A Nationwide Population-Based Study Identifying Health Disparities Between American Indians/Alaska Natives and the General Populations Living in Select Urban Counties

Article (PDF Available)inAmerican Journal of Public Health 96(8):1478-84 · September 2006with37 Reads
DOI: 10.2105/AJPH.2004.053942 · Source: PubMed
Abstract
Despite their increasing numbers, little is known about the health of American Indians/Alaska Natives living in urban areas. We examined the health status of American Indian/Alaska Native populations served by 34 federally funded urban Indian health organizations. We analyzed US census data and vital statistics data for the period 1990 to 2000. Disparities were revealed in socioeconomic, maternal and child health, and mortality indicators between American Indians/Alaska Natives and the general populations in urban Indian health organization service areas and nationwide. American Indians/Alaska Natives were approximately twice as likely as these general populations to be poor, to be unemployed, and to not have a college degree. Similar differences were observed in births among mothers who received late or no prenatal care or consumed alcohol and in mortality attributed to sudden infant death syndrome, chronic liver disease, and alcohol consumption. We found health disparities between American Indians/Alaska Natives and the general populations living in selected urban areas and nationwide. Such disparities can be addressed through improvements in health care access, high-quality data collection, and policy initiatives designed to provide sufficient resources and a more unified vision of the health of urban American Indians/Alaska Natives.
American Journal of Public Health | August 2006, Vol 96, No. 81478 | Research and Practice | Peer Reviewed | Castor et al.
RESEARCH AND PRACTICE
Objectives. Despite their increasing numbers, little is known about the health
of American Indians/Alaska Natives living in urban areas. We examined the health
status of American Indian/Alaska Native populations served by 34 federally funded
urban Indian health organizations.
Methods. We analyzed US census data and vital statistics data for the period
1990 to 2000.
Results. Disparities were revealed in socioeconomic, maternal and child health,
and mortality indicators between American Indians/Alaska Natives and the gen-
eral populations in urban Indian health organization service areas and nation-
wide. American Indians/Alaska Natives were approximately twice as likely as
these general populations to be poor, to be unemployed, and to not have a col-
lege degree. Similar differences were observed in births among mothers who
received late or no prenatal care or consumed alcohol and in mortality attributed
to sudden infant death syndrome, chronic liver disease, and alcohol consumption.
Conclusions. We found health disparities between American Indians/Alaska Natives
and the general populations living in selected urban areas and nationwide. Such
disparities can be addressed through improvements in health care access, high-
quality data collection, and policy initiatives designed to provide sufficient resources
and a more unified vision of the health of urban American Indians/Alaska Natives.
(Am J Public Health. 2006;96:1478–1484. doi:10.2105/AJPH.2004.053942)
A Nationwide Population-Based Study Identifying
Health Disparities Between American Indians/Alaska Natives
and the General Populations Living in Select Urban Counties
| Mei L. Castor, MD, MPH, Michael S. Smyser, MPH, Maile M. Taualii, MPH, Alice N. Park, MPH, Shelley A. Lawson, MPA, and Ralph A. Forquera, MPH
Over the past 3 decades, American Indians and
Alaska Natives have increasingly relocated from
rural and reservation communities to the urban
centers of the United States. Census data show that
61%ofAmerican Indians/Alaska Natives resided
in these areas in 2000, up from 38% in 1970.
1
Such demographic shifts are related to the
federal relocation and termination policies of
the 1950s, as well as the educational, em-
ployment, and housing opportunities that exist
in urban settings.
2
Although urban living offers more of cer-
tain opportunities, the departure of American
Indians/Alaska Natives from reservations
has typically resulted in a loss of access to
health care, historically provided by the In-
dian Health Service (IHS).
3
To provide health
care for the increasingly urban American
Indian/Alaska Native (AIAN) population, the
IHS awards contracts and grants to 34 non-
profit agencies located in major metropolitan
areas across the United States. These agen-
cies, referred to as urban Indian health organ-
izations (UIHOs), exist largely in cities desig-
nated in the past as AIAN relocation sites by
the federal government.
Despite the increasing numbers of urban
American Indians/Alaska Natives, little is
known about their health. It is difficult to iden-
tify and target this group because of the geo-
graphic dispersal and small numbers of urban
American Indians/Alaska Natives relative to
the general population of the United States.
Also, unlike reservation populations, the urban
AIAN population comprises multiple tribal
groups with diverse ethnic, cultural, and social
characteristics. Political diversity exists between
tribes that may or may not be recognized by
the federal government or state governments.
Moreover, degrees of urban acculturation vary,
and movement around urban centers may be
high as a result of feelings of social and cultural
isolation associated with nonreservation living.
Finally, in some regions of the country,
American Indians/Alaska Natives are misclas-
sified on vital statistics records.
4,5
Such errors
result in consistent underestimation of AIAN
rates of infant mortality, injuries, cancer, and
overall mortality; some rates are as much as
47% higher after correction for miscoding.
6–9
Studies also indicate a greater likelihood of ra-
cial misclassification when American Indians/
Alaska Natives die in urban settings.
7,10
A few studies have addressed the health
status of urban American Indians/Alaska
Natives but only on a local or regional basis.
