significant interac-tions were retained in the final models. Because these modelswere developed for only those participants who used services,their total n’s were 1480 for physical health problems and 271for psychiatric problems. In these models, we discuss signif-icant associations at the P �0.05 level.
RESULTS
Use of Biomedical ServicesThe estimated prevalences of the use of biomedical
services for physical health and psychiatric problems areshown at the top of the left-hand columns of Table 2.Biomedical service use was much more prevalent for physicalthan psychiatric problems among participants from both theSouthwest (40.9% vs. 6.4%, respectively) and NorthernPlains (59.1% vs. 6.8%). Those from the Northern Plainswere more likely to use biomedical services for physicalhealth problems than those in the Southwest, but the 2 tribesdid not differ in terms of the prevalence of biomedical serviceuse for psychiatric problems.
The characteristics of users of biomedical services areshown in the left-hand columns of Table 2. For both tribes, usersof biomedical services for physical health problems were morelikely to be from the older age groups and reported higher scoreson the spirituality and white identity scales. The prevalence ofbiomedical service use increased with educational level andpercent of life spent on the reservation. In the Northern Plainstribe, biomedical service use for physical problems was alsoassociated with female gender and being married.
In contrast, there were very few characteristics thatdistinguished users from nonusers of biomedical services forpsychiatric problems. In the Northern Plains, use of biomed-ical services was associated with a greater percentage of lifespent on the reservation.
Use of Traditional HealingThe estimated prevalences of the use of traditional
healing for physical health and psychiatric problems aresummarized at the top of the right-hand columns in Table 2.Use of traditional healing was more common for physicalthan psychiatric problems among participants from both theSouthwest (22.9% vs. 7.8%, respectively) and NorthernPlains (8.4% vs. 3.2%). In addition, use of traditional healingwas more prevalent in the Southwest than the Northern Plainsfor both physical health and psychiatric problems.
For both tribes, use of traditional healing for bothphysical health and psychiatric problems was associated with
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n � 2,595.%/mean � percent for categorical variables, mean for scaled variables. SE � standard error.Percentages reported are column percentages (e.g., the percentage of males from the Southwest tribe who used services for physical health problems).*Indeterminates included in nonpoor.†Includes homemaker, looking for work, unemployed, retired, permanently disabled, other.‡Includes living together as if married.Significant differences from other groups (p�.01) are indicated by superscripts (two groups with the same superscript differed significantly from each
other). For all participants (the first row), contrasts are across service type, problem type and tribe. For all other variables, contrasts are within service type,problem type, and tribe. For the scaled variables, the §indicates where users of biomedical services for the specific problem type scored significantly higherthan non-users on that scale.
Novins et al Medical Care • Volume 42, Number 7, July 2004
higher scores on the spirituality and American Indian identityscales. Individuals from the older age groups were morelikely than individuals from the younger age groups in bothtribes to report using traditional healing for physical prob-lems. In the Southwest tribe, use of traditional healing forphysical health problems was associated with being married.In the Northern Plains tribe, use of traditional healing forpsychiatric problems was associated with having spent agreater percentage of life on the reservation.
Combined and Independent Use of BiomedicalServices and Traditional HealingPrevalence
Combined and independent use of biomedical and tra-ditional services was also examined (table available from theauthors).
Physical Health ProblemsThe 2 tribes differed in their patterns of combined and
independent use of biomedical and traditional services forphysical health problems. Overall service use for physicalproblems (both biomedical and traditional) was higher in theNorthern Plains tribe (61.2%) than the Southwest (52.4%).The relative combined and independent use of biomedicaland traditional services also varied by tribe. Compared withtheir counterparts in the Northern Plains, service users fromthe Southwest were more likely to use these services incombination (22.6% vs. 10.4%), less likely to use biomedicalservices only (55.5% vs. 86.1%), and more likely to usetraditional healing only (22.0% vs. 3.5%).
