1. Felicia Schanche Hodge, Dr.PH Center for American Indian Research & Education

2. American Indian/Alaskan Native Population 1996 U.S. Bureau of Census Population Estimates 1996 IHS service population 2.3 million 1.4 million More than 550 Federally recognized tribes in the U.S.

3. American Indian/Alaskan Native Health Services IHS Service Area - 12 Area Offices Service area consists of counties on and near federal Indian reservations 37 hospitals 64 healthcenters 5 school health centers 50 health stations 34 urban Indian health projects

4. 12 hospitals 116 health centers 3 school health centers 56 health stations 167 Alaska village clinics Tribally operated health services American Indian/Alaskan Native Health Services (cont.)

5. 50% or more reside in urban areas Non - IHS eligible population falling through the cracks

6. hard to reach populations

7. acute  chronic

8. Leading Causes of Death IHS Service Area 1991-1993 Diseases of the Heart 116.1 Malignant neoplasms 80.6 Accidents 78.0 Diabetes Mellitus 25.0 Chronic Liver disease and cirrhosis 23.6 Cerebrovascular diseases 23.3 (Deaths per 100,000)

9. Leading Causes of Death IHS Service Area 1991-1993 (cont.) Pneumonia and influenza 19.5 Suicide 15.2 Homicide and legal intervention 14.0 Chronic obstructive pulmonary diseases and allied conditions 12.8

10. Causes of Death IHS Service Area 1991-1993 Compared to rates for the U.S. Population, death rates among American Indians are: 465% higher due to alcoholism (703%)* 425% higher due to tuberculosis (525%)* 184% higher due to accidents (282%)* 166% higher due to diabetes (248%)* 46% higher due to suicides ( 89%)* *excluding 3 areas with problems underreporting death rates for Indians

11. Culture Public awareness Missed opportunities Recruitment strategies

12. Culture

13. fatalism fear white man’s disease introduction of foreign matter

14. Public Awareness

15. Threat is on-going Where to obtain health care For yourself and your community

16. Culturally Competent Outreach Culturally sensitive programs Utilize community resources Educate via Indian way

17. Demographic Barriers - written materials inappropriate - not culturally appropriate

18. Social Barriers - caretakers - childhood disease

19. Institutional Barrier - lack of access - patient / provider communication

20. Missed Opportunities

21. at IHS clinics at urban clinics at health fairs

22. Barriers to Care Access to medical care Transportation Financial limitations Cultural barriers

23. CAIRE Projects Smoking Cessation Project Data collected from a sample of 1,369 adult Northern California Indian male/female patients at 18 Indian health clinics

24. CAIRE Projects Smoking Cessation Project (cont.) Participants completed a self- administered questionnaire designed to assess smoking rates, patterns and attitudes as well as health status

25. Smoking and American Indians IHS statistics show 2 out of 5 deaths of Indians are related to smoking Ceremonial vs. Habitual Tobacco Use - Tobacco in American Indian culture Estimated that nationwide 50% of American Indians smoke and 41 % of Indian teens smoke

26. Smoking and American Indians (cont.) Combined chronic alcohol consumption and tobacco use substantially increases the risk of cancer Women who smoke may be at a higher risk for developing cervical cancer Tobacco control policies

27. CAIRE Projects Cervical Cancer Project Data collected from a sample of 413 adult California Indian patients at 8 Indian health clinic sites Participants completed a self-administered questionnaire designed to assess cancer screening, knowledge, attitudes and behavior and health status

28. CAIRE Projects Nutrition Project Data collected from a sample of 440 adult female heads of households at 8 Indian health clinic sites Participants completed a self-reported questionnaire designed to assess patterns of dietary habits, nutrition KAB, and anthropometric measures

29. CES-D Caseness Rates Smoking Cessation Study  16 cutoff  28 cutoff Nutrition Study36.2%13.6% 42.3%14.7% Original Study 19% 5% Cervical Cancer Study 43.0%15.8%

30. Depression: CES-D Scale Original Study (Radloff) Smoking Cessation Study Cervical Cancer Study Nutrition Study  16  28

31. Recruitment Strategies Identify gatekeepers Utilize Community Health Representatives (CHRs) Work from “Inside” not “Outside” Utilize community resources

32. Education Strategies Talking Circles Community newsletters Community clinics Fully explain participation Answer all questions

33. Communication Strategies Body language Organization of speech Less direct / more generalized Talk slower - pauses Minimize complaints

34. Barriers Understand fears Address concerns Extend family needs Money, childcare, transportation

35. Cultural Considerations Loss of body parts Illness beliefs Healing ceremonies