One population-based investigation compared
urban American Indians/Alaska Natives with
other urban racial groups residing in a metro-
politan area of Washington State. Disparities
were found between urban American Indians/
Alaska Natives and urban Whites in rates of
low birthweight, risk factors for poor birth
outcomes, communicable diseases, mortality
among nonelderly individuals, injuries, and
alcohol-related deaths.
11
The results of other
studies have confirmed the disparities found
between these 2 urban groups.
12 , 13
There is also little information available on
the urban AIAN population targeted by the
34 federally funded UIHOs. Such informa-
tion is necessary for these organizations to al-
locate their resources effectively, customize
health care services, implement program eval-
uations, and launch policy initiatives. As a
group, UIHOs have minimal technological in-
frastructure with no shared standardized data
system that can be used to provide a collec-
tive description of their target populations.
Our primary goal was to assess the health
status of the urban AIAN population served
by UIHOs. As mentioned, this information is
critical if these organizations are to demon-
strate the effectiveness and impact of their
services. Because of the lack of data on the
UIHO patient population, data on American
Indians/Alaska Natives living in UIHO ser-
vice areas were used as a proxy for data on
American Indians/Alaska Natives served by
August 2006, Vol 96, No. 8 | American Journal of Public Health Castor et al. | Peer Reviewed | Research and Practice | 1479
RESEARCH AND PRACTICE
TABLE 1—Urban Indian Health
Organizations, by Location and Service
Area County or Counties
Service Area
Location County or Counties
Albuquerque, NM Bernalillo
Bakersfield, Calif Kern
Billings, Mont Big Horn,
a
Yellowstone
a
Butte, Mont Silver Bow
a
Chicago, Ill Cook
Dallas,Tex Collin, Dallas, Denton, Ellis,
a
Hood,
a
Johnson,
a
Kaufman,
a
Parker,
a
Rockwall,
a
Tarrant,Wise
a
Denver, Colo Adams, Arapahoe, Boulder,
a
Denver, Douglas,
a
Gilpin,
a
Jefferson
Detroit, Mich Genesee, Ingham, Kent,
Wayne
Flagstaff, Ariz Coconino
a
Fresno, Calif Fresno, Madera,
a
Tulare
Great Falls, Mont Cascade
a
Green Bay,Wis Brown,
a
Door
a
Helena, Mont Jefferson,
a
Lewis and Clark
a
Jamaica Plains, Mass Suffolk
Lincoln, Neb Douglas, Lancaster,
a
Sarpy,
a
Washington
a
(Neb);
Woodbury
a
(Iowa)
Los Angeles, Calif Los Angeles
Milwaukee, Wis Milwaukee, Waukesha
Minneapolis, Minn Hennepin, Ramsey
Missoula, Mont Missoula
a
New York, NY Bronx, Essex,
a
Kings, Nassau,
New York, Queens,
Richmond,Westchester
Oakland, Calif Alameda, Contra Costa,
Marin,
a
San Francisco,
San Mateo
Phoenix, Ariz Maricopa
Pierre, SD Brown,
a
Hughes,
a
Minnehaha,
a
Stanley
a
Portland, Ore Clackamas, Multnomah,
Washington (Ore);
Clark
a
(Wash)
Reno, NV Carson City,
a
Churchill,
a
Douglas,
a
Storey,
a
Washoe
Sacramento, Calif Sacramento
Salt Lake City, Utah Davis,
a
Salt Lake, Tooele,
a
Utah, Weber
a
San Diego, Calif San Diego
Continued
the UIHOs. In addition, their health status
was used to approximate that of the larger
urban AIAN population. By assessing stan-
dard socioeconomic, maternal and child
health, and mortality indicators, our study
also addressed the Healthy People 2010 initia-
tive to eliminate racial health disparities.
14
Specifically addressing the health of the
urban AIAN population is an important
step in including this group in efforts to im-
prove the health status of the entire AIAN
population; however, this inclusion of urban
American Indians/Alaska Natives in such ef-
forts should not minimize the importance of
nonurban AIAN populations facing similar
health disparities. To our knowledge, this is
the first nationwide population-based study
examining the health status of urban Ameri-
can Indians/Alaska Natives.
METHODS
In our analyses, we used national data
from the 2000 US census as well as death
certificate (1990–1999), birth certificate
(1991–2000), and linked infant death/natality
(1995–2000) data from the National Cen-
ter for Health Statistics (NCHS). For confiden-
tiality reasons, identifying information was
omitted from all of the vital record data we
obtained, and linked infant death/natality
data were restricted to counties with popula-
tions greater than 250000 according to
1990 US census counts.
We included all of the 34 UIHOs, which are
located in 19 states (Table 1). The overall
UIHO service area comprises 94 counties,
with the number of counties per individual ser-
vice area ranging from 1 to 11. As a result of
the exclusion of 43 counties with populations
less than 250000, we conducted linked infant
death/natality analyses on 51 (53%) of the 94
UIHO service area counties. Approximately
78% of all AIAN births and 95% of overall
births in UIHO service area counties occurred
in this combined 51-county area.
Here the term “American Indians/Alaska
Natives,” which can refer to either mixed-race
or single-race groups, is used to indicate the
single-race category unless otherwise indi-
cated. The term “general population” refers to
the overall population of the United States,
including all racial/ethnic groups. In addition,
American Indians/Alaska Natives” and “gen-
eral population” are used to identify residents
of UIHO service areas or the respective na-
tionwide populations. The nationwide general
population includes the AIAN populations
living in UIHO service areas.
