North Carolina Minority Health Facts: American Indians

State Center for Health Statistics and Office of Minority Health and Health Disparities July 2010

The purpose of this report is to present basic health in 12 counties, five of which are clustered in the facts about American Indians in North Carolina in southeastern part of the state. Forty-five percent of the areas of mortality, chronic diseases, HIV and North Carolina’s American Indian population lives sexually transmitted diseases, health risk factors, in Robeson County (mostly Lumbee), accounting access to health care, quality of life, maternal and for 38 percent of that county’s total population. infant health, and child and adolescent health. But Seven percent of North Carolina’s American first we give some background information on the Indians live in Jackson and Swain counties (mostly American Indian population in the state. Cherokee), accounting for nearly 15 percent of the total population in these counties.1 Age and Geographic Characteristics of Among the American Indian tribes in North Carolina American Indians in North Carolina are eight state-recognized tribes: the Eastern Band North Carolina has the largest American Indian of Cherokee (who live primarily in Swain, Jackson, population east of the Mississippi River and the and Graham counties), Coharie Tribe (Harnett, sixth largest American Indian population in the Sampson), Haliwa Saponi Indian Tribe (Halifax, nation, according to 2008 U.S. Census Bureau Warren, Nash), Lumbee Tribe of North Carolina population estimates. According to the census, there (Robeson, Scotland, Hoke), Meherrin Indian Tribe were 108,279 American Indian/Alaskan Native (Hertford, Bertie, Gates, Northampton), Occaneechi residents of North Carolina in 2008. Although the Band of Saponi Nation (Orange, Alamance), percentage of North Carolina’s population that is Sappony (Person), and Waccamaw-Siouan Tribe American Indian has not changed since 1990, the (Columbus, Bladen). The Eastern Band of Cherokee number has increased by nearly 40 percent since is a federally-recognized tribe, and the only tribe 1990 and by 9 percent since 2000. American Indians served by the Indian Health Service of the United now represent a little more than 1 percent of the States Public Health Service. These tribes are total population of the state.1 referenced in Chapter 71 A of the North Carolina General Statutes. The state-recognized tribes hold American Indians in North Carolina are younger membership on the North Carolina Commission than the majority white population. According to of Indian Affairs. The American Indian tribes in the 2008 American Community Survey, the median Cumberland, Guilford, Johnston, Mecklenburg, and age of the state’s American Indian population was Wake counties are represented through the following 33.8 years, compared to 40.5 years for the white associations or organizations: Cumberland County population of North Carolina.2 Association for Indian People, Guilford Native Although American Indians live in each of North American Association, Metrolina Native American Carolina’s 100 counties (see 2008 data on the map, Association, and the Triangle Native American Figure 1), three-fourths of the population lives Society. In 1956, the United States Congress passed school education or less, compared to 40 percent Table 1 for whites.2 The unemployment rate for American Leading Causes of Death Among American Indians in North Carolina, 2008 Indians was 7.5 percent, compared to 5.4 percent for whites.2 Number of Rank Cause of Death Deaths 1 Cancer 145 Mortality 2 Diseases of the heart 142 Table 1 shows the leading causes of death for 3 Other unintentional injuries 38 American Indians in North Carolina in 2008. 4 Motor vehicle injuries 35 Cancer, heart disease, and other unintentional 5 Diabetes mellitus 31 6 Cerebrovascular disease 28 injuries are the top three causes of death, 7 Homicide 25 compared to heart disease, cancer, and chronic 8 Alzheimer’s disease 22 lower respiratory diseases for the white 9 Kidney diseases 21 population. Motor vehicle injuries (fourth) and 10 Chronic lung diseases 18 homicide (seventh) rank substantially higher as All other causes (residual) 194 Total Deaths — All Causes 699 causes of death among American Indians than among whites (10th and 19th, respectively). the Lumbee Act (HR 4656) which provided federal Table 2 shows 2004–2008 age-adjusted death recognition of the Lumbee tribe, but did not include rates (deaths per 100,000 population) for major health services for the Lumbee by the Indian Health causes of death, comparing American Indians, Service. whites, and African Americans. American Indian death rates were at least twice that of whites for Social and Economic Well-Being diabetes, HIV disease, motor vehicle injuries, and homicide. Low income, low educational level, and unemployment all are associated with a higher rate of health problems. The Table 2 percentage of American Indian families Age-Adjusted Death Rates* for Major Causes of Death by living below the federal poverty level Race/Ethnicity, North Carolina Residents, 2004–2008 ($21,834 annual income for a family of American African Cause of Death Indian White American four) in 2008 was 21.2 percent, compared to 6.7 percent for whites and 21.3 percent Chronic Conditions Heart disease 207.7 192.6 236.0 for African Americans. Approximately Cancer 166.4 185.2 224.0 Stroke 54.6 49.2 73.5 29 percent of American Indian family Diabetes 45.0 19.5 51.0 households were headed by females, Chronic lung disease 30.1 51.1 30.4 Kidney disease 23.5 14.8 36.5 compared to 13 percent for white family Chronic liver disease 11.8 9.3 8.4 households and 44 percent for African Infectious Diseases American family households. Thirty-eight Pneumonia/influenza 13.5 20.2 19.2 Septicemia 17.1 12.3 22.3 percent of the family households headed by HIV disease 2.9 1.2 16.5 American Indian females lived in poverty, Injury and Violence compared to 25 percent of the family Motor vehicle injuries 39.0 18.1 18.0 Other unintentional injuries 30.9 30.9 21.8 households headed by white females and Homicide 20.4 3.6 16.4 37 percent by African American females. Suicide 9.5 14.4 5.0 * Rates are age-adjusted to the 2000 U.S. standard population and are expressed as deaths per 100,000 More than 58 percent of American Indian population — using underlying cause of death. adults (ages 25 and older) had a high

