Motor vehicle deaths among American Indian and Alaska Native populations

In the United States, the American Indian and Alaska Native (AI/AN) population has the highest motor vehicle death rate, which is significantly greater than that of any other race or ethnic group. To better understand why this significant disparity exists and how to eliminate it, the authors conducted a systematic review of the published scientific literature. Included studies were published between January 1, 1990, and January 31, 2011, and identified risk factors, or implemented and tested interventions, targeting motor vehicle deaths among the AI/AN population. Only 14 papers met the study's inclusion criteria. Most of the epidemiologic studies explored alcohol use as a risk factor for deaths of both motor vehicle occupants and pedestrians; few studies addressed risk factors specifically for pedestrians. All of the intervention studies focused on mitigating risks for motor vehicle occupants. On the basis of the authors' review, injury prevention interventions that are multifaceted and involve partnerships to change policy, the environment, and individual behavior can effectively mitigate motor-vehicle-related deaths among AI/ANs. Priority should be given to implementing interventions that address pedestrian safety and to sound investment in the states with the highest AI/AN motor vehicle death rates because reducing their burden can dramatically reduce the overall disparity.     

Implementing women's cancer screening programs in American Indian and Alaska Native populations

The National Breast and Cervical Cancer Early Detection Program provides funding to tribes and tribal organizations to implement comprehensive cancer screening programs using a program model developed for state health departments. We conducted a multiple-site case study using a participatory research process to describe how 5 tribal programs implemented screening services, and to identify strategies used to address challenges in delivering services to American Indian and Alaska Native women. We analyzed data from semistructured interviews with 141 key informants, 16 focus groups with 132 program-eligible women, and program documents. Several challenges regarding the delivery of services were revealed, including implementing screening programs in busy acute-care environments, access to mammography, providing culturally sensitive care, and providing diagnostic/treatment services in rural and remote locations. Strategies perceived as successful in meeting program challenges included identifying a "champion" or main supporter of the program in each clinical setting, using mobile mammography, using female providers, and increasing the capacity to provide diagnostic services at screening sites. The results should be of interest to an international audience, including those who work with health-related programs targeting indigenous women or groups that are marginalized because of culture, geographic isolation, and/or socioeconomic position.     

Self-reported asthma among American Indian and Alaska Native people in Alaska

This study describes the lifetime prevalence of self-reported asthma among American Indian and Alaska Native (AI/AN) people who participated in the Education and Research Towards Health (EARTH) study in Alaska. We conducted a cross-sectional analysis of asthma prevalence by sex and its associations with sociodemographic, health, and environmental factors. Among 3,828 AI/AN adults, we found a higher age-sex adjusted prevalence of asthma (15.4%) than is found in the general U.S. adult (11.0%) population based on the 2006 National Health Interview Survey. After multivariable analysis, self-reported asthma among men was associated with increased age, unemployment, lower income, and obesity. Among women, self-reported asthma was associated with increased age, being divorced/separated, living in Alaska's southcentral region, self-reported fair/poor health status, obesity, and indoor mold. Our data suggest that AI/AN adults have higher prevalence of lifetime asthma than the general U.S. population. Further study is necessary to understand asthma in this population.     

Asthma prevalence among American Indian and Alaska Native children.

OBJECTIVES: Although asthma is the most common chronic childhood illness in the United States, little is known about its prevalence among American Indian and Alaska Native (AI/AN) children. The authors used the latest available household survey data to estimate the prevalence of asthma in this population. METHODS: The authors analyzed data for children ages 1 through 17 years from the 1987 Survey of American Indians and Alaska Natives (SAIAN) and the 1987 National Medical Expenditure Survey (NMES). At least one member of each AI/AN household included in the SAIAN was eligible for services through the Indian Health Service. RESULTS: The weighted prevalence of parent-reported asthma was 7.06% among 2288 AI/AN children ages 1-17 (95% CI 5.08, 9.04), compared with a US estimate of 8.40% for children ages 1-17 based on the 1987 NMES (95% CI 7.65, 9.15). The AI/AN sample was too small to yield stable estimates for a comparison between AI/AN children and all US children when the data were stratified according to household income and metropolitan vs non-metropolitan residence. The unadjusted asthma prevalence rates were similar for AI/AN children and for children in the NMES sample. CONCLUSIONS: In 1987, the prevalence of parent-reported asthma was similar for AI/AN children in the SAIAN sample and for children in the NMES sample. More recent data are needed to better understand the current prevalence of asthma among AI/AN children.     