The data sources examined varied in terms
of the racial categories used. In the 1990
census and the mortality, natality, and linked
infant death/natality data, 5 categories were
used: White, Black, American Indian/Alaska
Native, Asian/Pacific Islander, and other. In
the 2000 census, 6 categories were used:
White, Black, American Indian/Alaska Na-
tive, Asian, Hawaiian or other Pacific Islander,
and other; respondents could also indicate
mixed racial heritage.
Causes of death were classified according
to the International Classification of Diseases,
10th Revision (ICD-10).
15
We converted data
collected before 1999 to ICD-10based
causes using ICD-9 equivalents, adjusting
discrepancies through the use of NCHS com-
parability ratios.
16
VistaPHw software (Public Health, Seattle,
Washington) was used in conducting the
analyses.
17
Mortality rate calculations were
based on NCHS census and intercensal popu-
lation estimates (i.e., “bridged” population esti-
mates based on the 2000 census, adjusted to
reflect 1990 census racial group estimates).
18 , 19
Total population mortality rates were adjusted
to a standardized year 2000 age distribu-
tion.
20
Otherwise, standard methods were
used in calculating rate estimates.
16 ,17,20–23
Statistical significance was defined as lack of
overlap in the 95% confidence intervals be-
tween different rates. An extension of the Man-
tel–Haenszel χ
2
trend test was used to measure
the significance (P<.05) of trends observed.
24
TABLE 1—Continued
San Jose, Calif Santa Clara
Santa Barbara, Calif San Luis Obispo,
a
Santa
Barbara, Ventura
Seattle, Wash King
Spokane, Wash Spokane
Tucson, Ariz Pima
Wichita, Kan Butler,
a
Reno,
a
Sedgwick,
Sumner
a
a
Population less than 250 000.
American Journal of Public Health | August 2006, Vol 96, No. 81480 | Research and Practice | Peer Reviewed | Castor et al.
RESEARCH AND PRACTICE
TABLE 2—Socioeconomic Characteristics Among Urban American Indians/Alaska Natives, 2000
UIHO Service Area Populations, % (95% CI) Nationwide Populations, % (95% CI)
AIAN General AIAN General
Income below 100% of federal poverty level 24.1 (23.5, 24.6) 13.5 (13.5, 13.6) 25.7 (25.5, 25.9) 12.4 (12.4, 12.4)
Income below 200% of federal poverty level 48.2 (47.6, 48.9) 30.4 (30.4, 30.5) 51.4 (51.2, 51.6) 29.6 (29.6, 29.7)
Adult (18 y) income below 100% of 21.2 (20.6, 21.9) 11.8 (11.8, 11.9) 22.7 (22.5, 23.0) 10.9 (10.9, 10.9)
federal poverty level
Child (< 18 y) in family with income below 30.1 (29.1, 31.1) 18.4 (18.3, 18.5) 31.6 (31.2, 32.0) 16.6 (16.5, 16.6)
100% of federal poverty level
Education level (25 y)
High school 70.4 (69.6, 71.2) 79.6 (79.6, 79.7) 70.9 (70.6, 71.2) 80.4 (80.4, 80.4)
College 13.0 (12.4, 13.6) 28.9 (28.9, 29.0) 11.5 (11.3, 11.7) 24.4 (24.4, 24.4)
Unemployed (16 y) 11.5 (10.9, 12.1) 6.3 (6.3, 6.4) 12.3 (12.0, 12.5) 5.7 (5.7, 5.7)
Single-parent family with related children 46.1 (44.5, 47.7) 31.0 (30.8, 31.1) 43.5 (42.9, 44.2) 29.2 (29.2, 29.3)
Disability (5 y) 23.9 (23.3, 24.4) 19.1 (19.1, 19.2) 24.3 (24.1, 24.5) 19.3 (19.3, 19.4)
Note. UIHO = urban Indian health organization; CI = confidence interval; AIAN = American Indian/Alaska Native. All AIAN results
differed significantly from those of the corresponding general population. Data were derived from the US Census Bureau.
We performed data averaging to minimize
data variability and improve the stability of our
estimates. In addition, data averaging promoted
confidentiality by preventing identification of
years of occurrence in instances in which there
were small numbers of measured events. We
calculated 10-year averages for mortality
(1990–1999) and natality (1991–2000) data
and 6-year averages for infant mortality data
(1995–2000). We did not perform data aver-
aging for census data. Mortality and natality
data from UIHO service areas with fewer than
10 relevant events were excluded from UIHO-
specific analyses but were included in analyses
of the overall UIHO service area.
RESULTS
In the 2000 census, of approximately 4.1
million Americans who reported AIAN her-
itage (alone or mixed race), 60% (2.5 million)
reported AIAN heritage alone. Sixty-one per-
cent (1.5 million) of the AIAN-alone group
lived in urban areas, and 34% (500000) of
these urban residents lived in counties served
by UIHOs. The number of American Indians/
Alaska Natives living in different UIHO ser-
vice areas ranged from 700 to 77 000.