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Minority Health Facts ♦ American Indians — July 2010 Office of Minority Health and Health Disparities and State Center for Health Statistics 3 Cancer Incidence Table 3 Age-Adjusted Rates* for Cancer Incidence by Race/Ethnicity Table 3 shows the 2002–2006 age-adjusted North Carolina Residents, 2002–2006 rates for cancer incidence, comparing

Site American Indian White African American American Indians, whites and African Americans. American Indians had Female Breast 45.6 149.5 143.0 Lung / Bronchus 60.5 76.9 69.9 substantially lower rates of breast, prostate, Prostate 84.0 136.8 242.5 lung, and colon cancers, though their age- Colon / Rectum 30.2 46.9 57.5 adjusted liver cancer rate was higher than Liver 6.2 4.4 5.1 the rate for whites. Total Cancer (All sites) 348.7 478.0 497.9 American Indians in North Carolina had a * Rates are age-adjusted to the 2000 U.S. standard population and are expressed as deaths per 100,000 population. Female and male population estimates, respectively, are used in the denominators of the lower rate of new cancer cases during 2002– female breast and prostate cancer incidence rates. 2006 than whites (age-adjusted rate of 348.7 versus 478.0 for whites). However, there is some indication that American Indian Fi gure 2 race is not always accurately captured on Pe rcentages of No rth Carolina Adults with Se lected Chronic Conditions, by Race/Ethnicity cancer and other health records (this issue (Based on Weighted 2005/2007 and 2006–2008 BRFSS Survey Data) is discussed in the section Challenges of Collecting Accurate Data); this may 50 40.8 45 42.4 partially account for the lower cancer rate 40 33.3 35 among American Indians. 29.9 30.5 29.1 ge 30 ta 25 18.6 20 13.3 14.8 P ercen 13.7 15 11.6 Chronic Diseases 10 9.4 5 Figure 2 compares the percentages of adult 0 Diabetes High Blood As thma Ar thritis American Indians, whites, and African (2006–2008) Pressure (2006–2008) (2005/2007) (2005/2007) Americans who reported that they had

Americ an I n dian White African Americ an certain chronic conditions. American Indians were significantly more likely than whites to report that they had diabetes and arthritis, or that they ever had asthma. Figure 3 Rates (per 100,000 Population) of Diagnosed Adult/Adolescent (Ages 13+) Ne w Cases of HIV HIV and Sexually Transmitted by Race/Ethnicity, North Carolina, 2004–2008 Diseases 80 74.4 Figure 3 shows the rate of newly diagnosed on 70 ti la 60 cases of HIV. The HIV rate for American

opu 50 Indians is nearly 80 percent higher than 40 the rate for whites, but much lower