Public education strategies for delivering breast and cervical cancer screening in American Indian and Alaska Native populations.

A 1993 amendment to the authorizing legislation for the Center of Disease Control and Prevention's National Breast and Cervical Cancer Early Detection Program allows direct funding to tribal organizations and urban Native health centers. This study examined tribal programs' implementation of the public education and outreach component utilizing a multisite case study design implemented in partnership with tribal programs. Data were collected from 141 semistructured interviews with key informants and 16 focus groups with program-eligible women. Innovative strategies built on native iconography and personal encounters have encouraged participation and made the programs culturally relevant, providing insights for other communities with little experience in providing early detection services.     

Nutritional concerns in American Indian and Alaska Native children: transitions and future directions

The nutritional health of American Indian and Alaska Native children has changed dramatically over the past 30 years. The prevention and treatment of malnutrition (primarily undernutrition) was a major health issue until the mid to late 1970s. Now, a generation later, obesity in American Indian and Alaska Native children is a major health threat. In 1969, the National Institutes of Health sponsored a conference to review the nutritional status of North American Indian children and to set a national agenda to improve the nutritional health of Indian children. Subsequently, increased food availability; food assistance programs; and improved sanitation, transportation, and health care have eliminated undernutrition as a major health issue. However, the substantial reduction in undernutrition has been accompanied by a rapid increase in childhood obesity. The current epidemic of child and adult obesity and associated obesity-related morbidities, such as type 2 diabetes mellitus and other chronic diseases, has implications for the immediate and long-term health of young American Indians. This article reviews the current nutritional health of American Indian and Alaska Native children, the changes that have occurred the past 30 years, and the nutrition transition to increasing obesity and subsequent diabetes that is being seen in American Indians. Future directions to improve the health of American Indian and Alaska Native children are discussed, as is the urgent need for obesity prevention programs that are culturally oriented, family centered, and community- and school-based and that target healthful eating and physical activity beginning in childhood.     

Infectious disease hospitalizations among older American Indian and Alaska Native adults

OBJECTIVES: American Indians and Alaska Natives (AI/AN) adults > or = 65 years of age (older adults) have the second highest age group-specific infectious disease (ID) hospitalization rate. To assess morbidity and disparities of IDs for older AI/AN adults, this study examined the epidemiology of overall and specific infectious disease hospitalizations among older AI/AN adults. METHODS: ID hospitalization data for older AI/AN adults were analyzed by using Indian Health Service hospital discharge data for 1990 through 2002 and comparing it with published findings for the general U.S. population of older adults. RESULTS: ID hospitalizations accounted for 23% of all hospitalizations among older AI/AN adults. The average annual ID hospitalization rate increased 5% for 1990-1992 to 2000-2002; however, the rate increased more than 20% in the Alaska and the Southwest regions. The rate for older AI/AN adults living in the Southwest region was greater than that for the older U.S. adult population. For 2000-2002, lower respiratory tract infections accounted for almost half of all ID hospitalizations followed by kidney, urinary tract, and bladder infections, and cellulitis. CONCLUSIONS: The ID hospitalization rate increased among older AI/AN adults living in the Southwest and Alaska regions, and the rate for the older AI/AN adults living in the Southwest region was higher than that for the U.S. general population. Prevention measures should focus on ways to reduce ID hospitalizations among older AI/AN adults, particularly those living in the Southwest and Alaska regions.     

