Expert Commentary

Native Americans, public health and well-being: Research roundup and key data

2014 review of studies and reports that provide insight into public health issues with Native Americans living in urban areas and on tribal lands in the United States.

Native american women

While the term “Native American” has no official definition, the category usually refers to American Indians, Alaska Natives and Native Hawaiians. On the 2010 U.S. Census, 5.2 million people identified as American Indian or Alaska Native, including 2.9 million who did not also identify as another race. An additional 527,000 people identified as Native Hawaiian, including 156,000 who did not identify as any other race. Together, these three Native American groups comprise about 2% of the U.S. population.

The Indian Health Service (IHS), an agency funded by the U.S. government, is the main health care provider for the estimated 1.9 million enrolled members of federally recognized American Indian and Alaska Native tribes. The IHS maintains a network of hospitals and health care centers throughout the United States; some facilities are located on tribal lands while others are in urban areas. Sixty percent of tribes manage their own health care facilities through contracts with the IHS, and the U.S. Department of Health and Human Services manages the rest. American Indians and Alaska Natives who are not enrolled members of the 566 federally recognized tribes or who live far away from IHS facilities are unable to obtain care. A 2004 study in the American Journal of Public Health found that less than half of low-income, uninsured American Indians/Native Alaskans had access to IHS care. Although there is no comparable system covering the medical needs of Native Hawaiians, a federal grant funds primary care services that benefit about 6,600 indigenous people on the Hawaiian Islands each year.

Positive trends and context

Despite the history of oppression of these native peoples — and negative images that often pervade American popular culture — Native Americans have much to celebrate beyond their historically important traditions and cultures, which provide a vital link to the country’s history and pre-history for all citizens.

According to the Census Bureau, American Indian- and Alaska Native-owned businesses generated $34.4 billion in gross receipts in 2007, a 28% increase from 2002. These businesses numbered 236,967, up 17.7% from 2002. The Economic Policy Institute notes that “Native Americans have increased their income and wealth through new and innovative economic development activities. For instance, tribes have increased their control over their natural resources and food systems, they have become players in the country’s energy sector, and they have begun trading with Asia.” Further, a 2013 report from the National Congress of American Indians notes:

Over the last 30 years, Indian Country has experienced significant economic growth as measured by average individual and tribal incomes. The growth is substantial. Although poverty for tribal citizens on reservation and trust land is more than two-and-a-half times higher than for the total population, poverty declined from 2000 to the 2006-2010 period by almost three percentage points on reservations, while increasing for the entire nation…. Meanwhile, tribal citizens have witnessed progress in addressing some of the most basic infrastructure disparities since 2000. In Alaska, 38 percent of tribal households in Native Village Statistical Areas lacked complete plumbing, 33 percent had an incomplete kitchen, and 34 percent were overcrowded in 2000. By the 2006-2010 period estimate, incomplete plumbing dropped by a third to 25 percent, complete kitchens increased by 13 percentage points, and the number of homes lacking a telephone was cut nearly in half.

More than 156,000 Native American veterans had served in the United States military, as of 2010. Despite stereotypical images of gloom and decay, the population has been growing in recent years — there was a 1.1 million-person increase in the nation’s American Indian and Alaska Native population between the 2000 Census and 2010 Census, and the “population of this group increased by 26.7% during this period compared with the overall population growth of 9.7%.” It is also a relatively young population, with a median age of 29, compared to 37.2 for the general population.

In terms of preserving the cultural diversity of the United States, Native Americans have maintained non-English languages in the home at higher rates (28% among those age 5 or older, versus 21% across the population as a whole), with that percentage rising to 73% on the Navajo Nation Reservation and Off-Reservation Trust Land, in Arizona-New Mexico-Utah.

However, beyond these trends — and many others that seldom get mass attention from the non-native press and the public — there are a variety of profound political and moral challenges confronting native peoples and U.S. public officials.

Overview of health outcomes

Native Americans suffer disproportionately from a variety of mental and physical health problems, which may largely stem from the social marginalization and high poverty rates that they experience. A 2008 study by the Urban Indian Health Board in Seattle found that urban American Indian/Alaska Native youths were three times more likely to engage in suicidal behaviors compared to whites and were twice as likely to use illegal drugs. A 2014 systematic review published in PLoS One found that rates of obesity, diabetes and heart disease were consistently higher in American Indian/Alaska Native populations compared to whites. Obesity, poor nutrition and related health problems have their own unique, complex history and explanations on tribal lands. Basic access to supermarkets, for example, continues to be a big problem.

While health researchers have paid less attention to Native Hawaiians, it appears that this population experiences similar patterns of elevated morbidity. A 2009 study by University of Hawaii researchers found that Native Hawaiians and other Pacific Islanders are among the highest risk demographic groups for heart disease in the United States.

