Anonymous Student
Professor Adrianna Reyes
PAM 3180
11/26/2018
Health and Healthcare Service Disparities Among American Indian Populations
Summary
American Indians (AIs) experience substantial health disparities relative to the general U.S. population. These disparities include a considerably higher prevalence of preventable diseases such as obesity and alcoholism and their resulting health complications. The purpose of this report is to outline patterns and causes of health disparities for American Indian and Alaska Native populations and explore means of intervention. First, we will focus on the difficulties and obstacles faced by American Indian populations, underlining the different social, demographic, and health care inequalities as fundamental causes of poorer health outcomes. Second, we will review the positive and negative contributions to these disparities resulting from current and past policy implementations, as well introduce any ongoing policy proposals. Third, we will discuss our own recommendations to address this issue in light of the many barriers and challenges to conducting research and intervention in American Indian communities, where to best target relief effort to make meaningful, fundamental changes, and the varying roles individuals, communities, private organizations, and different levels of government can play to promote reductions in health disparities.
Background
With the wealth of data that currently exists, there is little doubt that the American Indian populations in general are faced with substantial disparities in health. The Indian Health Service (IHS) reports that age‐adjusted death rate for American Indian adults is roughly 40% greater than that of the general population. Deaths due to influenza, pneumonia, homicide, suicide, and heart disease are greater than the national average, while deaths due to liver disease, cirrhosis, diabetes, and accidents occur at over three times the rate of the general population (IHS, 2014). Studies conducted on specifically on urban American Indian populations reveal similar disparities when compared to the overall populations of the same area (Katz, 2011). According to the NCHS, American Indian infants are two to three times as likely to experience insufficient prenatal care and post‐neonatal death; this rate is even higher for rural American Indian infants (Baldwin, 2002). American Indian children also experience rates of fetal alcohol spectrum disorders at roughly five times the national average (IHS, 2014)
From infancy onwards, health disparities only become even more apparent. For American Indian children, deaths between the ages of one and four years are roughly three times as common than in the general population, with accidents (3.3 times national rate) and homicide (2.2 times national rate) being the leading causes of death (IHS, 2014) The overall relative risk for injury‐related mortality among American Indian children was 4.6 times greater that of the general populations for ages 0–19 years. Despite injury-related death rates being higher for American Indian children across all categories, the highest rates were for pedestrian injuries (17 times national average), poisoning (15.4 times national average), homicide by piercing (15.4 times national average), and suicide by hanging (13.5 times national average). These studies also revealed the role alcohol played in injury‐related mortality among American Indian children.
Additional disparities appear for American Indians beginning in early adolescence and progressing throughout development. In one study assessing childhood obesity among American Indians, 39% were determined to be overweight or obese (possessing a body mass index higher than the 85th percentile. American Indian children experience three times the national rate of children obesity, and this rate has been growth by 4% each year the disparities for childhood tooth decay are also substantial. Recent IHS data reported that 79% of American Indian preschool children experienced tooth decay – a rate three times greater than their peers (IHS).
Social Determinants
There are several broad and fundamental factors that lead health disparities responsible for the health disparities present in American Indian populations. These factors include: socioeconomic status, education, and access to technologies and services.
SES
Over a quarter of American Indians live in poverty (roughly twice that of the general population) and, for certain tribal groups, the rate can approach 40%. The U.S. Census Bureau reveals that American Indian families with children are even more likely to be living in poverty; 27% of families with children are impoverished, and the rate is 32% for families with children younger than five years old. American Indian people also have relatively lower labor force participation rates; unemployment rates can range from 14.4% to 35% in certain tribal communities (Sandefur, 1997).
Living in areas of concentrated poverty makes American Indians particularly likely to endure or witness traumatic and violent events involving serious injury or threat of injury to self or others. American Indians have the highest rate of violent victimization among all races; children between ages 12 and 19 are especially more likely than their white and non‐native peers to become victims violent crime and assault. Additionally, due to the interconnectedness of American Indian communities, the serious injury or death of one individual often has greater more widespread consequences.
Exposure to such events ranges from 19% to 46% based on event type (Jones, 2006). Domestic violences and child abuse are additional stressors and sources of trauma that stem from low SES. These living situations and constant exposure to extreme stressors has been associated with many other health disparities (Blum, 2002). The immediate and long‐term effects of exposure to these events within American Indian communities includes higher rates of, substance abuse, suicidal, mental disorders, and behavioral issues among exposed individuals (Bohn, 2009).
Education
Fewer American Indians possess a high school diplomas or GED than the general population (71% compared to 80%), and even fewer possess a bachelor's degree (11.5% compared to 24.4%) (U.S. Census Bureau, 2007). Such educational inequalities appear early in childhood; standardized tests show that American Indian children's math and reading abilities fall increasingly behind those of their non-native peers starting as early as kindergarten. Throughout their school years, American Indians persistently experience higher rates of grade retention and dropout (Sarche & Spicer, 2008) Many of the health disparities previously discussed are only exacerbated by educational disparities; aside from correlating with future income and SES, educational disparities can drive poor health literacy and health behavior. Historically, educational institutions played roles in the removing American Indian children from their families, and forbidding the American Indian cultural practices and languages, in order to undermine American Indian ways of life and assimilate communities into the society. It is, therefore, to be expected that American Indian children often perform poorly in both primary and secondary educational settings.
Additionally, while both alcoholism and diabetes do have genetic components that determine individuals’ and certain populations’ predispositions to acquiring the disease. However, factors do not provide a sufficient explanation for the occurrence of such stark health disparities among American Indians and need to be put into a larger context of historical oppression, social factors, and the resulting culture of poverty.