100,000 P 100,000 30 r r than the rate for African Americans.

pe 20 16.0 Figure 4 presents the overall rate of certain

ses ses 9.0 10 sexually transmitted diseases (early syphilis, Ca 0 gonorrhea, and chlamydia) for American American Indian WhiteAfrican American Indians, whites, and African Americans

Minority Health Facts ♦ American Indians — July 2010 4 Office of Minority Health and Health Disparities and State Center for Health Statistics during the period between 2004–2008. Figure 4 Rates for American Indians are all at least Rates (per 100,000 Population) of New Cases of twice the corresponding rates for whites, Sexually Transmitted Diseases, by Race/Ethnicity but much lower than the rates for African North Carolina, 2004–2008 Americans. 1,200

on 982.1 ti 1,000 la

opu 800 604.3 Health Risk Factors 600

100,000 P 100,000 396.0 Table 4 presents BRFSS survey data r 400 pe for North Carolina adults who reported 191.4 ses ses 200 127.6

Ca 40.0 selected risk factors or conditions. 4.5 2.2 18.4 0 American Indians in North Carolina American IndianWhiteAfrican American were significantly more likely than Syphilis Gonorrhea Chlamydia whites to smoke, not engage in leisure- time physical exercise, and to be overweight or obese. Table 4 Percentages of North Carolina Adults with Selected Risk Factors/Conditions, by Race/Ethnicity 1 2 Access to Health Care (Based on Weighted 2005/2007 and 2006–2008 BRFSS Survey Data) American African Figure 5 shows the percentages of Indian White American

American, white, and African American Current Smoking2 36.4 22.2 22.4 adults who reported certain problems Did not get recommended level of related to access to health care, using physical activity1 56.0 53.6 63.6 2006–2008 North Carolina BRFSS data. No leisure-time physical activity1 35.4 21.3 29.4 Consumption of less than 5 servings American Indians were more likely of fruits and vegetables per day1 79.2 76.2 82.2 than whites or African Americans Binge drinking2 10.6 12.8 9.5 to report that they currently had no Overweight or Obese2 68.6 62.3 74.9 health insurance and that they could not see a doctor due to cost.

Figure 5 Quality of Life Percentages of North Carolina Adults with Problems Re lated to Access to He alth Care, by Race/Ethnicity Table 5 shows the percentages of (Based on Weighted 2006–2008 BRFSS Survey Data)

American Indian, white, and African 40 28.3 American adults with selected indicators 35 25.3 30 related to quality of life, using 2006–2008 23.1 20.5 21.2 ge 25 20.6

North Carolina BRFSS data. American ta 16.7

en 20 14.2 rc 13.5 Indians had the highest percentages 15 Pe of any of the three racial groups for 10 each of these five measures of quality 5 of life: fair or poor health; self-reported 0 No Current Could Not See a No Personal disability; 14 or more poor mental health He alth Insurance Doctor Due to Cost Doctor days in the past month; 14 or more poor American Indian White African American

Minority Health Facts ♦ American Indians — July 2010 Office of Minority Health and Health Disparities and State Center for Health Statistics 5 physical health days in the past month; and Table 5 14 or more days in the past month when Percentages of North Carolina Adults Reporting Selected Health Indicators, by Race/Ethnicity the usual activities of daily living were (Based on Weighted 2006–2008 BRFSS Survey Data) limited.

American African Indian White American Fair or poor health 27.5 15.7 21.6 Maternal and Infant Health Disability 45.6 31.8 34.3 14 or more poor mental health Figure 6 presents data on smoking during days in the past month 19.1 10.8 11.4 pregnancy and prenatal care among 14 or more poor physical health days in the past month 20.4 11.6 12.2 live births to American Indian, white, 14 or more days in the past and African American women residing month when the usual activities of daily living were limited 25.1 14.0 16.0 in North Carolina from 2004 to 2008. American Indian women were the most likely to have smoked during pregnancy, Figure 6 and they were twice as likely than white Percentages of 2004–2008 North Carolina Resident women to have late or no prenatal care. Live Births with Maternal Smoking During Pregnancy and with Late or No Prenatal Care, by Race/Ethnicity Table 6 presents selected 2003–2007 30 results from the Pregnancy Risk 25 24.1 24.0 Assessment Monitoring Systems 21.2 (PRAMS). American Indian women 20

