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

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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

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]

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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