Psychiatric ProblemsSimilarly, the 2 tribes differed in their combined and
independent use of biomedical and traditional services for psy-chiatric problems. Twelve percent of participants from theSouthwest and 8.9% of participants from the Northern Plainsused biomedical and/or traditional services for psychiatric prob-lems in the past year. As was the case for physical healthproblems, service users from the Southwest tribe were morelikely to use combined services (16.8% vs. 12.3%), less likely touse biomedical services only (36.2% vs. 63.9%), and more likelyto use traditional services only (47.0% vs. 23.8%). Overall,traditional healing provided a greater proportion of care forpsychiatric (63.8% in the Southwest, 36.1% in the NorthernPlains) than for physical health problems (44.6% and 13.9%).
Multinomial Logistic Regression ModelsPhysical Health Problems
The final multinomial logistic regression model predictingthe use of biomedical and/or traditional services for physicalhealth problems is summarized in the left-hand columns ofTable 3. When compared with their counterparts in the South-west, service users from the Northern Plains were more likely to
use biomedical services only than traditional healing only orcombined services. Readers will note that 1 of the odds ratios fortribe are large, which is likely the result of the relatively smallproportion of individuals from the Northern Plains who usedtraditional services only for physical health problems (3.5%).The lower bound for biomedical services only versus traditionalservices only was 27.54. This is the appropriate (and conserva-tive) estimate of this effect size, and we have included this valuein Table 3. Females were more likely than males to use com-bined services than traditional healing only. After controlling forother variables in the model, higher levels of education wereassociated with a greater likelihood of using biomedical servicesonly or combined services compared with traditional only.Individuals who were not working for pay were more likely thanthose working for pay to use combined services rather thantraditional healing only. Higher scores on the white identity scalewere associated with a greater likelihood of using combined orbiomedical services only than traditional healing only. Higherscores on the American Indian identity scale were associatedwith a greater likelihood of using combined services or tradi-tional healing only rather than biomedical services only.
In addition, we identified an interaction between tribeand the spirituality scale, which is displayed in the bottomportion of Table 3. After controlling for other variables in themodel, higher scores on the spirituality scale were associatedwith a greater likelihood of using combined services ortraditional healing only rather than biomedical services in theNorthern Plains, but not in the Southwest.
Psychiatric ProblemsThe final multinomial logistic regression model pre-
dicting the use of biomedical and/or traditional services forpsychiatric problems is summarized in the right-hand col-umns of Table 3. When compared with their counterparts inthe Southwest, service users from the Northern Plains weremore likely to use biomedical services only rather thancombined services or traditional healing only. After control-ling for other variables in the model, higher scores on thewhite identity scale were associated with a greater likelihoodof using combined services than biomedical services only ortraditional healing only. Higher scores on the AmericanIndian identity scale were associated with a greater likelihoodof using combined services or traditional healing only ratherthan biomedical services only.
In addition, we identified an interaction between tribeand the formal education, which is displayed in the lowerportion of Table 3. After controlling for other variables in themodel, having received some college education was associ-ated with an increased likelihood of using biomedical ser-vices only or traditional healing only rather than combinedservices, but only in the Southwest tribe. In the NorthernPlains, having received some college education was associ-
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TABLE 3. Final Multinomlal Logistic Regression Models Predicting Utilization of Biomedical, Traditional, and CombinedBiomedical/Traditional Services Among Services Users for Physical and Psychiatric Problems
Service Use for Physical Health Problems (n � 1,480) Service Use for Psychiatric Problems (n � 271)
Less than 12 years 1.00 - 1.00 - 1.00 -High school graduate or GED 1.08 1.00 0.37 1.84 0.39 1.00Some college 0.76 1.80 0.17 1.90* 0.13 1.85*
Northern PlainsLess than 12 years 1.00 - 1.00 - 1.00 -High school graduate or GED 1.50 2.09 1.39 2.24 2.09 2.87Some college 0.23 1.94* 2.53 2.29 0.59 2.33
*� p � .05.‡Includes homemaker, looking for work, unemployed, retired, permanently disabled, other.¶This parameter estimate was 124.8, and is likely the result of the relatively small proportion of individuals from the Northern Plains who used traditionalhealing only for physical health problems (3.5%). Instead of including the parameter estimate in the table, we have reported the lower bound of the 95thpercentile confidence interval, the appropriate (and conservative) estimate of this effect size.�Significant interaction identified. See bottom of table.**Variable dropped from final model.††Significant interaction identified. Values reported are for the reference group in these interactions. Tables reporting the remainder of these values are availablefrom the authors upon request.OR � odds ratio; SE � standard error.