Research limitations

Most studies of Native American health have focused on documenting problems among the population. When it comes to evaluating policies and programs that may improve Native American health, the research is lacking in many areas. The research deficit is more general for indigenous peoples globally. For example, a 2012 systematic review by researchers at Australia’s Queen Elizabeth Hospital looked at the effectiveness of tobacco cessation programs for indigenous people throughout the world, and it found only four studies on the topic, none of which identified effective interventions. There has been more research on Native American health promotion for other health outcomes — for example, a 2009 review in the American Journal of Health Promotion found 64 studies looking at interventions designed to increase levels of physical activity among American Indians and Alaska Natives. That article notes, however, that considering the high prevalence of disease such as diabetes among Native Americans, there were disproportionately few studies looking at physical activity among indigenous peoples, with a particular lack of research on urban American Indians.

Wider health and safety context

Beyond the historical legacy of marginalization and socioeconomic factors, there are deep structural problems with the current justice system and basic public safety on tribal lands, severely affecting public health outcomes of all kinds across tribal populations. These systems are in urgent need of attention, according to a 2013 report to the President and Congress by the Indian Law and Order Commission (comprised of designated representatives of the executive and legislative branches). The report, “A Roadmap for Making Native America Safer,” is the product of multi-year hearings and fact-gathering missions across Indian country. It states that governance and justice systems must be reformed, as the “extraordinary waste of governmental resources resulting from the so-called Indian country ‘jurisdictional maze’ can be shocking, as is the cost in human lives.” The report’s authors conclude that the current reliance on federal and state justice systems is simply not working:

Ultimately, the imposition of a non-Indian criminal justice institution in Indian country extracts a terrible price: limited law enforcement; delayed prosecutions, too few prosecutions and other prosecution inefficiencies; trials in distant courthouses; justice system and players unfamiliar with or hostile to Indians and Tribes; and the exploitation of system failures by criminals, more criminal activity and further endangerment of everyone living in and near Tribal communities. When Congress and the Administration ask why the crime rate is so high in Indian country, they need look no further than the archaic system in place, in which Federal and State authority displaces Tribal authority and often makes Tribal law enforcement meaningless.

The studies below characterize public health problems that Native American communities face and evaluate interventions meant to improve health and well-being:


“Association of Contextual Factors with Drug Use and Binge Drinking among White, Native American and Mixed-Race Adolescents in the General Population”
Chen, Hsing-Jung; Balan, Sundari; Price, Rumi Kato. Journal of Youth and Adolescence, November 2012, Vol. 41, Issue 11, pp 1426-1441. doi: 10.1007/s10964-012-9789-0.

Abstract: “Large-scale surveys have shown elevated risk for many indicators of substance abuse among Native American and mixed-race adolescents compared to other minority groups in the United States. This study examined underlying contextual factors associated with substance abuse among a nationally representative sample of white, Native American and mixed-race adolescents 12-17 years of age, using combined datasets from the National Survey on Drug Use and Health (NSDUH 2006-2009, N = 46,675, 48.77 % female). Native American adolescents displayed the highest rate of past-month binge drinking and past-year illicit drug use (14.06 and 30.91 %, respectively). Results of a logistic regression that included seven predictors of social bonding, individual views of substance use and delinquent-peer affiliations showed that friendships with delinquent peers and negative views of substance use were associated significantly with both substance abuse outcomes among white and mixed-race adolescents and, to a lesser extent, Native American adolescents. The association of parental disapproval with binge drinking was stronger for white than for Native American adolescents. Greater attention to specific measures reflecting racial groups’ contextual and historical differences may be needed to delineate mechanisms that discourage substance abuse among at-risk minority adolescent populations.”


“Poverty and Health Disparities for American Indian and Alaska Native Children: Current Knowledge and Future Prospects”
Sarche, Michelle; Spicer, Paul. Annals of the New York Academy of Science, 2009, Issue 1139. doi:  10.1196/annals.1425.017.

Findings: “There remain enormous gaps in our knowledge of the predicaments confronted by American Indian and Alaska Native children, but we have long known enough to begin to act, in concert with indigenous communities, to begin to address the most glaring disparities. Both our community partners and we are placing bets on the value of early intervention, beginning prenatally with a mother’s first pregnancy, and extending throughout the first years of life and beyond, as one of the surest ways to begin to address past centuries of neglect and improve the prospects of American Indian and Alaska Native children in this century.”


“Urban American Indian and Alaska Native youth: Youth Risk Behavior Survey, 1997-2003.”
Rutman, Shira; Park, Alice; Castor, Mei; Taualii, Maile; Forquera, Ralph. Maternal and Child Health Journal, 2008. Suppl. 1. doi: 10.1007/s10995-008-0351-3.