ge were at significantly higher risk than ta 15.0 15

cen white women for (1) unintended r 10.4 10.4 Pe 10 pregnancy, (2) mother not taking folic acid every day during the month before 5 pregnancy, and (3) mother not initiating 0 breastfeeding. Mother Sm oked Be gan Prenatal Care Du ring Pregnancy after First Trimester, or No Prenatal Care Figure 7 shows the percentage of live American Indian White African American births that were low birth weight (less than 5 lbs., 9 oz.) and Figure 8 shows the infant death rate (infant deaths per 1,000 live Table 6 births), for the three race/ethnicity groups. Percentages of North Carolina Women with a Recent Live Compared with whites, American Birth Who Had Selected Risk Factors, by Race/Ethnicity (Based on Weighted 2003–2007 PRAMS Survey Data) Indians have higher rates of low birth weight and the American Indian infant American African Indian White American mortality rate is more than twice the Pregnancy was unintended rate of whites. (wanted later or not at all) 58.2 36.7 61.2 Mother did not take folic acid every day before pregnancy 85.7 64.9 80.5 Child and Adolescent Health Usual sleeping position for baby was not on back 36.5 31.0 53.1 Figure 9 shows the death rate for children Mother did not breastfeed at all 47.1 25.3 41.6 ages 1 to 17 years of age (per 100,000 Mother reported violence during pregnancy 9.5 3.3 7.4 population). American Indian children Mother reported smoking after had the highest death rate among all pregnancy 25.1 18.1 17.0

Minority Health Facts ♦ American Indians — July 2010 6 Office of Minority Health and Health Disparities and State Center for Health Statistics Figure 7 Figure 8 Percentages of 1998–2002 North Carolina Infant Deaths per 1,000 Live Births, Resident Live Births that Were by Race/Ethnicity, North Carolina, 2004–2008 Low Birth Weight, by Race/Ethnicity 18 16 14.4 16 15.1 14 14 13.2 te 12 10.7 12 Ra

10 h 10 ge

ta 7.8 8

en 8 6.2 nt Deat rc

fa 6

Pe 6 In 4 4 2 2 0 0 American Indian WhiteAfrican American American Indian WhiteAfrican American

Figure 9 Deaths per 100,000 Population of Children Ages 1–17 three groups. Figure 10 shows the teen pregnancy by Race/Ethnicity, North Carolina, 2004–2008 rate (reported pregnancies per 1,000 female 50 population for ages 15–19), broken out by the three 40.9 race/ethnicity groups. While the American Indian 40 33.1 teen pregnancy rate slightly exceeded that of te Ra

h 30 African Americans, their pregnancy rate was 23.7 Deat

almost twice the rate of white girls. d

il 20 Ch Understanding the Data 10

In most instances the data presented for American 0 Indians, African Americans, and whites in this American Indian WhiteAfrican American report exclude Hispanics and Latinos. Hispanic is considered an ethnicity, not a race, and Hispanics Figure 10 are often included in the white racial category. Pregnancies* per 1,000 Girls, Ages 15–19 Removing Hispanics/Latinos from the racial groups by Race/Ethnicity, North Carolina, 2004–2008 allows for a more accurate portrayal of health 100 85.7 86.9 3 90 disparities by race (for data on persons of Hispanic/ 80

Latino ethnicity, see the report “North Carolina te 70 Ra y y Minority Health Facts: Hispanics/Latinos”). 60 nc

na 50 43.9 Some of the rates presented in this fact sheet eg Pr 40

are age-adjusted. This is a statistical technique en 30 for calculating rates or percentages for different Te 20 populations as if they all had the age distribution 10 of a “standard” population (in this publication, the 0 2000 United States population). Rates adjusted American Indian WhiteAfrican American * Reported pregnancies include live births, fetal deaths of 20 or more weeks to the same standard population can be directly gestation, and induced abortions.