Socioeconomic Characteristics
Table 2 lists the socioeconomic characteris-
tics of American Indians/Alaska Natives and
the general populations living in UIHO service
areas and nationwide in 2000. According to
1999 figures, approximately 25% of Ameri-
can Indians/Alaska Natives living in UIHO
service areas and nationwide were members
of households with incomes below the poverty
level, a percentage roughly twice that of the
corresponding general populations. Analyses
conducted by age group showed that the high-
est poverty rates were those among AIAN
children (30%–32%).
The percentages of American Indians/
Alaska Natives with a 4-year college degree,
both in UIHO service areas and nationwide,
were less than half the percentages found for
the corresponding general populations; simi-
lar disparities were observed in unemploy-
ment rates. In addition, the percentages of
AIAN children living in UIHO service areas
and nationwide who were members of single-
parent families were substantially higher than
those of the corresponding general popula-
tions. In all UIHO service areas, AIAN rates
of poverty, unemployment, and children liv-
ing in single-parent families exceeded those
of the general population.
Nearly 1 in 4 American Indians/Alaska
Natives living in UIHO service areas and
nationwide had a disability (defined in this
study as a long-lasting physical, mental, or
emotional condition making it difficult for one
to engage in activities such as walking, climb-
ing stairs, dressing, bathing, learning, and re-
membering), compared with 1 in 5 members
of the corresponding general populations. In
all but 1 UIHO service area, the percentage
of American Indians/Alaska Natives who
were disabled exceeded the percentage ob-
served in the general population.
Maternal and Child Health
Between 1991 and 2000, of approxi-
mately 400 000 AIAN infants born nation-
wide, roughly 20% were born in UIHO ser-
vice areas. Whereas the nationwide AIAN
birth rate during this period was similar to
the general population rate (15.5 and 14.8
per 1000, respectively), the birth rate among
American Indians/Alaska Natives living in
UIHO service areas was approximately one
quarter lower than that in the general popula-
tion (12.8 and 16.5 per 1000, respectively).
Table 3 lists prevalences of poor birth out-
comes and risk factors as well as factors asso-
ciated with infant deaths. The percentages of
AIAN infants with low birthweights born to
mothers living in UIHO service areas and na-
tionwide were significantly lower than the
percentages for all mothers combined (i.e., the
general populations) in these areas. Patterns
of disparities varied between UIHO service
areas. Over time, from 1991 to 2000, low-
birthweight rates significantly increased in all
populations with the exception of American
Indians/Alaska Natives living in UIHO ser-
vice areas. Rates of premature births among
AIAN mothers living in UIHO service areas
and nationwide were higher than rates
among all mothers combined in these areas.
From 1991 to 2000, prematurity rates in-
creased significantly in all populations.
Analyses of risk factors for poor birth out-
comes revealed significant disparities between
American Indians/Alaska Natives and the
general population in birth rates among moth-
ers who were teenagers, who were unmarried,
who received late or no prenatal care, and
who smoked or consumed alcohol during
their pregnancy. Birth rates among teenage
AIAN mothers living in UIHO service areas
and nationwide were 80% higher than rates
among all teenage mothers combined. Over
time, birth rates among teenage mothers sig-
nificantly decreased in all populations with the
exception of the UIHO AIAN population.
Both in UIHO service areas and nation-
wide, AIAN mothers received late or no
August 2006, Vol 96, No. 8 | American Journal of Public Health Castor et al. | Peer Reviewed | Research and Practice | 1481
RESEARCH AND PRACTICE
TABLE 3—Poor Birth Outcomes, Risk Factors for Poor Birth Outcomes, and Factors Associated With Infant Deaths
Among American Indians/Alaska Natives: Selected Time Periods
UIHO Service Area Populations Nationwide Populations
AIAN General AIAN General
Direction of Direction of Direction of Direction of
% (95% CI) Trend (P)% (95% CI) Trend (P)% (95% CI) Trend (P)% (95% CI) Trend (P)
Risk factors for poor birth
outcomes (1991–2000)
a
Low birthweight (< 2500 g) 6.8 (6.6, 7.0) NS 7.3 (7.2, 7.3) Upward (.000) 6.6 (6.5, 6.7) Upward (.000) 7.4 (7.4, 7.4) Upward (.000)
Premature birth 12.3
b
(12.1, 12.5) Upward (.028) 10.9 (10.9, 11.0) Upward (.000) 12.2
b
