Regional differences in Indian health - 1997

This study (1) determined the present health status of the urban Indian population in the State of Arizona, and determined the extent of use and availability of all health resources for that population, (2) identified the health needs of the population and the barrier\\u27s that exist in addressing those needs, and (3) provided accurate and timely information that will serve as an objective base for decision making in addressing the identified needs and problems.A needs assessment approach was used with an overall framework represented by the model: Health Status (minus-) Health Resources Used (plus+) Barriers/Health Resources Not Used (equals=) Health Needs. The study also incorporated the PRECEDE model developed by Lawrence Green of the University of Texas and the Needs Assessment for Prevention Planning developed by the Alcohol, Drug Abuse and Mental Health Administration of the PHS. The study used data compiled on the Phoenix Service Unit for Phoenix and the Pima County urban census tract mortality data for Tucson. Interview data and other sources were also used.The health status of urban Indians in Arizona is poor, and three of the six major causes of death - accidents, alcoholism, homicide - are complex problems with which medical technology has had little success. Heart disease, cancer and diabetes, the other leading causes of death are chronic conditions requiring long-term health monitoring. Urban Indian reported high prevalence of vision problems (40.5%), overweight (37.3%), dental (30.7%), and back problems (21.7%). Mental health problems affected many in the Indian community - 14.5% reported anxiety and depression and 13.5% reported fatigue and exhaustion. Infant mortality rates for urban Indians are well above the rate of the Arizona general population and the overall Arizona Indian population. The urban Indian infant mortality rate exceeds the 1990 U.S. Surgeon General\\u27s Objective for the nation by 60%. Health risk factor levels are high among the Arizona urban Indian community. High blood pressure readings in the Indian males combined with the low numbers taking blood pressure medication point to the importance of screening and follow-up for heart health risks. Levels of obesity, binge drinking and diabetes are also elevated within the urban Indian community in Arizona. Other health risks of urban Indians include high driving speeds, driving while intoxicated, and sedentary life-styles. The major source of health care for urban Indians is the IHS. Other sources such as county medical facilities, community health centers, and private providers are rarely used. Over 40% of the urban Indian community went to the emergency room for health care during 1988. However, many of these visits represent inappropriate use of the emergency facilities. Social services in the metropolitan areas are under-utilized by the Indian community. Indian-specific programs with the exception of alcohol-related services and Women, Infants, and Children (WIC) nutrition services are not available. Both WIC and the alcohol-related programs are among the few used by the Indian community, indicating that services geared toward Indian people will have greater utilization than those not culturally specific. American Indians living in urban areas with limited access to phones and transportation are best reached by the word-of-mouth about services. American Indian staff in urban health programs, particularly the Community Health Representatives, provide an important link to the urban Indian community. They are able to outreach through their work in both homes and community health. They can follow the movement of clients through their family and friends within the community. Most of the urban health programs provide transportation services that enable urban Indians to access services they would otherwise forego. Barriers to care were identified in the categories of socioeconomic factors, lack of health insurance, complexity of Medicaid program requirements, limited availability of services for low-income Indians in urban areas, and limited accessibility and acceptability of services for urban Indians. The combination of poor health status, underutilization of services, and numerous barriers to services leave the urban Indian community with service requirements for medical items, prescriptions, emergency care, pediatric care, and overnight hospital stays. In addition, culturally sensitive mental health programs are needed based on the high prevalence of anxiety, depression, and exhaustion within the community. There is a critical need for basic preventive, family-centered medical services, and for comprehensive perinatal care. Because of the high number of young children, there is a great need for well-child clinics focusing on preventive medicine. Clinics providing culturally-specific services need to be incorporated into the health plan for the urban Indian community. Low-cost ambulatory clinic facilities with eye and dental care are needed. Prevention programs targeting diabetes, alcohol and drug abuse, sexually transmitted diseases, violence, and accidental injuries should be established to assuage the high costs of such conditions among urban Indian communities in Arizona. Transition programs for new residents in each urban area would help bring Indians into the service stream and avoid the downward spiral into despairing poverty. Indian-specific mental health services are needed to deal with the high rate of homicide and suicide among Indian youth, the high rates of alcohol and substance abuse, and reported mental health problems. In policy terms, there is a need for a Medicaid education program and a coalition of efforts among the tribes, IHS, state, and private agencies. Arizona should be addressed as a contract care state since legislation has been already passed; but no funding has been allocated to carry out the legislation. The role of the Phoenix Indian Medical Center needs to the clarified to establish whether it functions as a referral hospital (as originally intended) or as an outpatient clinic (as it is currently utilized but without adequate resources). The IHS needs to explore the feasibility of shared service in Arizona between urban Indian health care delivery programs and local service units. Full-time urban Indian positions at the state and federal levels need to be established

