SCHS Studies A Special Report Series by the State Center for Health Statistics 1908 Mail Service Center, Raleigh, N.C. 27699-1908 North Carolina Public Health www.schs.state.nc.us/SCHS/ No. 146 December 2004 Health Risks and Conditions among American Indians in North Carolina by Ziya Gizlice, Ph.D. Sara Huston, Ph.D. ABSTRACT Objectives: North Carolina has the eighth largest American Indian population in the United States. American Indians have high death rates for a number of specific causes of death. However, North Carolina has lacked comprehensive statewide information about health risks in its American Indian populations. The objective of this study is to examine health risks and conditions among adult North Carolina American Indians, in comparison to whites and African Americans, and to provide baseline data for health indicators among American Indians. Data: The 2002-2003 North Carolina Behavioral Risk Factor Surveillance System (BRFSS) data. Methods: Unadjusted and age-adjusted percentages and adjusted odds ratios were calculated using weighted BRFSS data for 20 selected health indicators from five major areas: chronic conditions, risk factors, access to health care, preventive behavior, and quality of life. Results: Seventeen of the 20 age-adjusted health indicators examined in this study showed a significant health disparity between American Indians and whites: diabetes (14.1% among American Indians vs. 6.8% among whites); high blood pressure (40.2% vs. 26.6%); asthma (16.4% vs. 11.1%); arthritis (36.3% vs. 29.1%); obesity (33.2% vs. 20.9%); not getting the recommended level of physical activity (71.0% vs. 59.0%); having no leisure- time physical activity (32.4% vs. 23.7%); consuming less than 5 servings of fruits and vegetables a day (80.3% vs.74.8%); not getting a flu shot in the last year (73.0% vs. 66.1%); not having current health insurance (19.2% vs. 13.4%); not being able to see a doctor due to cost (29.4% vs. 12.4%); not having a personal doctor (21.8% vs. 16.4%); fair or poor health (25.9% vs. 17.5%); disability (38.5% vs. 24.9%); 14 or more poor mental health days a month (13.9% vs. 8.8%); 14 or more poor physical health days a month (14.2% vs. 9.7%); and 14 or more activity-limited days a month (11.6% vs. 5.7%). Many of these differences persisted even after controlling for socio-demographic characteristics. Conclusions: North Carolina American Indians adults have significantly higher rates of chronic conditions and risk factors, less access to health care, and lower quality of life compared to whites. The levels of these health problems are similar for American Indians and African Americans. To eliminate health disparities between American Indians and whites and improve the quality of life among American Indians (Healthy People 2010 goals), North Carolina needs to tailor health promotion and disease control programs to the American Indian population. The prevalence estimates provided in this study can serve as baseline information for designing and evaluating these programs. NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES Introduction Studies focusing on health risks at tribal levels also found that many tribes had higher health risks and North Carolina has the eighth largest American conditions than the general populations of the states Indian population in the nation. According to 2002 where these tribes lived. In Montana, more than half United States population estimates, 111,255 of American Indians were current smokers and a American Indians live in North Carolina, approx- third were using smokeless tobacco on the Black- imately 4 percent of all American Indians in the feet Reservation and in Great Falls. 13 Hopi Indian country. American Indians have higher overall death women had a higher obesity rate than other Arizona rates than whites, particularly for heart disease, adult women,14 and Catawba and Lumbee Indians, diabetes, homicide, AIDS, and motor vehicle along with upper Midwest Indians, had higher rates injuries, both in North Carolina and nationwide.1,2 of cardiovascular disease, diabetes, hypertension, Yet there has not been comprehensive North fair/poor perceived health status, and current Carolina statewide information available regarding tobacco use compared to other adults in their states, American Indian health risks, conditions, and respectively. 15,16 behaviors that are associated with these leading causes of death. North Carolina has eight organized American Indian tribes: Coharie, Eastern Band of Cherokee, A few studies have examined health risks and Haliwa-Saponi, Lumbee, Waccamaw-Siouan, behaviors of American Indians nationwide. These Meherrin Indian, Occaneechi, and Sappony tribes. studies found that American Indians were at Only the Eastern Band of the Cherokee Nation is significantly higher risk than whites for fair-to-poor federally recognized and has access to Indian general health status, lack of access to health care, Health Service facilities. Approximately 60 percent binge drinking, cigarette smoking, being diagnosed of North Carolina’s American Indians belong to the with diabetes, and obesity. 