2 tables omitted
Despite overall declines in morbidity and mortality in the United States
in recent years, a persistent gap in health status remains between American
Indians (AIs) and non-Hispanic whites.1,2 This
report compares the health status of AIs with that of other racial/ethnic
minority populations by using data from a survey conducted during 2001-2002
in 21 communities through the Racial and Ethnic Approaches to Community Health
(REACH) 2010 project. The results indicate that although AIs had a higher
prevalence of chronic disease risk factors than other racial/ethnic minority
populations, they also were more likely to use preventive services. Culturally
sensitive primary prevention strategies to reduce risk factors and disease
burden in AI communities should be developed and implemented.
REACH 2010 is a community-based demonstration project designed to reduce
racial/ethnic disparities in health. As a part of the project evaluation,
CDC contracted with the National Opinion Research Center at University of
Chicago to conduct the REACH 2010 Risk Factor Survey. The baseline survey
was conducted during June 2001–August 2002 in 21 minority communities
in the United States. Sample designs were customized for each of the 21 communities,
taking into account geography, racial/ethnic density, expected telephone coverage,
and other factors (e.g., suggestions received from the communities). In the
18 communities in which expected telephone coverage was >80%, interviews were
conducted by telephone. Face-to-face interviews were conducted in three communities
in which (1) the expected telephone coverage was low or inconclusive or (2)
cooperation over the telephone was expected to be difficult. The survey sampled
eligible households and interviewed an average of 1,000 minority residents
aged ≥18 years in each community. Uniform screening and interview questionnaires
were used for all households and were administered in English, Spanish, Vietnamese,
Khmer, or Chinese. The median response rate was 74% (range: 60%-99%).
The 21 communities are located in 14 states (Alabama, California, Georgia,
Illinois, Louisiana, Massachusetts, Michigan, North Carolina, New York, Oklahoma,
South Carolina, Tennessee, Texas, and Washington). The survey included two
AI groups, 14 black groups, seven Hispanic groups, and four Asian groups;
five communities had multiple ethnic groups. For this report, data for persons
of the same race/ethnicity from different communities were aggregated. The
presence of a risk factor or chronic condition was based on self-reported
data. Obesity was defined as body mass index of ≥30.0 kg/m2,
calculated from self-reported height and weight. Cardiovascular disease was
defined as having any of the following conditions: heart attack, coronary
heart disease, or stroke. High blood cholesterol was defined as ever being
told by a doctor or other health professional that blood cholesterol was high.
Women who had diabetes diagnosed only during pregnancy were not considered
to have diabetes. Data were weighted to represent the communities surveyed,
and SUDAAN was used to account for the complex survey sampling designs.
The sample included 1,791 AIs, 10,953 blacks, 4,257 Hispanics, and 4,204
Asians (Table 1). Among both men and women in these four groups, AIs had the
highest prevalences of obesity, current smoking, cardiovascular disease, and
diabetes. Among men, AIs also had the highest prevalences of self-reported
hypertension and high blood cholesterol levels. Among women, blacks had the
highest prevalences of these two conditions, and AIs had the second highest
prevalences. Approximately 80% of AIs had one or more adverse risk factor
or chronic condition, and one third had three or more.
A substantial percentage of AIs received preventive services (Table
2). Compared with other minority populations, AIs with diabetes reported the
highest percentages of receiving hemoglobin A1C (HbA1C) and foot examinations.
AIs aged ≥65 years reported the highest prevalences of receiving pneumonia
vaccination. Overall, AIs had the second highest rates for blood cholesterol
screening, mammography, Papanicolaou (Pap) smear, and influenza vaccination.
A total of 84% of AIs had received at least one preventive service.
Y Liao, MD, P Tucker, DrPH, WH Giles, MD, Div of Adult and Community
Health, National Center for Chronic Disease Prevention and Health Promotion,
The findings in this report indicate that AI communities bear a greater
burden of health risk factors and chronic disease than other racial/ethnic
minority populations. Although earlier investigations reported relatively
low rates of hypertension in AIs who do not have diabetes,3 incidence
is increasing.4 For the populations surveyed,
self-reported hypertension was as common among AIs as it is among blacks.
The Strong Heart Study conducted during 1989-1992 reported that fewer AIs
had high blood cholesterol levels compared with national samples from the
Third National Health and Nutrition Examination Survey.5 However,
in the REACH 2010 survey, approximately one third of AIs had high blood cholesterol
levels, and prevalence of cardiovascular disease was higher than in other
minority populations. Diabetes was uncommon among AIs before World War II,
but prevalence has increased sharply during the previous 20 years.6 Approximately half of the adult population in some
tribes have diabetes.6 The epidemic of obesity
also is a relatively recent phenomenon and is believed to contribute to the
rising prevalence of diabetes, hypertension, and heart disease.
The age-adjusted death rates for heart diseases and cerebrovascular
diseases are lower among AIs than the general U.S. population.2 However,
the disproportionate burden of risk factors and disease in AIs likely will
increase mortality rates in this population. The findings in this report underscore
the importance of primary prevention in AI communities and the need for prevention
strategies that emphasize lifestyle modification, including changes in diet,
physical activity levels, weight control, and smoking cessation. Because habits
often are formed early in life and carried into adulthood, culturally sensitive
prevention strategies directed toward children and young adults are needed
if increases in obesity, diabetes, and other risk factors among AIs are to
Results of the REACH 2010 survey indicate that AIs had higher prevalence
of self-reported use of certain preventive services than any other minority
populations. In 2001, the prevalence of blood cholesterol screening among
AIs was approaching national levels (74.9% for men and 79.5% for women in
the U.S. general population).7 Given the
high burden of diabetes complications (e.g., eye and kidney disease, cardiovascular
disease, and lower extremity amputation) among AIs,6 intensive
measures are necessary to prevent these conditions. The REACH 2010 survey
indicates that the proportions of AIs with diabetes who have had HbA1C measurements
and foot examinations during the preceding year have surpassed national levels.8 For mammography and Pap smears, AIs have reached
or are close to reaching the national health objectives for 2010 (i.e., 70%
for mammogram during the preceding 2 years and 90% for Pap smear during the
preceding 3 years [objectives 3-13 and 3-11b, respectively]).9 This
achievement demonstrates the commitment of AI communities, tribal corporations,
public health authorities, and health-care providers.
The findings in this report are subject to at least two limitations.
First, AIs from different tribal communities and locations exhibit ethnic,
cultural, and social diversity. The REACH 2010 survey included only two AI
communities and might not represent AIs from other communities. However, the
data from this survey are consistent with the general pattern of health status
in AIs reported in other studies.4 Second,
because estimates are based on self-reported data, the prevalence of some
chronic conditions and use of preventive services might be underestimated.
However, the questions on the REACH 2010 survey have demonstrated good reliability
The REACH 2010 demonstration project is under way in eight AI and Alaska
Native communities. Community coalitions have been established, priority target
areas have been identified, and several public health education and prevention
programs to reduce health risk factors and chronic diseases are being implemented.
The findings of the REACH 2010 survey underscore the need for additional,
nationwide efforts to eliminate health disparities between AIs and other populations.
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