Responses
The federal programs created to provide healthcare to American Indian populations have always been critically underfunded (Warne, 2005). The Indian Health Service, was the primary agency established in order to provide health care services to American Indian populations. The IHS was created out of long history of legislation and treaties that made U.S. government responsible for providing healthcare and other services in exchange for land and resources. Unfortunately, per-capita expenditures for the IHS are low are extremely low compared to other federally funded healthcare services. The per-capita funding of the IHS is less than that of Medicaid and the Bureau of Prisons; meaning that federal expenditures for prison inmates exceeds that of American Indian (Waren, 2005).
This lack of federal funding is even worse for mental health services. One study estimated the to be only four psychologists and two psychiatrists per 100,000, roughly one seventh of the number of psychologists and psychiatrists for the general population. Given the dire shortage in mental and physical health services accessible to the general American Indian population, it is not remarkable that services directed at the social, physical, and emotional needs of American Indian children are even more seriously limited.
There so far have been no attempts of health care interventions aimed at American Indian children. For older American Indians most attempts concentrated on the shortage of services for American Indians or were mostly descriptive and provided little data on the overall performance of their services. The absence of available studies does not necessarily mean that services in intervention attempts are not being provided in American Indian communities, but it does indicate that little is known regarding what works for whom, outside of a few specific American Indian communities. This dearth of such studies reveals a substantial gap in research literature and is detriment to American Indian communities that must be addressed.
In regards to improving education, however, attempts so far have concentrate on ways of improving the effectiveness of American Indian Head Start and Early Head Start program but are now moving, to analyze the implications that these improvements might have on the lives of children and their families.
Recommendations
The complexity and range of underlying causes of health disparities for American Indians necessitates a comprehensive research approach and educational agenda that is both culturally suitable and based on the community’s health needs. We must go beyond merely documenting the health disparities of American Indian communities and begin devising and carrying out effective culturally aware interventions. American Indian communities have been increasingly dissatisfied by the abundance of research that solely serves to archive and record problems that have long been known to exist. However, these communities can often be reluctant to accept interventions developed from others’ experiences that do not take into account their unique cultural and social contexts. If medical research and academic health professional communities are not mindful of theses obstacles to health improvement and disease prevention, American Indian communities may decide to not allow the research or intervention efforts to take place, possibly resulting in even worse health outcomes.
Works Cited
Baldwin, Laura-Mae. “Perinatal and Infant Health Among Rural and Urban American Indians/Alaska Natives.” Cross-Sectional and Longitudinal Effects of Racism on Mental Health Among Residents of Black Neighborhoods in New York City | AJPH | Vol. 105 Issue 4, American Journal of Public Health, 2002, ajph.aphapublications.org/doi/abs/10.2105/ajph.92.9.1491.
Blum, Robert W. “American Indian-Alaska Native Youth Health.” JAMA, American Medical Association, 25 Mar. 2002, jamanetwork.com/journals/jama/article-abstract/395994.
Bohn, Diane k. “Lifetime Physical and Sexual Abuse, Substance Abuse, Depression, and Suicide Attempts Among Native American Women.” Taylor and Francis Online, Issues in Mental Health Nursing, 2009, www.tandfonline.com/doi/abs/10.1080/01612840305277.
Castor, Mei L. “A Nationwide Population-Based Study Identifying Health Disparities Between American Indians/Alaska Natives and the General Populations Living in Select Urban Counties.” Cross-Sectional and Longitudinal Effects of Racism on Mental Health Among Residents of Black Neighborhoods in New York City | AJPH | Vol. 105 Issue 4, Oct. 2011, ajph.aphapublications.org/doi/abs/10.2105/AJPH.2004.053942.
IHS. “Trends in Indian Health: 2014 Edition | IHS Headquarters Publications.” Phoenix Area, Indian Health Services, 2014, www.ihs.gov/dps/publications/trends2014/.
Jones, Monica C., et al. “Trauma‐Related Symptomatology among American Indian Adolescents.” The Canadian Journal of Chemical Engineering, Wiley-Blackwell, 19 Feb. 2006, onlinelibrary.wiley.com/doi/abs/10.1002/jts.2490100202.
Katz, Ruth J. “Addressing the Health Care Needs of American Indians and Alaska Natives.” Cross-Sectional and Longitudinal Effects of Racism on Mental Health Among Residents of Black Neighborhoods in New York City | AJPH | Vol. 105 Issue 4, American Journal of Public Health, Oct. 2011, ajph.aphapublications.org/doi/full/10.2105/AJPH.94.1.13.
Sandefur, Gary D., and Carolyn A. Liebler. “The Demography of American Indian Families.” SpringerLink, Springer, 1997, link.springer.com/article/10.1023/A:1005788930351.
Sarche, Michelle, and Paul Spicer. “Poverty and Health Disparities for American Indian and Alaska Native Children.” Annals of the New York Academy of Sciences, Wiley/Blackwell, 25 July 2008, nyaspubs.onlinelibrary.wiley.com/doi/full/10.1196/annals.1425.017.
U.S. Census Bureau. We the People: American Indians and Alaska Natives in the United States. Aug. 2007.
Warne, Donald. “Research and Educational Approaches to Reducing Health Disparities Among American Indians and Alaska Natives.” Journal of Research in Crime and Delinquency, Arizona State University, 2005, journals.sagepub.com/doi/pdf/10.1177/1043659606288381.