Findings: “In this analysis, we examined national YRBS [Youth Risk Behavior Survey] data to identify health risk-behaviors that may be in need of greater attention among [American Indian/Alaska Native] youth compared to white youth in urban areas. Despite an ongoing effort to eliminate health disparities across all races and ethnicities, AI/AN are experiencing a crisis. Therefore it is not surprising that we found disparities in health risk-behaviors between urban AI/AN and white youth in these data. In urban areas, AI/AN students were significantly more likely than white students to engage in illegal drug use, suicidal behaviors and risky sexual behaviors. American Indians/Alaska Natives also had higher estimates for early initiation of sexual intercourse and use of tobacco, alcohol and marijuana. They were more likely to drink alcohol, smoke cigarettes and carry weapons on school property. And, urban AI/AN youth were more likely than whites to have a fight, and sustain an injury or avoid school altogether.”


“Systematic Review of Physical Activity Interventions Implemented With American Indian and Alaska Native Populations in the United States and Canada”
Teufel-Shone, Nicolette I.; Fitzgerald, Carrie; Teufel-Shone, Louis; Gamber, Michelle. American Journal of Health Promotion, 2009. Vol. 23, Issue 6. doi: 10.4278/ajhp.07053151.

Findings: “Although effective [physical activity] interventions have and continue to be implemented among [American Indian/Alaska Native] populations, this review highlights the absence of programs that (1) target the growing population of urban AI/ANs and (2) are designed from an AI/AN perspective using culturally relevant styles of promotion coupled with evaluation plans using scientifically proven methods that are acceptable to the community and practical for local personnel to implement. Public health practitioners need to assume the challenge of developing effective, culturally appropriate PA interventions for urban AI/ANs, yielding programs that fit their residence pattern and lifestyle. Native people should be encouraged and supported to become health promotion practitioners and researchers. Native and nonnative health promotion practitioners and researchers who work with tribal entities should incorporate a community-based participatory research approach to (1) enhance the cultural and local relevance of the intervention; (2) integrate the interventions into tribal infrastructure to assure local leadership, ownership and support; and (3) develop sustainable evaluation plans to assess impact to justify continued financial support and guide program modifications. The most effective programs demonstrated impact on multiple levels, specifically risk behaviors, health and fitness measures, shifting local norms by gaining support of local leadership and blending formal public health practices and cultural traditions.”


“Medical Mistrust and Less Satisfaction With Health Care Among Native Americans Presenting for Cancer Treatment”
Guadagnolo, B. Ashleigh, et al. Journal of Health Care for the Poor and Underserved, 2009. Vol. 20, Issue 1. doi: 10.1353/hpu.0.0108.

Findings: “In conclusion, our study is the first to document significantly higher levels of medical mistrust and dissatisfaction among Native American cancer patients, a population with known and persistent cancer-related health disparities. Our findings underscore that successful clinical or public health interventions will require full engagement with and involvement of Native American communities in order to establish trust and deliver culturally competent care. More resources are, of course, needed to eliminate cancer disparities in this vulnerable population. However, an infusion of funding alone will not suffice to improve health care access in a population with demonstrated mistrust of and wariness towards the health care system. We assert, based on our findings and experience, that Native American community members must be recruited and trained to serve as liaisons to the health care system. Culturally responsive programs and interventions should be developed and expanded in health care systems serving Native American patients.”


“Health Indicators of Native Hawaiian and Pacific Islanders in the United States”
Moy, Karen L.; Sallis, James F.; David, Katrine J. Journal of Community Health, 2010. Vol. 35, Issue 1. doi: 10.1007/s10900-009-9194-0.

Abstract: “This study aimed to describe health indicators and behaviors of Native Hawaiian and Pacific Islander (NHPI) adults and to compare findings to previous reports on U.S. NHPI and the U.S. population. A sample of N = 100 (56 M, 44 F) NHPI adults aged 40–59 years completed an anonymous questionnaire addressing education and household income, tobacco use, physical activity, fruit and vegetable (F&V) consumption, cancer screening and health status. Objective measures of height and weight were taken to calculate body mass index (BMI). The study sample consisted of 49% current smokers and the majority was not meeting guidelines for physical activity (80%) or F&V consumption (99%). Cancer screening rates ranged from 0 to 57% and were higher among females. Mean BMI was 33.9 ± 7.5 kg/m2 and 95% were overweight or obese. While 36.7% were hypertensive, only 11.1% were taking prescribed medication. Compared to both the general U.S. population and available data for U.S. NHPI, study participants reported higher prevalence of obesity and chronic conditions (hypertension, high cholesterol, diabetes and angina/CHD) and lower levels of physical activity, F&V consumption and cancer screening rates. Study findings contribute to the limited knowledge regarding health behaviors of U.S. NHPI. Comparisons to U.S. data increase evidence of NHPI health disparities, while comparisons to previous NHPI studies emphasize the magnitude of unhealthy lifestyle behaviors and subsequent adverse health conditions for this particular sample. Further improvements to community outreach and recruitment strategies could successfully encourage high-risk individuals to participate in health promotion and behavior intervention studies to improve NHPI health behaviors.”


