Learning Module Topics

American Indian Health Equity/Disparities

What Are They?

Definitions Provided by the Centers for Disease Control and Prevention (Centers for Disease Control and Prevention [CDC], 2014)
Health Equity: “When all people have the opportunity to ‘attain their full health potential’ and no one is ‘disadvantaged from achieving this potential’ because of their social position or other socially determined circumstance.”
Health Disparities: “A type of difference in health that is closely linked with social or economic disadvantage. Health disparities negatively affect groups of people who have systematically experienced greater social or economic obstacles to health. These obstacles stem from characteristics historically linked to discrimination or exclusion such as race or ethnicity, religion, socioeconomic status, gender, mental health status, sexual orientation, or geographic location. Other characteristics include cognitive, sensory, or physical disability differences in health along social, economic, and racial or ethnic lines.”
Health Inequalities: “Differences in health status or in the distribution of health determinants between different population groups.”

American Indian Health Disparities

Health disparities as mentioned before are differences associated with social and economic disadvantages in relation to race, gender, and more. Below are a few factors that can contribute to health disparities
  • Poverty
  • Low Educational attainment/ low literacy
  • Unemployed
  • Language barriers
  • Unequal access to health care
  • Limited access to transportation
  • Limited access to healthy food
  • Limited housing options
  • Environmental conditions
  • And MORE

These health disparities are known to affect socially disadvantaged groups such as but not limited to:

  • Racial and ethnic minorities (American Indian, Latinos, African Americans)
  • Immigrants
  • Children
  • Elderly
  • Poor
  • Less educated
  • No health insurance
  • Rural/remote geographical areas
  • People who live in developing countries
  • Lesbian, Gay, Bisexual, Transgender, and Queer (and/or questioning) individuals/identities

Understand the Underlying Causes of Health Inequity

Health Inequity: Disparities in health that are a result of systemic, avoidable and unjust social and economic policies and practices that creates barriers to opportunity (Virginia Department of Health, 2013).
American Indians have a history of health inequity according to the United States Census Bureau (2015) 28.3% of American Indians live in poverty, this is the highest rate among any other race. In addition to having the highest rate of poverty “American Indians and Alaska Natives born today have a life expectancy that is 4.4 years less than the U.S. races population, 73.7 years to 78.1 years, respectively” (IHS, 2016). There may be a possible link between poverty and the reduced life expectancy that American Indians (AI) face. Furthermore, in a recent study by the Indian Health Service (2016) AI have higher rate of easily avoidable diseases such as diabetes, liver disease and more. In the table below, you will see mortality rates for American Indians compared to All other races in 2007-2009 as well as the ratio.

Mortality Disparity Rates Table (IHS, 2016)

American Indians and Alaska Natives (AI/AN) in the IHS Service Area 2007-2009 and U.S. All Races 2008 (Age-adjusted mortality rates per 100,000 population) Accordion Closed

 

AI/AN Rate 2007-2009

U.S. All Races Rate - 2008

Ratio: AI/AN to U.S. All Races

ALL CAUSES

943.0

774.9

1.2

Diseases of the heart

182.4

192.1

0.9

Malignant neoplasm

170.8

176.4

1.0

Unintentional injuries*

94.5

39.2

2.4

Chronic lower respiratory diseases

43.2

44.7

1.0

Diabetes mellitus

61.0

22.0

2.8

Chronic liver disease and cirrhosis

43.1

9.2

4.7

Cerebrovascular diseases

39.1

42.1

0.9

Influenza and pneumonia

24.1

17.8

1.4

Nephritis, nephrotic syndrome

22.1

15.1

1.5

Intentional self-harm (suicide)

18.5

11.6

1.6

Septicemia

16.5

11.3

1.5

Alzheimer's disease

14.6

24.4

0.6

Assault (homicide)

11.0

5.9

1.9

Essential hypertension and hypertensive renal disease

12.8

13.9

0.9

Parkinson's disease

5.1

6.6

0.8

* Unintentional injuries include motor vehicle crashes.

NOTE: Rates are adjusted to compensate for misreporting of American Indian and Alaska Native race on state death certificates. American Indian and Alaska Native age-adjusted death rate columns present data for the 3-year period specified. U.S. All Races columns present data for a one-year period. ICD-10 codes were introduced in 1999; therefore, comparability ratios were applied to deaths for years prior to 1999. Rates are based on American Indian and Alaska Native alone; 2000 census with bridged-race categories.

Not only do AIs have a higher rates of preventable diseases there is also evidence to higher infant mortality rates, according to U.S. Department of Health and Human Services Office of Minority Health (2015), “American Indian/Alaska Natives have 1.5 times the infant mortality rate as non-Hispanic whites. In addition to the high rate American Indian/Alaska Native babies are twice as likely as non-Hispanic white babies to die from sudden infant death syndrome (SIDS). As well as American Indian/Alaska Native infants are 70 percent more likely as non-Hispanic white infants to die from accidental deaths before the age of one year.
A lack of access to health care and/or a lack of trust in health care providers and systems may keep AI/AN from receiving adequate medical care, including HIV testing and treatment (Vernon, 2001 & 2004). In a recent published article on Sexually Transmitted Infections (IHS, 2011) it was found that the 2011 chlamydia rate among AI/AN was 1.4 times higher than the U.S. rate (457.6 cases per 100,000 population). In addition to the high prevalence of Chlamydia among the AI population, the national rate of reported gonorrhea in 2011 was 115.7 cases per 100,000 population, an increase of 7.7% from 2010 (107.4 cases per 100,000 population). Furthermore, the rate of Primary and Secondary Syphilis in the U.S. decreased throughout the 1990s, and in 2000 reached an all-time low. However, since that time U.S. and AI/AN syphilis rates have slowly increased. Between 2010 and 2011, the AI/AN P&S rate increased slightly, from 2.5 to 2.7 cases per 100,000 population (IHS, 2011).

