Insights in Public Health

Background

There are approximately 370 million Indigenous Peoples worldwide, making up 6% of the world's population.¹ Indigenous People experience grave disparities, such as worse health outcomes, higher representation amongst the poor and disadvantaged, lower life expectancies, and limited success in improving disparities.^2–7 Many of the current inequalities are the result of historical, national, and local policies designed to eliminate and/or assimilate Indigenous People.^2–5

Hawai‘i's Indigenous People suffer some of the worst health disparities and socioeconomic status compared to other populations residing in the State. Native Hawaiians live 13 years less than those with greatest life expectancy⁸ and have a high infant mortality rate, which is more than twice that of Caucasians (7.9 versus 3.5 per 1,000 live births).^9,10 Significant contributors to the infant mortality disparity are education, age and smoking; all of which could be improved with education and support services. Cardiovascular disease mortality is double and diabetes related mortality is three times higher than Caucasians.¹¹

In an effort to address the disparities faced by Native Hawaiians and other Indigenous Peoples, the University of Hawai‘i, Office of Public Health Studies has recently launched a specialization in Native Hawaiian and Indigenous Health (NHIH) within the Master of Public Health (MPH) degree. The need for such a program was identified by existing MPH students who felt the application of public health tools to serve the Native Hawaiian and Indigenous community did not meet its full potential. This specialization is designed to prepare students with public heath skills and training necessary to serve Indigenous People globally and assist in addressing their health and wellness needs by contextualizing health determinants within historical and political frameworks. In addition, the specialization will provide extensive training in culturally sensitive research ethics which is critical for safely and effectively implementing public health research and programs aimed to address and eliminate the inequities faced by Indigenous People.^12,13

Public Health Competencies for Indigenous Health

The Core Competencies for Public Health Professionals were developed to help strengthen the public health workforce.^14,15 The core competencies represent a set of skills, knowledge, and attitudes necessary for the broad practice of public health in the United States. They transcend the boundaries of specific disciplines within public health and help to unify the profession.

Because the historical and political context for Indigenous People differs substantially from the mainstream population in which they are domestically dependent, public health professionals serving Indigenous Peoples may require an additional layer of skills and competencies. As an emerging field, there is no consensus on the knowledge, skills, and abilities of Indigenous public health professionals. Professional competencies have been identified by various disciplines serving Indigenous People, such as the First Nations, Inuit, Métis Health Core Competencies.¹⁶ These competencies were developed to provide undergraduate medical education guidance on health knowledge, skills and attitudes to engage both patient and community-centered approaches to health care delivery for First Nations, Inuit, Métis (FN/I/M) Peoples. Like the FN/I/M health core competencies, the development of Indigenous public health competencies is critical to support all levels of public health professionals serving Indigenous People. Proficiency in these competencies will enable today's public health professionals to leverage the history of Indigenous People, combined with knowledge of the law, policy, health provision, culture and traditions as they relate to improving the health and wellness of Indigenous People.

In an effort to address this need for Indigenous public health competencies, international Indigenous health leaders convened a meeting in July 2011 to discuss competencies essential for the practice of Indigenous public health. Hosted by the University of Hawai‘i, scholars from Canada, the United States, Australia and New Zealand gathered to discuss a collaborative project for improving Indigenous health. They agreed by consensus that developing a core competency model for Indigenous public health would be their focus and named the project CIPHER, which stands for Competencies for Indigenous Public Health, Evaluation and Research. The core competency model is intended to promote cultural safety practices and influence Indigenous health policy, public health education, health service mandates, research methodology, and program evaluation.

The CIPHER group created a working list of competencies that would; (a) Define the discipline of Indigenous public health; (b) Provide a framework for Indigenous public health training and career development; and (c) Entwine traditional knowledge—including relationship-based and Indigenous value-driven ideologies and protocols—with current public health acumen, to include Indigenous viewpoints, community-level involvement, and systems-wide change management (Table 1).

Table 1.

Indigenous Public Health Competencies

1. Describe Indigenous People's health in a historical context and analyze the impact of colonial processes on health outcomes.

2. Analyze key comparative health indicators and social determinants of health for Indigenous Peoples.

3. Critically evaluate Indigenous public health policy and programs.

4. Apply the principles of economic evaluation to Indigenous programs with a particular focus on the allocation of resources relative to need.

5. Demonstrate a reflexive public health practice for Indigenous Peoples' health contexts.

6. Demonstrate a disease prevention strategy which values and incorporates Indigenous Peoples' traditional knowledge.

These Indigenous Public Health Competencies are central to the development of the University of Hawai‘i's MPH NHIH specialization. Students enrolled in the NHIH specialization are required to take advanced level training in Indigenous health policy, ethics and research design. In addition, students will participate in on-going research programs with Indigenous communities through a practicum assignment.

The NHIH specialization was officially launched in early March and will receive its first cohort in the fall semester of 2013. Applications are being accepted on an on-going basis. Students who would like to apply are expected to demonstrate their commitment to community service by providing a letter of support for their application by a community willing to continue the student's learning with them either through an internship or employment opportunity.

All specializations in the accredited MPH program are expected to complete core courses that count for 17 credits. Core MPH coursework, specialization requirements and personal electives total 42 credits required for graduation. For the NHIH specialization, there are 16 required specialization credits, which is comparable to other specializations. An integrative seminar is part of those credits and will serve a few specific purposes. For example, due to the close relationships students may have with the communities with whom they work, the dual expectations of being both a health professional and community member can present unique challenges and opportunities. This integrative seminar will create a space for students, professors and other faculty to navigate the unique context of NHIH health. Additionally the seminar is going to challenge students to merge their learning and practical experiences into new knowledge that can be disseminated locally, and appropriately with interested communities as well as internationally though publication and targeted conference settings, among others.

As other specializations, MPH students in the NHIH track complete a required practicum or internship. The practicum experiences ideally will provide an opportunity to work with their own or another Indigenous community. The program is working with partners in Australia, Canada, New Zealand and the United States to create international practicum opportunities.

The program aims to enroll individuals who are passionate and sincere in using and creating knowledge and skills to improve the conditions in which the lives and well-being of NHIH are influenced. We invite people who are ready to work hard and are dedicated to understanding the complex determinants of health. The goal of all this is to provide students with an exciting learning experience so that they can make a positive impact when they work with their own or other Indigenous communities.

Summary

The Native Hawaiian and Indigenous Health MPH is a new specialization in that it will be available to University of Hawai‘i public health students in fall 2013. The curriculum integrates Indigenous Public Health Competencies with traditional competencies to help build a stronger, more effective public health workforce in Native Hawaiian and Indigenous communities. The NHIH specialization will prepare students for leadership roles in Indigenous health policy and culturally safe health services. Graduates will better meet the social and cultural needs of Indigenous People, thereby enhancing the quality and effectiveness of those health services and policies. The improved quality and effectiveness of Indigenous health services will contribute to the reduction of Indigenous health disparities and the improvement of Indigenous Peoples' health.