(12.1, 12.3) Upward (.000) 11.2 (11.2, 11.2) Upward (.000)
Mother’s age < 18 y 8.2
b
(8.0, 8.4) NS 4.6 (4.5, 4.6) Downward (.000) 8.2
b
(8.2, 8.3) Downward (.008) 4.8 (4.8, 4.9) Downward (.000)
Mother unmarried 60.3
b
(59.8, 60.8) Upward (.000) 34.8 (34.7, 34.8) Downward (.000) 57.4
b
(57.2, 57.7) Upward (.000) 31.9 (31.9, 31.9) Upward (.000)
Mother received late or no 9.8
b
(9.6, 10.0) Downward (.000) 5.0 (5.0, 5.0) Downward (.000) 9.5
b
(9.4, 9.6) Downward (.000) 4.4 (4.4, 4.4) Downward (.000)
prenatal care
Mother smoked during 17.2
b
(16.9, 17.5) Downward (.000) 10.7 (10.7, 10.7) Downward (.000) 21.1
b
(21.0, 21.3) Downward (.000) 14.3 (14.3, 14.3) Downward (.000)
pregnancy
Mother used alcohol during 5.2
b
(5.0, 5.3) Downward (.000) 1.5 (1.5, 1.5) Downward (.000) 4.6
b
(4.6, 4.7) Downward (.000) 1.6 (1.6, 1.6) Downward (.000)
pregnancy
Factors associated with infant
deaths (1995–2000)
c
Mother unmarried 69.8
b
(61.3, 79.2) NS 49.4 (48.7, 50.1) NS 65.4
b
(62.1, 68.9) NS 47.1 (46.8, 47.5) Upward (.006)
Very low birthweight (< 1500 g) 38.9 (32.6, 46.1) Upward (.005) 51.4 (50.6, 52.1) Upward (.000) 35.1 (32.7, 37.8) Upward (.004) 51.0 (50.6, 51.3) Upward (.000)
Low birthweight (< 2500 g) 54.4 (46.9, 62.8) NS 65.7 (64.9, 66.5) Upward (.000) 49.8 (46.8, 52.9) Upward (.017) 65.3 (64.9, 65.7) Upward (.000)
Premature birth 53.6 (46.0, 62.1) NS 64.1 (63.3, 64.9) Upward (.000) 50.1 (47.1, 53.3) Upward (.033) 64.3 (63.9, 64.6) Upward (.000)
Mother smoked during 25.1
b
(19.3, 32.0) NS 15.5 (15.0, 16.0) Downward (.000) 29.6
b
(27.1, 32.3) NS 19.5 (19.3, 19.7) Downward (.000)
pregnancy
Mother’s age < 18 y 11.1
b
(7.9, 15.2) NS 7.0 (6.8, 7.3) Downward (.000) 10.1
b
(8.8, 11.6) NS 7.6 (7.4, 7.7) Downward (.000)
Mother used alcohol during 9.1
b
(5.7, 13.7) NS 2.2 (2.0, 2.4) Downward (.000) 7.4
b
(6.2, 8.8) NS 2.3 (2.2, 2.4) Downward (.000)
pregnancy
Mother received late or no 16.6
b
(12.4, 21.6) NS 9.0 (8.7, 9.3) Downward (.000) 13.9
b
(12.3, 15.7) NS 8.8 (8.6, 8.9) Downward (.000)
prenatal care
Note. UIHO = urban Indian health organization; AIAN= American Indian/Alaska Native; CI = confidence interval; NS = no statistically significant trend over the time period; Upward = significant
increasing trend over the time period; Downward = significant decreasing trend over the time period.
a
Data derived from National Center for Health Statistics natality files.
b
Significantly higher for American Indians/Alaska Natives than for the general population.
c
Data derived from National Center for Health Statistics linked birth/infant death files.
prenatal care at approximately twice the fre-
quency of all mothers combined. Also, rates
of maternal smoking were substantially
higher among American Indians/Alaska
Natives living in UIHO service areas and na-
tionwide than among all mothers combined.
Alcohol consumption rates among AIAN
mothers living in UIHO service areas were
significantly higher than rates among AIAN
mothers nationwide; both rates were approxi-
mately 3 times higher than rates among all
mothers combined in these areas.
Mortality Statistics
Table 3 presents data on several factors as-
sociated with AIAN infant deaths between
19 95 and 2000. Unmarried status was asso-
ciated with 70% of the AIAN infant deaths in
UIHO service areas and 65% nationwide.
Other associated factors included maternal
smoking, teenage motherhood, late or no pre-
natal care, and maternal alcohol consumption,
the last of which was 3 to 4 times more com-
mon among AIAN mothers living in UIHO
service areas and nationwide than among all
mothers combined in these areas.
Table 4 lists overall and cause-specific
mortality rates for infants and for individuals
of all ages. From 1995 to 2000, AIAN in-
fant mortality rates in UIHO service areas
and nationwide were higher than rates for
the corresponding general populations. Over
time, infant mortality rates significantly de-
creased in the general populations living in
UIHO service areas and nationwide; how-
ever, no such trends were observed in the
AIAN population.
From 1995 to 2000, sudden infant death
syndrome (SIDS) was the leading cause of
AIAN infant mortality in UIHO service areas.
The SIDS rates among American Indians/
Alaska Natives in UIHO service areas and
nationwide were at least twice the rates
observed in the corresponding general
populations. Over time, SIDS rates signifi-
cantly decreased in all populations with the
exception of American Indians/Alaska Na-
tives living in UIHO service areas.
American Journal of Public Health | August 2006, Vol 96, No. 81482 | Research and Practice | Peer Reviewed | Castor et al.