Minority Health Facts ♦ American Indians — July 2010 Office of Minority Health and Health Disparities and State Center for Health Statistics 7 compared to each other, with differences being the National Center for Health Statistics found that attributed to factors other than the age distributions death rates for minority groups tend to be biased in of the populations. two directions: upward due to undercounting of the population in the denominator, and downward due Confidence intervals are displayed for the BRFSS to undercounting of health events in the numerator.5 figures (Figures 2 and 5). The confidence interval is This study found that the net effect of these two the range within which we would expect the “true” biases was that officially reported death rates for population percentage to fall 95 percent of the time. American Indians were understated by 21 percent. As an approximation, if the confidence intervals of groups being compared do not overlap, then the The State Center for Health Statistics recently difference is statistically significant at the 95 percent provided 932,670 North Carolina death certificate level. records for the 14-year period from 1990–2003 to On most health records, information about the the federal Indian Health Service (IHS) National specific tribe to which an American Indian belongs Epidemiology Program, which matched the is not requested or reported. For this reason, and certificates to its national IHS patient database. also due to problems in obtaining accurate tribe- Only deaths of members of the Cherokee tribe specific population data to use as denominators would be expected to match to the IHS patient in rates, the data in this report are presented for records, since no other tribes in North Carolina are North Carolina American Indians as a whole. In served by the IHS. Results show that, over this 14 general, whites and African Americans are used year period, 1,032 North Carolina death certificates as comparison groups. The white population is that had race recorded as American Indian matched often used as a point of comparison in the report to the IHS patient records. However, another 172 to determine the health disparities for American death certificates that did not have race recorded Indians, because whites are the majority population as American Indian also matched to the IHS in North Carolina and because they often have the patient records. Similar results have been found best health outcomes. Comparing American Indians with cancer incidence data that is routinely linked to the white majority population does not mean with the IHS, suggesting an undercounting of that whites are setting a “gold standard.” The white American Indian deaths from North Carolina population in North Carolina also has major health death certificates. issues that need to be addressed. However, for the majority of health indicators, if American Indians The survey data used in this report also have had the same rates as the white population, then limitations. The BRFSS and CHAMP surveys are significant improvements in health would be made. landline telephone surveys. While only about 5 percent of households in North Carolina do not have a telephone,6 the surveys will miss all of these Challenges of Collecting Accurate Data households, which often are lower socioeconomic American Indians in North Carolina experience status. This may result in underreporting of certain worse outcomes on many health measures than health problems. In addition, recent increases do whites. Some of these measures rely on death in the number of cell phone-only households, certificate data, where there may be misreporting has implications for traditional landline surveys of the race of the decedent.4 Also, the U.S. Census such as the BRFSS and NC CHAMP. Cell phone has historically undercounted minority populations, only samples are more likely to be male, African and low population estimates (based on the American, Hispanic, under the age of 34, employed, Census) in the denominators of rates would lead of lower income, and unmarried. Both NC BRFSS to overestimation of health problems. A study by and NC CHAMP weight their survey data to adjust