The epidemiologic evidence underlying recommendations for use of pneumococcal polysaccharide vaccine among American Indian and Alaska Native populations

Alaska Native and some American Indian (AI/AN) populations suffer disproportionately high rates of invasive pneumococcal disease (IPD) in both the pediatric and adult populations compared to the general U.S. population. Two pneumococcal vaccines are currently available in the U.S.: a 23-valent pneumococcal polysaccharide vaccine (PPSV23), available since 1983 and recommended for the elderly and those over 2 years of age with underlying medical conditions, and a 13-valent pneumococcal conjugate vaccine (PCV13), used in the routine infant immunization schedule since 2010. The U.S. Advisory Committee on Immunization Practice (ACIP) previously recommended use of PPSV23 for persons living in special environments or social settings, including AN and certain AI persons 2-64 years of age, on the basis of higher disease rates. The recommendation for routine PPSV23 use among AI/AN persons <65 years of age, regardless of underlying conditions, was removed in 2008, although the option for use among those 50-64 years of age living in areas with high pneumococcal disease rates was maintained. The rationale for the revised recommendations lay in the recognition that much of the excess disease burden occurs among those with an existing medical indication for PPSV23. Other considerations for the change were the potential risks of giving multiple PPSV23 doses and the considerable heterogeneity in pneumococcal disease risk among American Indian populations requiring a more tailored approach to local recommendations based on local epidemiology.     

Reforming American Indian/Alaska Native health care financing: the role of Medicaid

Chronic underfunding of American Indian and Alaska Native (AIAN) health care by the federal government has weakened the capacity of the Indian Health Service, tribal governments, and the urban Indian health delivery system to meet the health care needs of the AIAN population. I describe the current role of Medicaid in financing health care services for American Indians/Alaska Natives and offer 3 suggestions for reforming Medicaid financing of AIAN health care: (1) apply a 100% federal matching rate to the cost of Medicaid services furnished by urban Indian health programs; (2) apply a 100% federal matching rate to the cost of Medicaid services furnished by referral to AIAN patients of hospitals or clinics operated by the Indian Health Service, tribes, tribal organizations, or urban Indian health programs; and (3) exempt AIAN Medicaid beneficiaries who receive services from such hospitals or clinics from state reductions in Medicaid eligibility and benefits.     

Use of sexual health services among American Indian and Alaska Native Women

Because use of sexual health services among American Indian/Alaska Native women is understudied we: (1) examined disparities in use of sexual health services between American Indian/Alaska Native and non-Hispanic white women and (2) identified factors associated with service use among American Indian/Alaska Native women. We used data from the National Survey of Family Growth regarding the use of sexual health services collected between 2006 and 2010 from women aged 15–44 years who self-identified as American Indian/Alaska Native (n = 819) and white (n = 6,196). Weighted logistic regression models estimated the likelihood of reporting the use of sexual health services by race and factors associated with use in the American Indian/Alaska Native sample. Compared to whites, American Indian/Alaska Native women were less likely to use birth control services and more likely to use services for sexually transmitted diseases and HIV. Among American Indian/Alaska Natives, younger women were more likely to use birth control services, and women who had a higher number of sexual partners were more likely to use services for sexually transmitted diseases and HIV. Our results provide a national baseline against which to assess disparities and changes in the use of sexual health services among American Indian/Alaska Native women over time.     

Strategies for Successful Retention of Alaska Native and American Indian Study Participants

This paper reports the strategies used to track and follow 3,828 Alaska Native and American Indian study participants in the city of Anchorage and more rural areas of Alaska and provides characteristics of respondents and non-respondents. Over 88% were successfully followed-up, with 49% of respondents completed in three or fewer attempts. Follow-up completion rates were significantly higher for women, those living in a rural area, over age 55, married, employed, having a higher household income, and at current residence for more than five years. Follow-up of large numbers of Alaska Native and American Indian people living in geographically diverse areas is feasible, although challenging. Successful strategies to avoid attrition include using telephones as the primary method of contact; using a computerized contact relationship management system to track efforts and manage data; obtaining contact information from participant contact networks, medical records, and community networks; using local village interviewers to contact participants without telephone service; and mailing paper questionnaires to participants who are incarcerated or use social services.     

