Month: November 2016

Health Disparities Among American Indians and Alaska Natives: Enormous Hurdles and Opportunities to Advance Health Status

By Linda Burhansstipanov, M.S.P.H., Dr.P.H.
Founder, Native American Cancer Research Corporation and President, Native American Cancer Initiatives, Inc., Pine, Colorado

Linda U. Krebs, RN, Ph.D., AOCN, FAAN
Associate Professor (retired), College of Nursing, University of Colorado at Denver, Anschutz Medical Campus

American Indians and Alaska Natives (AI/ANs) have long experienced lower health status than other U.S. populations do. AI/ANs born in 2011 have a lower life expectancy than all other U.S. populations (73.7 years vs. 78.1 years).[1] The poverty level among AI/ANs is nearly twice that of the overall U.S. population, and only half as many AI/ANs have health insurance.

linda-b-1

Dr. Linda Burhansstipanov

The socioeconomic conditions where people live and work have a substantial influence on health, and effects are cumulative over a lifetime.[2],[3] In the United States, educational attainment and income are the indicators most commonly used to measure the effect of socioeconomic status on health.3 Compared with other populations, AI/ANs are more likely to have lower socioeconomic status and to live in poverty, leading to less access to cancer prevention and screening and other healthcare services. Additionally, 20 percent of AI/ANs have not completed high school, compared with 8 percent of non-Hispanic Whites. Not completing high school has been associated with unhealthy and risk-taking behaviors.

Adult AI/ANs have behaviors and co-morbidities that increase their risk for cancer and other chronic conditions. They are more likely to be obese, use commercial tobacco, and have diabetes or high blood pressure.[4] Centers for Disease Control and Prevention (CDC) data reported that more than ¼ (29.5 percent) of AI/ANs reported having no healthcare provider, compared with 18.9 percent for whites and 24.2% of AI/ANs report having no healthcare coverage as compared with 12.5 percent for whites.[5]

 

Dr. Linda U. Krebs

Frequently, AI/ANs are also physically inactive. For example, one third of participants in the Education and Research Towards Health Study did not meet current physical activity recommendations; a high proportion were completely sedentary during leisure time.[6]

The Indian Health Service (IHS) reported that AIAN cancer screening rates were significantly lower than in the overall population, with only 59 percent receiving cervical screening, 48 percent breast screening, and 37 percent completing colorectal screening, leading to increased risk of late diagnosis and decreased survival from cancer.[7]

 What does this mean for AI/ANs? These data tell us we need:

  • Tobacco prevention programs and interventions, starting early with pregnant mothers as well as elementary school students
  • Tobacco control and cessation programs targeting adolescents and adults
  • Physical activity/exercise programs, starting with pregnant mothers
  • Environmental safety programs (e.g., safe well water, pollution and contamination reduction)
  • Cancer screening programs
  • Cancer survivorship programs, including resources that are culturally relevant for AI/AN cancer survivorship plans
  • Palliative care and end-of-life programs that are culturally and geographically relevant
  • Genetic studies on molecular markers or alleles that may contribute to or interfere with cancer medicines and treatments
  • Clinical trial recruitment and retention protocols that address barriers to participation (e.g., high blood pressure, cost of medications, lengthy travel to in-person clinic sessions)

Although AI/ANs continue to struggle with health inequities, they have many strengths. AI/ANs need interventions that build upon these strengths rather than repeatedly focusing on weaknesses. This community has survived hundreds of years of invasion and has the potential to continue to thrive as strong Native Peoples. Their traditions honor and respect their elders and families (despite historical trauma and community dysfunction). Their communities have strong foundations and emphasize the need to be healthy again like their ancestors by continuing to use native languages, consuming traditional foods, reserving tobacco for ceremonial uses only, and taking part in daily prayers, healing rituals (e.g., sweat lodges), and formal ceremonies (e.g., Green Corn, Stomp Dance, Sun Dance) as part of organized religions. These strengths affect AI/AN spirits, minds, emotions, bodies, and social interactions and contribute to the balance of these for health and wellness.

References

[1]     IHS. IHS fact sheets. Indian Health Service website. https://www.ihs.gov/newsroom/factsheets/disparities/ Published 2016.

[2]     Beckles GL, Truman BI, CDC. Education and income—United States, 2009 and 2011. MMWR Suppl. 2013; 62(3): 9-19.

[3]     CDC. CDC health disparities and inequalities report—United States, 2013. MMWR Suppl. 2013; 62(3): 1-187. http://www.cdc.gov/MMWR/pdf/other/su6203.pdf

[4]     Yurgalevitch SM, Kriska AM, Welty TK, Go O, Robbins DC, Howard BV. Physical activity and lipids and lipoproteins in American Indians ages 45-74. Med Sci Sports Exerc. 1998; 30(4): 543-549.

[5]     Cobb N, Espey D, King J. Health behaviors and risk factors among American Indians and Alaska Natives, 2000-2010 [published online April 22, 2014]. Am J Public Health. 2014; e1-e9. doi:10.2105/AJPH.2014.301879.