RESEARCH AND PRACTICE
TABLE 4—Overall and Cause-Specific Mortality Rates Among American Indians and Alaska Natives:
Selected Time Periods
UIHO Service Area Populations Nationwide Populations
AIAN General AIAN General
Rate per Direction of Rate per Direction of Rate per Direction of Rate per Direction of
100 000 (95% CI) Trend (P) 100000 (95% CI) Trend (P) 100000 (95% CI) Trend (P) 100 000 (95% CI) Trend (P)
Infant mortality 9.0
b,c
(8.1, 10.0) NS 6.8
b
(6.7, 6.8) Downward (.000) 9.1
c
(8.7, 9.5) NS 7.2 (7.2, 7.2) Downward (.000)
(1995–2000)
a
Sudden infant death 1.8
b,c
(1.4, 2.3) NS 0.7
b
(0.7, 0.7) Downward (.000) 1.7
c
(1.5, 1.8) Downward (.000) 0.8 (0.8, 0.8) Downward (.000)
syndrome
All-age/all-cause mortality 573.9 (564.3, 583.7) Downward (.000) 883.5 (882.7, 884.3) Downward (.000) 769.0 (763.7, 774.4) Upward (.001) 902.2 (901.8, 902.6) Downward (.000)
(1990–1999)
d
Heart disease 145.0 (139.8, 150.3) Downward (.002) 290.0 (289.6, 290.5) Downward (.000) 206.0 (203.0, 208.9) Downward (.000) 289.0 (288.8, 289.2) Downward (.000)
Cancer 98.0 (94.0, 102.2) NS 201.9 (201.5, 202.2) Downward (.000) 137.3 (135.0, 139.6) NS 210.1 (209.9, 210.2) Downward (.000)
Unintentional injuries 42.7
c
(40.7, 44.9) NS 31.0 (30.8, 31.1) Downward (.000) 60.4
c
(59.2, 61.6) Downward (.000) 35.5 (35.5, 35.6) Downward (.000)
Chronic liver disease/ 27.5
c
(25.9, 29.3) NS 12.2 (12.1, 12.3) Downward (.000) 25.5
c
(24.7, 26.3) NS 10.4 (10.3, 10.4) Downward (.000)
cirrhosis
Diabetes 32.0
c
(29.7, 34.4) Upward (.025) 20.8 (20.7, 20.9) Upward (.000) 44.7
c
(43.4, 46.0) Upward (.000) 22.9 (22.8, 22.9) Upward (.000)
Cerebrovascular 34.5 (32.0, 37.2) NS 61.2 (61.0, 61.5) Downward (.000) 48.8 (47.4, 50.3) NS 65.4 (65.3, 65.5) Downward (.000)
diseases
Assault (homicide) 9.0 (8.3, 9.9) Downward (.001) 11.5 (11.4, 11.6) Downward (.000) 9.5
c
(9.1, 9.9) Downward (.000) 8.2 (8.2, 8.2) Downward (.000)
Suicide 8.1 (7.3, 8.9) NS 11.2 (11.1, 11.3) Downward (.000) 10.9 (10.5, 11.4) NS 11.6 (11.6, 11.7) Downward (.000)
Chronic lower respiratory 21.8 (19.9, 24.0) NS 39.8 (39.7, 40.0) Upward (.000) 30.0 (28.9, 31.1) Upward (.000) 42.1 (42.0, 42.2) Upward (.000)
diseases
Influenza and pneumonia 20.6 (18.6, 22.8) NS 26.5 (26.3, 26.6) Downward (.000) 25.1
c
(24.0, 26.2) NS 23.8 (23.7, 23.8) Downward (.000)
Alcohol related 28.1
c
(26.5, 29.9) Downward (.001) 10.1 (10.0, 10.2) Downward (.000) 26.6
c
(25.8, 27.4) Downward (.000) 7.3 (7.3, 7.4) Downward (.000)
Drug related 9.0 (8.2, 9.9) Upward (.004) 9.4 (9.4, 9.5) Upward (.000) 6.0 (5.7, 6.3) Upward (.000) 6.2 (6.2, 6.2) Upward (.000)
Firearm related 8.0 (7.2, 8.8) Downward (.017) 14.1 (14.0, 14.1) Downward (.000) 10.5 (10.1, 10.9) Downward (.000) 13.0 (12.9, 13.0) Downward (.000)
Note. UIHO = urban Indian health organization; AIAN = American Indian/Alaska Native; CI = confidence interval; NS = no statistically significant trend over the time period; Downward = significant decreasing
trend over the time period; Upward = significant increasing trend over the time period. Cause-specific mortality rates for all ages are listed in rank order on the basis of total numbers of deaths.
a
Data derived from National Center for Health Statistics linked birth/infant death files.
b
Rate calculated only for counties with populations above 250 000 according to 1990 census.
c
Significantly higher for American Indians/Alaska Natives than for the general population.
d
Data derived from National Center for Health Statistics multiple cause of death files.
Of approximately 100000 AIAN deaths
reported nationwide from 1990 to 1999,
roughly 20% occurred among American
Indians/Alaska Natives living in UIHO ser-
vice areas. The mortality rate in the UIHO
AIAN population was substantially lower
than that in the nationwide AIAN population
(574 and 769 per 100000, respectively).
Also, the UIHO AIAN mortality rate was
lower than the rates observed in the general
population living in the UIHO service areas
(884 per 100000) and the overall US
general population (902 per 100000). From
1990 to 1999, mortality decreased signifi-
cantly in all of the populations examined
with the exception of the nationwide AIAN
population, in which there was a significant
increase. UIHO AIAN mortality rates ranged
from 120 to 1388 per 100 000.