American Indian/Alaska Native Uninsurance Disparities: A Comparison of 3 Surveys

Objectives. We examined whether 3 nationally representative data sources produce consistent estimates of disparities and rates of uninsurance among the American Indian/Alaska Native (AIAN) population and to demonstrate how choice of data source impacts study conclusions.Methods. We estimated all-year and point-in-time uninsurance rates for AIANs and non-Hispanic Whites younger than 65 years using 3 surveys: Current Population Survey (CPS), National Health Interview Survey (NHIS), and Medical Expenditure Panel Survey (MEPS).Results. Sociodemographic differences across surveys suggest that national samples produce differing estimates of the AIAN population. AIAN all-year uninsurance rates varied across surveys (3%–23% for children and 18%–35% for adults). Measures of disparity also differed by survey. For all-year uninsurance, the unadjusted rate for AIAN children was 2.9 times higher than the rate for White children with the CPS, but there were no significant disparities with the NHIS or MEPS. Compared with White adults, AIAN adults had unadjusted rate ratios of 2.5 with the CPS and 2.2 with the NHIS or MEPS.Conclusions. Different data sources produce substantially different estimates for the same population. Consequently, conclusions about health care disparities may be influenced by the data source used.Access to quality health care is a priority for the nation. Access to such care is designated in Healthy People 2010 as one of the 10 Leading Health Indicators, marking it as a priority area for improving the health of the nation¹ and reducing health disparities.² American Indians/Alaska Natives (AIANs) are one group that continues to have substantial health disparities compared with other racial groups.^3–8 However, disparities in health care coverage and access for AIANs have received only intermittent attention,^9–13 leaving a marked gap in our understanding. Previously documented issues for research on AIAN health care disparities include gaps in data availability for AIANs^14,15 as well as problems with national-level estimates masking the differences across geographic areas.^13,16 However, it is also possible that there are differences in the magnitude of estimates or the conclusions drawn, depending on which data source is used to examine health care disparities.Because no single data source contains all possible measures of health and health care, different data sources are often used to answer complementary but different questions. In the case of national surveillance and annual snapshot reports, information from numerous data sources are used to present a more complete picture of health for the US population. Healthy People 2010 uses National Health Interview Survey (NHIS) data to monitor insurance coverage and access to a usual source of care and uses National Vital Statistics System data to monitor access to prenatal care.¹ In the chapter on access to care, the National Healthcare Disparities Report also uses NHIS data to examine uninsurance and access to a usual source of care but uses the Medical Expenditure Panel Survey (MEPS) to examine all-year uninsurance and access to a primary care provider.¹⁷ A few recent studies that examined health care access for AIANs used other data sources, such as the National Survey of America''s Families¹² or the Behavioral Risk Factor Surveillance Survey.¹³We use 3 general population surveys commonly used for health care coverage and access research to examine the implications of using different data sources for estimating health care disparities specific to AIANs. We use uninsurance disparities as an example but acknowledge at the outset that different data sources measure insurance coverage in different ways. Our purpose is not to critically review measures of uninsurance or to critique the surveys that collect these data. Rather, we aim to demonstrate that choice of data source matters for disparities research, often for a variety of reasons. Our intent is 2-fold: (1) to examine whether 3 nationally representative data sources produce trustworthy and consistent estimates of the AIAN population in the United States and (2) to highlight the impact that choice of data source can have on conclusions about uninsurance disparities.     

Differences in asthma prevalence between samples of American Indian and Alaska Native children

OBJECTIVES: To better understand the prevalence of asthma among American Indian and Alaska Native (AI/AN) children and to explore the contribution of locale to asthma symptoms and diagnostic assignment, the authors surveyed AI/AN middle school students, comparing responses from metropolitan Tacoma, Washington (metro WA) and a non-metropolitan area of Alaska (non-metro AK). METHODS: Students in grades 6-9 completed an asthma screening survey. The authors compared self-reported rates of asthma symptoms, asthma diagnoses, and health care utilization for 147 children ages 11-16 self-reporting as AI/AN in metro WA and 365 in non-metro AK. RESULTS: The prevalences of self-reported asthma symptoms were similar for the metro WA and non-metro AK populations, but a significantly higher percentage of metro WA than of non-metro AK respondents reported having received a physician diagnosis of asthma (OR 2.33; 95% CI 1.23, 4.39). The percentages of respondents who reported having visited a medical provider for asthma-like symptoms in the previous year did not differ. CONCLUSIONS: The difference in rates of asthma diagnosis despite similar rates of asthma symptoms and respiratory-related medical visits may reflect differences in respiratory disease patterns, diagnostic labeling practices, or environmental factors. Future attempts to describe asthma prevalence should consider the potential contribution of non-biologic factors such as diagnostic practices.     