“American Indian and Alaska Native Mental Health: Diverse Perspectives on Enduring Disparities”
Gone, J; Trimble, J. Annual Review of Clinical Psychology, 2012, Vol. 8. doi: 10.1146/annurev-clinpsy-032511-143127.

Abstract: “As descendants of the indigenous peoples of the United States, American Indians and Alaska Natives (AI/ANs) have experienced a resurgence in population and prospects since the beginning of the twentieth century. Today, tribally affiliated individuals number over two million, distributed across 565 federally recognized tribal communities and countless metropolitan and nonreservation rural areas. Although relatively little evidence is available, the existing data suggest that AI/AN adults and youth suffer a disproportionate burden of mental health problems compared with other Americans. Specifically, clear disparities have emerged for AI/AN substance abuse, posttraumatic stress, violence and suicide. The rapid expansion of mental health services to AI/AN communities has, however, frequently preceded careful consideration of a variety of questions about critical components of such care, such as the service delivery structure itself, clinical treatment processes and preventive and rehabilitative program evaluation. As a consequence, the mental health needs of these communities have easily outpaced and overwhelmed the federally funded agency designed to serve these populations, with the Indian Health Service remaining chronically understaffed and underfunded such that elimination of AI/AN mental health disparities is only a distant dream. Although research published during the past decade has substantially improved knowledge about AI/AN mental health problems, far fewer investigations have explored treatment efficacy and outcomes among these culturally diverse peoples.”


“Reproductive Rights Denied: The Hyde Amendment and Access to Abortion for Native American Women Using Indian Health Service Facilities”
Arnold, Shaye Beverly. American Journal of Public Health, 2014. doi: 10.2105/AJPH.2014.302084.

Findings: “In 20 years of recordkeeping (1981–2001), the IHS performed 25 abortions. A 2002 study published by the Native American Women’s Health Education Resource Center (NAWHERC) reported that 85% of IHS facilities were not in compliance with IHS and Hyde Amendment regulations; in other words, they did not have abortion services available or did not refer to abortion providers even for women in the permitted circumstances. Only 5% of IHS facilities actually provided abortion services onsite, and no facility-based IHS pharmacies kept Mifeprex (RU-486), a medication used for nonsurgical abortion, in stock.”


“Estimating the Magnitude of Rape and Sexual Assault Against American Indian and Alaska Native (AIAN) Women”
Bachman, Ronet, et al. Australian & New Zealand Journal of Criminology, August 2010, 43:19. DOI: 10.1375/acri.43.2.199.

Findings: “Alcohol and drugs appear to play a larger role in the sexual attacks of AIAN women compared to other women. Over two-thirds (68%) of AIAN sexual assault victims believed their attackers had been drinking and/or taking drugs before the offence compared to 34% of white victims and 35% of African American victims. Reporting to police and subsequent police action also varied by the race of the victim…. [A] greater percentage of sexual assaults against AIAN women were reported to police compared to other women, however, fewer than one in five (17%) victims made the report herself. Those incidents that were not reported by the victim were either reported by another household member, another official or some other person. This low percentage of victim reporting is consistent with percentages for all women. When incidents were reported to police, an arrest or charge appeared to be much less likely for AIAN cases (13%) than for cases involving African American (35%) or white female victims (32%). What this means is that only 6% of all rapes and sexual assaults against AIAN women result in an arrest or charges being brought against the offender as compared to 12% for African American and 11% for Whites.”


“Health Service Access, Use and Insurance Coverage Among American Indians/Alaska Natives and Whites: What Role Does the Indian Health Service Play?”
Zuckerman, Stephen; et al. American Journal of Public Health, 2004. Vol. 94, Issue 1. doi: 10.2105/AJPH.94.1.53.

Findings: “The uninsurance rate of AIANs is also higher than that of African Americans and is comparable to the uninsurance rate of Hispanics. These higher rates for AIANs are troubling because uninsured people, regardless of race/ethnicity, have less access to routine care for chronic conditions and care for serious medical conditions. Although many assume that the IHS services are available to most, if not all, AIANs, just under half of low-income uninsured AIANs reported having access to the IHS. Higher rates of uninsured low-income AIANs are largely a function of lower rates of private coverage. Although these findings are consistent with those of other studies factors underlying the lower rates of private coverage deserve further investigation. However, given the large proportion of AIANs who had low incomes, it is likely that public approaches to expanding sources of coverage and care will need to be considered to reduce the disparity.”


Keywords: Native Americans, American Indians, poverty, minorities, native peoples, youth

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