The Connection

Most American Indian tribes have a majority of the factors that contribute to health disparities within their communities. For instance the lack of jobs is in correlation to the poverty rate among the AI population.
  • Some 63% of nonelderly American Indians and Alaska Natives are in a family with at least one full-time worker, compared to 74% of the U.S. nonelderly population. Reflecting this employment pattern, the poverty rate for American Indians and Alaska Natives (41%) is more than one and half times the overall rate for the nonelderly population (25%). However, despite this overall high rate of poverty, there is variation in economic status among American Indians and Alaska Natives. For example, there has been successful economic development among tribes, not only through gains stemming from casinos and natural resources, but also among tribes with a strong focus on American Indian and Alaska Native entrepreneurship and business development (Harrington, 2012; National Indian Gaming Association. 2009)
  • Native Americans have the lowest employment rate of any racial or ethnic group in the United States (Bureau of Labor Statistics, 2013).
  • In the poorest Native counties, only about 1/3 of men in Native American communities have full-time, year-round employment (Beal, 2004)

Also in correlation to health inequity and inequality is health care. Hospitals on the reservation serve large populations of people every day sometimes forcing people to hold off on care until the care is needed immediately. In addition to serving large populations, American Indian health hospitals are underfunded, causing reduction in care programs.

  • Among nonelderly adults, American Indians and Alaska Natives are significantly more likely than the overall population to report being in fair or poor health, being overweight or obese, having diabetes or cardiovascular disease, and experiencing frequent mental distress (Kaiser Commission on Medicaid and the Uninsured analysis of the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System Survey Data, 2011).
    • American Indian and Alaska Native children and adolescents are also at higher risk for health problems than their peers. Nearly four in ten American Indian and Alaska Native children are overweight or obese, and studies have found the overweight and obesity rates among American Indian and Alaska Native children to be higher than any other group (Leadership for Healthy Communities, 2010).
    • In addition, the suicide rate for American Indian and Alaska Native adolescents and young adults is two and half times higher than the national average, and suicide is the second leading cause of death among American Indian and Alaska Native adolescents and young adults, compared to the eleventh leading cause of death nationally (National Center for Injury Prevention and Control, Division of Violence Prevention, 2012).
  • The IHS provides health care and disease prevention services to approximately 2.2 million American Indians and Alaska Natives through a network of hospitals, clinics, and health stations (DHHS, 2013).
  • Urban Indian health programs serve a wider group of American Indians and Alaska Natives, including those who are not able to access IHS- or tribally-operated facilities because they do not meet eligibility criteria or because they reside outside their service areas. However, funding to urban Indian health programs is very limited and the share of IHS funding going toward urban programs over time has not reflected the overall demographic shift of American Indians and Alaska Natives away from reservations (Forquera, 2001).
  • The appropriated funds are distributed to IHS facilities across the country and serve as their annual budget. If service demands exceed available funds, services are prioritized or rationed. In FY2013, a total of $4.3 billion was appropriated for IHS services, with $3.1 billion going to health care services and the remaining funds supporting preventive health and other services (Figure 5) (DHHS, 2013).
  • IHS has historically been underfunded to meet the health care needs of American Indians and Alaska Natives. Although the IHS discretionary budget has increased over time, funds are not equally distributed across IHS facilities and remain insufficient to meet health care needs (Fox & Borner, 2012).
  • As such, access to services through IHS varies significantly across locations, and American Indians and Alaska Natives who rely solely on IHS for care often lack access to needed care, including preventive care and early treatment of chronic diseases (Fox 2011).
  • Moreover, access to services through facilities is significantly limited with available funding often only able to support “medical priority 1 cases, or those that threaten life or limb.” (Fox, 2005).

Furthermore, most reservations are considered food deserts, where access to healthy food is limited. Food deserts are defined as parts of the country lacking fresh fruit, vegetables and other healthful whole foods and are usually found in impoverished areas. This is largely due to a lack of grocery stores, farmer’s markets, and healthy food providers (American Nutrition Association, 2011). There are two types of food insecurity in Type I food insecurity, an individual or group of people do not have enough food to eat. In Type II food insecurity, the individual or the group does not have enough nutritional and culturally appropriate food to eat (First Nations Development Institute, 2014). In another study after controls for low income and educational status, food insecurity has been associated with poor health status in children and adults, depression and anxiety among adolescents and adults, and adolescent suicidal ideation. Even the mildest form of food insecurity is associated with risk of poor cognitive, social, and emotional development of children younger than 3 years (Chilton & Rose, 2009).

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