Disparities in infectious disease hospitalizations for American Indian/ Alaska Native people

Objectives

We described disparities in infectious disease (ID) hospitalizations for American Indian/Alaska Native (AI/AN) people.

Methods

We analyzed hospitalizations with an ID listed as the first discharge diagnosis in 1998–2006 for AI/AN people from the Indian Health Service National Patient Information Reporting System and compared them with records for the general U.S. population from the Nationwide Inpatient Survey.

Results

The ID hospitalization rate for AI/AN people declined during the study period. The 2004–2006 mean annual age-adjusted ID hospitalization rate for AI/AN people (1,708 per 100,000 populiation) was slightly higher than that for the U.S. population (1,610 per 100,000 population). The rate for AI/AN people was highest in the Southwest (2,314 per 100,000 population), Alaska (2,063 per 100,000 population), and Northern Plains West (1,957 per 100,000 population) regions, and among infants (9,315 per 100,000 population). ID hospitalizations accounted for approximately 22% of all AI/AN hospitalizations. Lower-respiratory--tract infections accounted for the largest proportion of ID hospitalizations among AI/AN people (35%) followed by skin and soft tissue infections (19%), and infections of the kidney, urinary tract, and bladder (11%).

Conclusions

Although the ID hospitalization rate for AI/AN people has declined, it remains higher than that for the U.S. general population, and is highest in the Southwest, Northern Plains West, and Alaska regions. Lower-respiratory-tract infections; skin and soft tissue infections; and kidney, urinary tract, and bladder infections contributed most to these health disparities. Future prevention strategies should focus on high-risk regions and age groups, along with illnesses contributing to health disparities.Infectious diseases (IDs) have historically caused widespread morbidity and mortality both worldwide and in the United States.^1–3 IDs remain a public health issue and are of particular concern for the American Indian/Alaska Native (AI/AN) population, which has had excessive ID morbidity and mortality for several decades.^4–9 Both hospitalizations and outpatient visits due to IDs have been disproportionately higher in the AI/AN population compared with the U.S. population.^7,10–13 These disparities affect all ages, especially infants and older adults.^6,8,13 Studies of specific IDs, including lower-respiratory-tract infections (LRTIs), diarrhea-related infections, and skin and ear infections, have also shown a disparity between AI/AN people and the general U.S. population.^{10,11,14–16} However, the trends and disparities of ID hospitalizations for AI/AN people have not been analyzed since an evaluation of 1994 ID hospitalizations.⁷We determined the epidemiology and trends of ID hospitalizations for AI/AN people in 1998–2006 using Indian Health Service (IHS) inpatient data to assess any changes in their ID burden, and to determine high-risk regions and age groups that should be targeted for further intervention. We also compared the trends and rates for AI/AN people with those for the general U.S. population to determine whether health disparities in ID hospitalizations remain for AI/AN people.     

Occupational and environmental exposures among Alaska Native and American Indian people living in Alaska and the Southwest United States

Most occupational and environmental research describes associations between specific occupational and environmental hazards and health outcomes, with little information available on population-level exposure, especially among unique subpopulations. The authors describe the prevalence of self-reported lifetime exposure to nine occupational and environmental hazards among 11,326 American Indian and Alaska Native (AI/AN) adults enrolled in the Education and Research Towards Health (EARTH) Study in the Southwest U.S. and Alaska. The top three hazards experienced by AI/AN people in Alaska were petroleum products, military chemicals, and asbestos. The top three hazards experienced by AI/AN living in the Southwest U.S. were pesticides, petroleum, and welding/silversmithing. The study described here found that male sex, lower educational attainment, AI/AN language use, and living in the Southwest U.S. (vs. Alaska) were all associated with an increased likelihood of hazard exposure. The authors' study provides baseline data to facilitate future exposure-response analyses. Future studies should measure dose and duration as well as environmental hazards that occur in community settings.     

The Health of American Indian and Alaska Native Women,Infants and Children

Maternal and Child Health Journal -