Novins et al Medical Care • Volume 42, Number 7, July 2004
ated with an increased likelihood of using traditional healingonly rather than biomedical services only.
DISCUSSIONThese results build on previous studies regarding the
use of traditional healing among American Indians and, toour knowledge, is the first study to describe the prevalenceand correlates of the use of biomedical services and tradi-tional healing from a population-based sample of this culturalgroup. Four key findings deserve further explication.
First, use of traditional healing was prevalent in bothtribes—a much higher prevalence than that reported for the useof complementary and alternative medicine among non-Ameri-can Indian samples.16,17,19 Clearly, traditional healing is animportant and independent source of care for American Indiansfrom these 2 tribes. Indeed, given this high prevalence oftraditional healing in these 2 communities and the continuity ofthese practices from precolonial times, it could be inappropriateto classify this use as complementary and alternative medicine.Instead, the World Health Organization’s designation of “tradi-tional medicine,” the name for this practice in nonallopathicsocieties, could be more appropriate for American Indians.34
Second, although the use of traditional healing wasprevalent in both tribes, we identified a number of differencesin the prevalence of the use of traditional healing and its usein combination with, or independent of, biomedical services.These tribal differences could be the result of the differinghealing traditions of these 2 tribes.25 For example, it ispossible that, because of its specificity, traditional healing inthe Southwest could be viewed as helpful for a greater varietyof physical health and psychiatric difficulties than in theNorthern Plains, and thus used more frequently. Also, themore formal organization of traditional healing in the South-west could facilitate the use of such practices. Althoughwe did not explicitly ask about the decision processesinvolved in the receipt of care in the survey portion of thisstudy reported on here, case studies developed in ourethnographic work in the Southwest and the NorthernPlains underscore the extent to which community healingresources in the Southwest can be more effectively mobi-lized for a patient because of the formally organizednetwork of traditional healers in that tribe.
Third, use of biomedical and traditional services variedby problem type with traditional healing providing a greaterproportion of care for psychiatric than for physical healthproblems. This is consistent with the literature regardingnon-American Indian populations that suggests that comple-mentary and alternative medicine is often used for mentalhealth problems.16,17,35,36 Traditional healing could beviewed as particularly helpful for psychiatric problems, re-sulting in their greater use for these difficulties. Alternatively,the stigma of psychiatric problems and biomedical servicesfor these problems could drive American Indians with these
difficulties to explore traditional healing options first beforeconsulting with a biomedical clinician.12
Fourth, the correlates of using different sources of caresuggest important sociodemographic patterns in the use ofbiomedical and traditional services in these tribes. We focushere on 2: education and ethnic identity.
Education showed several interesting associations withservice use. It appears that those American Indians withgreater exposure to this significant Western influence aremore likely to use Western-based biomedical services forphysical health problems. The relationship of education toservice use for psychiatric problems was more complex. Forexample, in the final multinomial logistic regression model,college education was associated with an increased likelihoodto use biomedical services only or traditional healing onlyrather than combined services in the Southwest. It is possiblethat college education in this tribe is associated with a greaterlikelihood of distinguishing between psychiatric problemsappropriate for biomedical treatment and those appropriatefor traditional healing. Further research is necessary to ex-plore this and other competing hypotheses such as the rela-tionships between education and stigma regarding psychiatricproblems.
The relationships of the 2 ethnic identity scales corre-sponded closely to the roots of these different types of care.It appears that individuals who identify more strongly withthese different cultures also are more likely to use the healingtraditions that have emerged from them (ie, white identitywith biomedical services and American Indian identity withtraditional services). That the spirituality scale was related tobiomedical service use for physical health and traditionalhealing for both problem types is probably related to thenature of the questions, which are relevant to both Christianand Syncretic (a fusion of traditional and Christian) beliefs.
