1. Public Health Strategies Kristin Hill, GLITC Jennifer Irving, Thunder Valley CDC Working Effectively with Tribal Governments Training Course

2. AI/AN Population US Census 2013 Population Estimates: –6.5 million AIAN Alone or in combination –1% of the overall U.S. population 2010 Distribution (AI/AN alone or in combination): –41% in the West –17% in Midwest –33% in the South –10% in Northeast Since Census 2000, grew by 28% Source: US Census Bureau, The American Indian and Alaska Native Population: 2013; Released in 2014 2

3. AI/AN Socio-Economic Indicators Education –77% with a High School education or equivalent (US=86%) –13% with Bachelor’s degree (US=28%) Income –$35,062 median income (US=$50,046) –28.4% live in poverty (US=15.3%) Health Insurance –29.4% lack insurance (US=15.5%) Source: US Census Bureau 3

4. Leading Causes of Death and All-Cause Mortality Life expectancy of AI/AN is 73.7 years US National Death Index linked with Indian Health Service registration records for 1990 – 2009 AI/AN all-cause death rates are substantially greater than those for Whites (Northern and Southern Plains most notable) Most prominent disparities for all-cause death rates are found in the younger age groups All-cause death rates for the White population has significantly decreased; not for the AI/AN population Death rates have either stagnated or worsened since 1990 Source: Espey, et al. Leading Causes of Death and All-Cause Mortality in American Indians and Alaska Natives. Supplement 3, 2014, Vol 104, No. S3; AJPH 4

5. AI/AN Health Indicators Infant Mortality Rate: 8.28 deaths per 1000 live births (NHW=5.58) Motor Vehicle Fatality: 29.1 deaths per 100,000 population (NHW=15.0) Suicide Rate: 14.6 (NHW=14.4) Binge Drinking Prevalence: 15.4% (NHW=17.5%) –Highest frequency (6.7) and intensity (8.4) Tobacco Use: –Ages 12-18 years: 17.2 (NHW=11.8) –Ages ≥18 years: 42.2 (NHW=26.9) Source: CDC Morbidly and Weekly Report Supplement 2011, Vol 60 Health Disparities and Inequalities Report 5

6. Diabetes Facts (AI/AN) adults are 2.3 times more likely to have diagnosed diabetes Death rate due to diabetes for AI/ANs is 1.6 times higher than the general U.S. population Frequent co-occurring disease and disorders Source: Bemidji Area Diabetes Coordinator; Fall Diabetes Conference, 2014 6

7. Effective Public Health Strategies Today 7 More Tribal “Public Health Departments” (community health) IHS system of environmental health services Broad use of Community Health Representatives (CHRs) Area Health Promotion/Disease Prevention Consultants Regional Tribal Health Boards Tribal Epidemiology Centers

8. 8 Collect data Evaluate data and programs Identify health priorities with Tribes Make recommendations for health service needs Make recommendations for improving health care delivery systems Provide epidemiological technical assistance to Tribes and Tribal Organizations Provide disease surveillance data to Tribes “Functions of TECs: in consultation with and on the request of Indian tribes, tribal organizations and urban Indian organizations, each service area epidemiology center established under this section shall, with respect to the applicable service area…”

9. Special Diabetes Program for Indians 9

10. AI/AN Data Features Today Age at mortality is increasing but level compared to increasing non-AI/AN Cancer rates are increasing; non-AI/AN are decreasing Greatest gender disease disparity 10

11. Data Challenges Social stigma Barriers to data sharing Small numbers issues Tribal borders Inter-state variation in data collection and reporting Community isolation Racial misclassification Culturally inappropriate survey/methods Political agendas Data threats 11

12. Data Strategies Explicitly encourage state and federal partners to act on behalf of underrepresented populations to operationalize data collection strategies to increase population visibility Increase primary data collection at the local level to inform policy, systems and environmental changes 12

13. Public Health Concerns Today 10 Leading Causes of Death in AI/AN Populations Source: “Leading Causes of Death by Race/Ethnicity” Health, U.S. 2010, Table 26 Heart disease Cancer Unintentional injuries Diabetes Chronic liver disease and cirrhosis Chronic lower respiratory disease Stroke Suicide Nephritis, nephrotic syndrome, & nephrosis Influenza & pneumonia 13

14. Funding Public Health in Indian Country Today Long standing history of underfunding 1976 Indian Health Care Improvement Act: increased the role of CMS 100% FMAP (Federal Medical Assistance Percentage) Federal spending on Indian health care covers 56% level of need Increasing 3 rd party reimbursements Special ACA provisions State partnerships Set asides Tribal enterprises; self insurance Grants 14

15. Cultural differences exist in seeking mental health services and in reporting distress. An historical distrust of the outside population exists among many American Indian communities. Traditional healing is often used in place of counseling. Compared to the general population, AI/AN individuals tend to underutilize mental health services, have higher therapy dropout rates, are less likely to respond to treatment. Mental Health American Indian and Alaska Native Resource Manual. NAMI, 2003, Mental Health: Culture, Race, Ethnicity Supplement to Mental Health: Report of the Surgeon General. US, Department of Health and Human Services, 2001, Dolores Subia BigFoot, PhD., & Barbara L. Bonner, PhD., Trauma in Native Children. Indian Country Child Trauma Center, Oklahoma City, OK, The Office of Minority Health, US Department of Health and Human Services, Elaine Slaton, Offering Technical Assistance to Native Families: Clues From a Focus Group, Federation of Families for Children’s Mental Health, 2000 15

16. A study of adult American Indians of a Northwest Coast Tribe demonstrated little differentiation between physical and emotional distress. The words “depressed” and “anxious” are absent from some American Indian and Alaska Native languages. High prevalence of substance abuse and alcohol dependence is tied to a high risk for concurrent mental health problems. A study of Alaska Natives in a community mental health center found substance abuse was the reason for 85% of men and 65% of women to seek mental health care. Mental Health Concerns Today American Indian and Alaska Native Resource Manual. NAMI, 2003, Mental Health: Culture, Race, Ethnicity Supplement to Mental Health: Report of the Surgeon General. US, Department of Health and Human Services, 2001, Dolores Subia BigFoot, PhD., & Barbara L. Bonner, PhD., Trauma in Native Children. Indian Country Child Trauma Center, Oklahoma City, OK, The Office of Minority Health, US Department of Health and Human Services, Elaine Slaton, Offering Technical Assistance to Native Families: Clues From a Focus Group, Federation of Families for Children’s Mental Health, 2000 16

17. 17 Cultural Health Culture = Prevention (NAHC)