Heart disease was the leading cause of
death in the AIAN and general populations.
As was the case with overall mortality, heart
disease mortality rates were substantially
lower among American Indians/Alaska Na-
tives living in UIHO service areas than in the
nationwide AIAN population and the corre-
sponding general populations. From 1990 to
1999, heart disease mortality rates decreased
significantly in all populations. UIHO AIAN
rates ranged from 46 to 385 per 100000.
Cancer was the second leading cause of
death among American Indians/Alaska Na-
tives living in UIHO service areas and na-
tionwide. As with overall mortality, cancer
mortality rates were substantially lower
among American Indians/Alaska Natives
living in UIHO service areas than in the na-
tionwide AIAN and corresponding general
populations. From 1990 to 1999, cancer
mortality rates decreased significantly in the
general population, whereas AIAN rates ei-
ther remained steady or increased. UIHO
AIAN cancer mortality rates ranged from 20
to 517 per 100 000.
Rates of mortality attributable to uninten-
tional injuries, chronic liver disease/cirrhosis,
diabetes, and alcohol use among American
Indians/Alaska Natives, both in UIHO ser-
vice areas and nationwide, surpassed those of
the corresponding general populations. From
19 90 to 1999, unintentional injury mortality
August 2006, Vol 96, No. 8 | American Journal of Public Health Castor et al. | Peer Reviewed | Research and Practice | 1483
RESEARCH AND PRACTICE
rates decreased significantly in all of the pop-
ulations assessed with the exception of Amer-
ican Indians/Alaska Natives living in UIHO
services areas; UIHO AIAN rates ranged
from 6 to 140 per 100000. From 1990 to
1999, chronic liver disease mortality rates
decreased significantly in the general popula-
tion; however, no such trends were observed
among American Indians/Alaska Natives.
UIHO AIAN rates ranged from 3 to 82 per
100 000. From 1990 to 1999, diabetes mor-
tality increased significantly in all popula-
tions; UIHO AIAN rates ranged from 4 to
105 per 100 000. Finally, from 1990 to
1999, mortality rates related to alcohol con-
sumption decreased significantly in all popu-
lations; UIHO AIAN rates ranged from 3 to
71 per 100000.
DISCUSSION
Health Disparities
The present findings reveal striking health
disparities between the AIAN and general
populations both in UIHO service areas and
nationwide; it is likely that disparities in socio-
economic status contribute to many of the
other disparities identified. American Indians/
Alaska Natives were approximately twice as
likely as the general populations of these
areas to be poor, to be unemployed, and to
not have a college degree. Similar differences
were observed in births among mothers who
received late or no prenatal care or con-
sumed alcohol and in mortality attributed to
SIDS, chronic liver disease, and alcohol con-
sumption. Most striking was the alcohol con-
sumption rate among AIAN mothers, which
was as much as 3 to 4 times that of all moth-
ers combined. The disparities observed in
maternal and child health were consistent
with the results of previous studies.
12 , 13
The percentages of AIAN infants born in
UIHO service areas proportionally mirrored
the percentages of American Indians/Alaska
Natives living in these areas. It is not clear
why UIHO AIAN birth rates were lower than
those observed in the general populations as-
sessed. This result contrasted with UIHO
AIAN infant mortality rates, which exceeded
those of the general populations. A possible
reason for the lower UIHO AIAN birth rates
is increased mobility among the maternal
UIHO AIAN population that results in deliver-
ies taking place outside of UIHO service areas.
Further clarification is needed on this issue.
Whereas percentages of AIAN infants with
low birthweights varied between individual
UIHO service areas, the overall UIHO service
area, and nationwide, the AIAN percentages
were lower than those of the corresponding
general populations. A previous study showed
that AIAN mothers who deliver in IHS facili-
ties were more likely to be diabetic than their
counterparts in the general population.
25
It is
unclear whether maternal diabetes, which
typically results in deliveries of larger new-
borns, was the reason for the decreased per-
centage of low-birthweight infants observed
here in the UIHO AIAN population; further
research is needed.
The percentages of American Indians/
Alaska Natives who died in UIHO service
areas proportionally mirrored the percentages
of American Indians/Alaska Natives living in
these areas. It is unclear why the UIHO AIAN
mortality rates observed were so much lower
than nationwide AIAN and general population
rates. The same patterns were seen with mor-
tality attributable to heart disease, cancer, cere-
brovascular diseases, and several other causes.
Although the findings just described may
suggest improved health among American
Indians/Alaska Natives living in UIHO service
areas, the differences seen between urban and
nationwide AIAN rates were not mirrored by
the differences seen between urban and na-
tionwide general population rates. An expla-
nation for the lower UIHO AIAN mortality
rates is movement among American Indians/
Alaska Natives to locations outside of UIHO
service areas. The extreme variability in rates
between UIHO service areas, however, sug-
gests racial misclassification errors; such er-
rors occur more frequently in urban settings
and on death certificates. Racial misclassifica-
tion errors have been shown to result in dis-
proportionately flawed cardiovascular mortal-
ity rates for the AIAN population.
26
Future
efforts need to focus on instituting changes
that prevent such errors from occurring.