This study has a number of important limitations. First,a number of participants had missing data (n � 489) and weretherefore excluded from these analyses. Individuals includedin these analyses were more likely to have used biomedicalservices for physical health problems than those who wereexcluded (40.9% vs. 30.9% among those excluded). Thus, wecould have overestimated the relative importance of biomed-ical services for physical health problems in this sample.Second, the data for these analyses were drawn from a studyof 2 large American Indian tribes. The results might not applyto other tribes or cultural groups. Third, although all serviceusers reported that they had a physical health and/or psychi-atric problems indicating a need for services, AI-SUPERPFPincluded additional measures of these problems as well asmeasures of adaptive functioning that were not included inthese analyses. Because of the powerful association betweenlevel of need for services and actual service use, we wereconcerned that inclusion of these variables would have ob-scured the important associations identified here. Therefore, it
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is important to note that unmeasured differences in healthstatus might explain associations found between sociodemo-graphic characteristics and utilization rates. For example,older tribal members could be more likely to have physicalhealth problems, and this could account for the relationshipbetween age and the use of biomedical services for physicalhealth problems. Future articles will address the relationshipsbetween need for services and use of biomedical and tradi-tional services in these data as well as the importance of thesesociodemographic and psychosocial correlates as the need forservices increases.
These findings have important implications for clini-cians and researchers. For clinicians, use of traditional heal-ing is likely to be common among American Indians, partic-ularly those with psychiatric problems. Clinicians shouldinclude questions about traditional healing in their assess-ments and consider with their patients the need for coordi-nating their services. For researchers, future research shouldexamine the help-seeking process,32 attitudes toward biomed-ical services and traditional healing,37 and the incorporationof traditional healing into biomedical service settings.1 Stud-ies that incorporate ethnographic approaches into their meth-ods are particularly likely to enhance our knowledge of theseissues, because they are more likely to illuminate their un-derlying dynamics,38,39 which might not fit within existingmodels of help seeking.38,40
ACKNOWLEDGMENTSAI-SUPERPFP would not have been possible without
the significant contributions of many people. The followinginterviewers, computer/data management and administrativestaff supplied energy and enthusiasm for an often difficultjob: Anna E. Baron, Antonita Begay, Amelia T. Begay, CathyA. E. Bell, Phyllis Brewer, Nelson Chee, Mary Cook, HelenJ. Curley, Mary C. Davenport, Rhonda Wiegman Dick, Mar-vine D. Douville, Pearl Dull Knife, Geneva Emhoolah, FayFlame, Roslyn Green, Billie K. Greene, Jack Herman,Tamara Holmes, Shelly Hubing, Cameron R. Joe, Louise F.Joe, Cheryl L. Martin, Jeff Miller, Robert H. Moran, Jr.,Natalie K. Murphy, Melissa Nixon, Ralph L. Roanhorse,Margo Schwab, Jennifer Settlemire, Donna M. Shangreaux,Matilda J. Shorty, Selena S. S. Simmons, Wileen Smith, TinaStanding Soldier, Jennifer Truel, Lori Trullinger, ArnoldTsinajinnie, Jennifer M. Warren, Intriga Wounded Head,Theresa (Dawn) Wright, Jenny J. Yazzie, and Sheila A.Young. The authors also acknowledge the contributions ofthe Methods Advisory Group: Margarita Alegria, Evelyn J.Bromet, Dedra Buchwald, Peter Guarnaccia, Steven G. Heer-inga, Ronald Kessler, R. Jay Turner, and William A. Vega.Finally, the authors thank the tribal members who so gener-ously answered all the questions asked of them. This studywas supported by National Institute of Mental Health grantsR01 MH48174 (S. M. Manson and J. Beals, PIs), P01
MH42473 (S. M. Manson, PI), K20 MH01253 (D. K. Novins,PI), R01 AA20110 (J. Beals, PI), and R21 AA 13053 (P.Spicer, PI).
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