[6]     Duncan Glen E, Goldberg, Jack, Buchwald, Dedra, Wen, Yang and Henderson, Jeffrey A. Henderson. Epidemiology of Physical Activity in American Indians in the Education and Research Towards Health Cohort. American Journal Preventive Medicine, 2009. December 37(6): 488-494. Doi: 10.1016/j.amerpre.2009.07.13

[7]     https://www.ihs.gov/default/assets/File/GPRA/2010_12AreaReport_FINAL.pdf (cited   11/21/2016)

 

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Mental Health Risk Factors and Interventions for American Indian and Alaska Native People

By Spero M. Manson, Ph.D.
Distinguished Professor of Public Health and Psychiatry; Director, Centers for American Indian and Alaska Native Health; and The Colorado Trust Chair in American Indian Health and Associate Dean for Research at the Colorado School of Public Health, University of Colorado Denver

Over the past 20 years, as research on alcohol, drug, and mental health disorders has advanced, scientific inquiry among American Indian and Alaska Native (AI/AN) people has shifted from a primary focus on describing the prevalence of such problems to explorations of ways to address well-documented health disparities.

smmanson_portraitOne example involves detecting and managing depression and subsequent alcohol and substance abuse, risk of suicide, and, more recently, trauma among patients in large primary care settings operated by tribal health programs. In 2001, the Southcentral Foundation’s Primary Care Center in Anchorage, Alaska, initiated Screening, Brief Intervention, and Referral for Treatment (SBIRT) among Alaska Native patients age 18 and older.1 Their efforts, which integrated masters-level behavioral health clinicians within the care teams, demonstrated that such evidence-based practices could be tailored to this population in scientifically sound and clinically meaningful ways.2 Over a 5-year period beginning in 2004, 55 percent of the 8,000 patients who scored positive for alcohol use disorder agreed to follow-up treatment. Thanks to those results, the state of Alaska authorized Medicaid reimbursement for SBIRT, leading to the service becoming fully self-sustainable. This approach has been expanded to other tribal primary care settings in Alaska and in rural, reservation, and urban clinics in the lower 48 states. It now includes AI/AN youth ages 12 to 17 and covers other conditions, notably suicide risk and trauma.3

A second example arose in response to the widespread lack of access to mental healthcare in rural, isolated Native communities. In 1999, I co-developed a pilot project with funding from the Veterans Health Administration that deployed real-time, interactive videoconferencing to increase tribal veterans’ access to treatment resources.4 The effort proved remarkably successful and was singled out by Telehealth Magazine as one of the 10 best telemedicine programs in the United States, well before use of such technologies to address the mental health needs of disadvantaged populations became common. Research sponsored by the National Institute on Minority Health and Health Disparities documented the effort’s organization, process, clinical reliability, treatment, and cost outcomes and justified its expansion across the country.5 The U.S. Department of Veterans Affairs now funds 12 telepsychiatry clinics co-located in tribal veterans centers and Indian Health Service primary care clinics that serve hundreds of patients and family members.

A third example reflects increasing attention to the role of anxiety, depression, and trauma in the risk, prevention, and treatment of chronic physical health conditions such as diabetes and cardiovascular disease, which occur with alarming frequency among Native people. Supported by the National Institute of Diabetes and Digestive and Kidney Diseases, my colleagues and I examined the association of psychological distress, coping skills, family support, trauma exposure, and spirituality with initial weight and weight loss among participants in the Special Diabetes Program for Indians’ Diabetes Prevention Program, which was implemented at 36 Indian health care programs across the country.6 Psychological distress and negative family support were linked to greater weight at the beginning of the study, while cultural spirituality was correlated with lower weight. Furthermore, over the course of the intervention, psychological distress and negative family support predicted less weight loss, and positive family support predicted greater weight loss. These findings demonstrate the influence of psychosocial factors on weight loss in AI/AN communities and have substantial implications for incorporation of additional intervention components.

These exciting advances, all supported in part by the National Institutes of Health (NIH), illustrate how the emphasis and scope of alcohol, drug, and mental health research among Native people have evolved over the last two decades. They represent the continued marriage of good science with local benefit, consistent with the expectations of NIH and tribal communities.

References

1Dillard DA, Muller CM, Smith JJ, Hiratsuka VY, Manson SM. The impact of patient and provider factors on depression screening of American Indian and Alaska Native people in primary care. J Prim Care Community Health. 2012; 3:120-124.

2Hiratsuka VY, Smith JJ, Norman SM, Manson SM, Dillard DA. Guideline concordant detection and management of depression among Alaska Native and American Indian people in primary care. Int J Circumpolar Health. 2015; 74: 28315. doi: 10.3402/ijch.v74.28315

3Hiratsuka VY, Moore L, Dillard DA, et al. Development of a screening and brief intervention process for symptoms of psychological trauma among primary care patients of two American Indian and Alaska Native health systems. J Behav Health Serv Res. 2016 doi: 10.1007/s11414-016-9519-6.

4Shore JH, Brooks E, Anderson H, et al. Characteristics of telemental health service use by American Indian veterans. Psychiatr Serv. 2012; 63(2): 179-181.

5Shore JH, Brooks E, Savin D, Manson SM, Libby A. An economic evaluation of telehealth and in-person data collection with rural and frontier populations. Psychiatr Serv. 2007; 58(6): 830-835.

6Dill EJ, Manson SM, Jiang L, et al. Psychosocial predictors of weight loss among American Indian and Alaska Native participants in a diabetes prevention translational project. J Diabetes Res. 2016; 1546939. doi: 10.1155/2016/1546939.

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