In general, the indicator rates and degrees
of disparity observed between American
Indians/Alaska Natives and the general popu-
lations living in UIHO service areas largely
mirrored those observed between American
Indians/Alaska Natives and the general popu-
lation nationwide. Exceptions included mater-
nal consumption of alcohol, for which the
degree of disparity was higher in UIHO ser-
vice areas, and mortality rates associated with
certain causes such as unintentional injuries
and alcohol use, for which the degree of dis-
parity was higher nationwide.
Limitations
As mentioned, our goal was to provide an
understanding of the health status of the
urban AIAN population residing in UIHO ser-
vice areas. However, 66% of urban American
Indians/Alaska Natives do not live in these
areas. Although exclusion of this group may
affect the generalizability of our findings, there
are several points to consider. For example,
the indicator rates and degrees of disparity ob-
served among American Indians/Alaska Na-
tives residing in UIHO service areas largely
mirrored those in the nationwide AIAN popu-
lation, suggesting that the former was a rea-
sonable proxy for the urban population not in-
cluded in our analyses. Also, given that our
results indicate the presence of significant dis-
parities between American Indians/Alaska
Natives and the general populations living in
UIHO service areas, UIHOs can use our data
to better serve these urban populations.
Although we used county-aggregated data,
43 counties with populations less than
250000 (46% of the overall UIHO service
area) did not have data available for analysis.
However, data on 78% of births and 85% of
the total UIHO AIAN population were still
available, and this exclusion of smaller coun-
ties was unlikely to have resulted in signifi-
cant differences in our results.
Despite the likelihood of racial misclassifi-
cation errors, we undertook no corrective
measures given that the racial misclassifica-
tion adjustment factors developed by the IHS
are useful only at the regional and state lev-
els. Because previous studies have shown that
misclassification of AIAN populations leads to
consistent underestimates, we assume that
any correction of our estimates would result
in larger disparities.
Addressing Health Disparities
The present findings highlight major health
disparities between the AIAN population and
American Journal of Public Health | August 2006, Vol 96, No. 81484 | Research and Practice | Peer Reviewed | Castor et al.
RESEARCH AND PRACTICE
general populations living in select urban set-
tings. Any presumptions that American
Indians/Alaska Natives are thriving in cities
should be reconsidered. Clearly, this population
faces many of the same challenges as nonurban
AIAN populations. Efforts to address health dis-
parities between American Indians/Alaska Na-
tives and general populations in urban settings
must also address disparities in access to care.
A recent study showed that, in comparison
with Whites, AIAN populations less frequently
have insurance coverage or access to health
care and that they use health care services less
often.
27
In addition, although UIHOs are the
primary health care venue for urban American
Indians/Alaska Natives, who represent more
than 60% of the nationwide AIAN population,
IHS allocations for these organizations repre-
sent 1% of the total IHS budget.
3
Effective efforts to address the health dispar-
ities found between the AIAN population and
general populations living in urban areas re-
quire ongoing collection of comprehensive and
accurate data. Racial misclassification errors
can be reduced or eliminated only through the
creation of standard definitions and collection
mechanisms that are consistently used by local,
state, and federal public health agencies. At
present, no formal mechanism exists for docu-
menting or tracking the health status of the
urban AIAN population. The gap in surveil-
lance data for this population raises questions
on how to best meet Healthy People 2010 goals
to reduce and eliminate health disparities in
the United States.
28
Public health institutions
should consider initiating surveillance systems
and incorporating and implementing standard-
ized racial classification schemes.
6
Policy initiatives are needed that would pro-
vide additional funding for health-related ser-
vices and research activities related to urban
AIAN health. In addition, further research is
needed to assess the extent to which the UIHO
AIAN population is representative of the over-
all AIAN population, the percentages of urban
American Indians/Alaska Natives served by
UIHOs, the scope of UIHO health-related ser-
vices, and the health care services and provid-
ers used by urban American Indians/Alaska
Natives not residing in UIHO service areas. Be-
cause the current urban AIAN health system is
fragmented and decentralized, there is an ur-
gent need for leadership to refocus and unify
the system into a more cohesive and coherent
national health care initiative.
Our findings show that urban American
Indians/Alaska Natives are faced with an on-
going health crisis. We found significant health
disparities between the AIAN population and
the general population both in urban areas
and nationwide. Partnerships between tribal,
federal, state, and local public health institu-
tions should be pursued to successfully assess,
address, and eliminate these disparities.
About the Authors
Mei L. Castor, Maile M. Taualii, Alice N. Park, and Ralph
A. Forquera are with the Urban Indian Health Institute,
Seattle Indian Health Board, Seattle, Wash. Mei L. Castor
is also with the Indian Health Service, Albuquerque, NM.
Michael S. Smyser and Shelly A. Lawson are with Public
Health–Seattle and King County, Seattle.
Requests for reprints should be sent to Mei L. Castor,
MD, MPH, Urban Indian Health Institute, Seattle Indian
Health Board, PO Box 3364, 606 12th Ave S, Seattle,
WA 98114 (e-mail: meic@uihi.org).
This article was accepted April 21, 2005.
Contributors
All of the authors helped to conceptualize ideas, inter-
pret findings, and review drafts of the article.
Acknowledgments
We acknowledge the urban Indian health organizations
that contributed to this study.
Human Participant Protection
No protocol approval was needed for this study.
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