Minority Health Facts ♦ American Indians — July 2010 8 Office of Minority Health and Health Disparities and State Center for Health Statistics for landline sampling deficiencies. Due to a lack of The North Carolina American Indian Health Task knowledge about a particular question or a tendency Force was created in 2004 by the North Carolina to provide socially acceptable answers, some Commission of Indian Affairs and the Secretary respondents may misreport some health problems. of the North Carolina Department of Health and Human Services. The purpose of the task force The BRFSS, CHAMP, PRAMS, and birth certificate was to identify and study American Indian health data that are presented in this report have the issues in North Carolina and to evaluate and advantage in that the respondent is asked to self- strengthen programs and services for American report his or her own race during the survey or Indians in the state. on the mother’s birth certificate worksheet. For the cancer and HIV/STD case data, however, race may be determined by the health care provider’s observation or derived from medical records, which References can lead to misclassification.7 For death certificates, 1. United States Department of Health and Human the funeral director should ask a family member or Services (US DHHS), Centers for Disease Control and other informant the race of the decedent; however, Prevention (CDC), National Center for Health Statistics the race sometimes is assigned just by physical (NCHS), Bridged-Race Population Estimates, United States July 1st resident population by state, county, age, appearance, leading to possible misclassification.8 sex, bridged-race, and Hispanic origin, compiled from 2000–2008 (Vintage 2008) bridged-race postcensal population estimates, on CDC WONDER On-line Conclusion Database. http://wonder.cdc.gov/Bridged-Race-v2008. This report shows that, for most of the measures HTML. presented here, American Indians in North Carolina 2. United States Census Bureau, 2008 American experience substantially worse health problems Community Survey. than whites. For many health measures, American Indians experience problems similar to those for 3. Buescher P, Gizlice Z, Jones-Vessey K. Self-Reported African Americans in the state. versus Published Data on Racial Classification in North Carolina Birth Records. SCHS Studies, No. 139. State The North Carolina Commission of Indian Affairs Center for Health Statistics, North Carolina Department has been active in advocating for issues related to of Health and Human Services, February 2004. www. schs.state.nc.us/SCHS/pdf/SCHS139.pdf. American Indian health since 1995. Since 2001, the Commission has organized statewide conferences 4. Sorlie PD, Rogot E, Johnson NJ. Validity of demographic designed to raise awareness of the health needs of characteristics on the death certificate.Epidemiology American Indians (Indian Unity Conferences, Indian 1992; 3:181–184. Health Summits, etc.); developed and implemented 5. Rosenberg HM, Maurer JD, Sorlie PD, et al. Quality of health care best practice guidelines; and facilitated death rates by race and Hispanic origin: a summary of networking among health care providers and current research, 1999. Vital and Health Statistics 1999; organizations to increase the awareness of the Series 2, No. 128. Hyattsville: National Center for Health health needs of American Indians. It also has been Statistics. instrumental in addressing health concerns in American Indian communities, including promoting 6. Blumberg SJ, Luke JV, Davidson G, Davern ME, Yu T, Soderberg K. Wireless substitution: State-level estimates diabetes education in American Indian churches, from the National Health Interview Survey, January– smoking cessation for American Indian youth, and December 2007. National Health Statistics Report; substance abuse awareness in American Indian No. 14. Hyattsville, MD: National Center for Health communities. Statistics, 2009.

Minority Health Facts ♦ American Indians — July 2010 Office of Minority Health and Health Disparities and State Center for Health Statistics 9 7. Greenlee R. Evaluation of methods to estimate and compare race/ethnicity specific cancer incidence rates using combined central cancer registry data. Springfield, IL: North American Association of Central Cancer Registries, June 2004.

8. Hahn RA. Why race is differentially classified in U.S. birth and infant death certificates: an examination of two hypotheses. Epidemiology 1999; 10:108–111.

Photo Identification and Credits for Masthead (left to right) • Dr. Martin Brooks, Family Medical Practitioner, The Lumbee Tribe of North Carolina • Quay Lynch, Miss Indian North Carolina 2010, Haliwa- Saponi Indian Tribe. • Drew Allen, permission given by his mother, Kristy Locklear, The Lumbee Tribe of North Carolina. • Addell Locklear, permission given by Mrs. Locklear and her granddaughter, Rudine Locklear, The Lumbee Tribe of North Carolina. • Leattner Keanu Locklear, permission given by his mother, April Locklear, The Lumbee Tribe of North Carolina. • Tamara Lowry, Lumbee Tribe’s 2010 Pow Wow, permission given by Ms. Lowry and her aunt, Una Locklear, The Lumbee Tribe of North Carolina.

Minority Health Facts ♦ American Indians — July 2010 10 Office of Minority Health and Health Disparities and State Center for Health Statistics

State Center for Health Statistics Office of Minority Health and Health Disparities Karen L. Knight, Director Barbara Pullen-Smith, Director 1908 Mail Service Center 1906 Mail Service Center Raleigh, NC 27699-1908 Raleigh, NC 27699-1906 919.733.4728 919.431.1613 www.schs.state.nc.us/SCHS www.ncminorityhealth.org

State of North Carolina Beverly Eaves Perdue, Governor Department of Health and Human Services Lanier M. Cansler, Secretary www.ncdhhs.gov Division of Public Health Jeffrey P. Engel, M.D., State Health Director Chronic Disease and Injury Section Ruth Petersen, M.D., M.P.H., Chief The North Carolina Department of Health and Human Services does not discriminate on the basis of race, color, national origin, sex, religion, age, or disability in employment or the provision of services. 07/10

Department of Health and Human Services State Center for Health Statistics 1908 Mail Service Center Raleigh, NC 27699-1908