3-5 Regional differences Lumbee or Cherokee tribes and live in a few have also been reported among American Indians counties (Hoke/Robeson/Scotland and Jackson/ in prevalence estimates for health risks and Swain). Large population sizes and high con- conditions. 6 For example, the prevalence of current centrations in a few counties have made the cigarette smoking was higher among Northern Plain Lumbee and Eastern Band of Cherokee tribes more Indians (44.1%) than among American Indians attractive to public health researchers to study. A overall in the United States (21.2%). study of Lumbee Indian women in Robeson County found that the prevalence of current smokeless Some studies have examined the health behaviors tobacco use was 20.6 percent, much higher than the and conditions of American Indians only at state or 1.3 percent rate for all North Carolina women, regional levels, often with findings similar to the according to the 2003 BRFSS survey. 17 national results. American Indians had higher rates Another of health risks and conditions than the general study found that prevalence rates of cardiovascular risk factors such as diabetes, hypertension, and high population in Oklahoma,7 and drastically higher cholesterol were much higher among Lumbees, rates of smoking and other cardiovascular disease compared to the state’s adult population.16 risk factors than did non-Indians in Montana 8,9 and Women from the Eastern Band of the Cherokee Nation had in Washington State.10 In contrast, the rate of non- a smoking rate of 39 percent, compared to the state ceremonial smoking among New Mexico rural rate of 25 percent.18 American Indians was lower than among the general population of New Mexico.11 A study in More than 40 percent of North Carolina American Minnesota showed that American Indian-Alaska Indians live in the rest of the 100 North Carolina Native adolescents reported higher rates of health- counties. Comprehensive data have not been compromising behaviors and risk factors than rural available on health risks and behaviors among all white youths in that state.12 American Indians in North Carolina. Recent SCHS Study No. 146 – Health of American Indians2 State Center for Health Statistics expansion of the Behavioral Risk Factor We chose 20 health indicators covering the topics Surveillance System (BRFSS) has yielded a large of chronic disease, health and behavioral risk, enough sample size to study all American Indian preventive practices, access to health care, and adults in North Carolina. This study examines quality of life. Two indicators – high blood pressure health risks and conditions among adult American and not being able to see a doctor due to cost in the Indians in North Carolina in comparison to whites past year – were asked only during 2003. For all and African Americans, using 2002-2003 North other indicators, the two years of data were Carolina BRFSS data, and provides baseline data aggregated. for leading health indicators among North Carolina American Indians. Chronic diseases were determined by self-reports of doctor-diagnosed arthritis, asthma, diabetes, and high blood pressure. The risk factors examined were current smoking, not getting the recom- Methods mended level of physical activity (at least 30 The data used for this study were from the 2002 and minutes per day of moderate physical activity on 5 2003 North Carolina Behavioral Risk Factor or more days per week or at least 20 minutes per Surveillance System (BRFSS), a multistage, day of vigorous physical activity on three or more random-digit dialing, statewide telephone survey of days per week), no leisure-time physical activity, non-institutionalized adult residents age 18 and consumption of less than 5 servings of fruits and older. During the two-year study period, 16,203 vegetables per day, binge drinking, and obesity (a North Carolina adults were interviewed. Of these, risk condition). The two preventive behaviors 12,050 were white, 2,933 were African American, examined were not having a flu shot within the past and 434 were American Indian, based on responses year and never having a pneumonia vaccination. No to two questions about race. (Hispanic ethnicity was current health insurance coverage, not being able not considered in racial grouping.) The first to see a doctor due to cost, and having no personal question was “Which one or more of the following doctor were the measures chosen to examine access would you say is your race?” If a respondent to health care. Fair or poor general health status, reported a single race, the response from the first perceived disability, and three “healthy days” question was used as the race variable. If a measures (14 or more poor mental health days, 14 respondent reported more than one race, a second or more poor physical health days, and 14 or more question was asked: “Which one of these groups activity-limited days in the past month) were used would you say best represents your race?” and the to examine quality of life.