Evaluation of the IHS Urban Health Business Office Concept

Purpose The Evaluation of the IHS Urban Health Business Office Concept, commonly called the Supplementary Security Income (SSI) Project, was a ten month grant demonstration project that was contracted to the American Indian Health Care Association (AIHCA) by the Indian Health Service (IHS) with cooperation of the Social Security Administration (SSA). The SSA was mandated to increase minority and target population enrollment for SSA benefits. The SSA provided funding to the IHS to oversee a project designed to locate and assist urban American Indians and Alaska Natives (AI/ANs) in applying for SSI. Methods Originally, the project was to be administered from the urban Indian clinics\u27 business offices. Since many urban clinics do not have a business office, AIHCA , IHS, and SSA agreed that locating eligible candidates would be more effectively conducted through established outreach programs. Three urban Indian health programs were chosen as project sites: Minneapolis, Minnesota; Seattle, Washington; and Detroit, Michigan. An AI/AN outreach worker was hired at each site with the responsibility to locate and assist potentially eligible clients from the clinic. The outreach worker reported their findings weekly to the Project Coordinator at AIHCA. Conference calls between the Project Coordinator and outreach workers allowed staff to exchange support and site information. The Project Coordinator made three site visits to each site over the course of the data collection period (March to June 1992). Results A total of 78 people participated in the SSI Project by completing the pre-screening forms and speaking to an outreach worker about the SSI program: 17 from Minneapolis; 13 from Seattle; and 48 from Detroit. Results from this analysis have shown that before this project, 41% of the clients that had completed the intake form had incorrect information about SSI; 17.9% had never heard of SSI before; and 11.5% did not know how to contact SSI. In addition, most staff at the urban Indian health programs had little or no information about SSI. Conclusion The SSI Project has furthered the objectives of the Social Security Administration as well as the American Indian Health Care Association, and has assisted the urban Indian health programs by identifying AI/ANs eligible for SSI as well as other SSA program benefits. This SSI study improved recipients\u27 lives and qualities of life by increasing their income, access to assistance services and health care benefits

Scope of the Problem of Alcohol and Substance Abuse Among American Indian and Alaska Native Communities

Purpose The purpose of this study is to: 1) investigate and examine the Indian Health Service (IHS) and Bureau of Indian Affairs (BIA) programs providing services to American Indians and Alaska Natives (AI/ANs) whom have alcohol and drug problems; 2) focus upon information and budget systems concerning the monitoring of services provided and funds expended; and 3) research the scope of the alcohol and drug problems, financial costs, and human costs among AI/ANs. Methods For operational purposes, this study was split into two major components. The first component involved the examination of current IHS and BIA program information systems with regard to the collection of alcohol and substance abuse (ASA) data. This component culminated with the development and field testing of a prototype, community-based information system to collect data associated with the services being provided by IHS, BIA, and tribal programs. The second component was labeled as the Cost Analysis Component. This component involves description of the scope of the problem of ASA including an economic cost-of-illness analysis to estimate the economic costs of alcohol and drug use and abuse for the AI/AN sub-population and comparisons with the all race data for the base year 1985. Results Some study findings include: 1) the economic burden in 1985 was $900 million nation-wide for Indian communities; 2) both BIA and IHS program information systems were not meeting the requirements of P.L. 99-750; 3) a mechanism like the alcohol and drug community-based information systems prototype should be implemented to assist tribal action committees and communities to make informed decisions; and 4) IHS, BIA, tribal and urban programs have not sufficiently evaluated ASA treatment and prevention programs. Conclusion Although alcoholism, drug abuse, and mental health can be statistically separated, in reality they co-exist, and that future research should include all 3 categories

Urban health program strategic planning report.

The rapidly changing health care delivery environment requires continued adaptation and change if an organization is to survive and fulfill its mission. Strategic planning is concerned with the decisions that must be made for the entire organization for the long-term. The Indian Health Service Urban Health Program, and the individual urban Indian health programs, are at a critical juncture as health care reform is developing for the future. In August 1991, the Indian Health Service published the Indian Health Service Executive Reference Guide on Strategic Planning. This report applied the Strategic Planning and Management Model to the Urban Indian Health Program. Although it sets forth the entire steps of the strategic planning model, it is more accurately a progress report through the first eight steps of the strategic planning model. Subsequent analysis should then continue the process for steps 9 through 11

Assessment of the Health Needs of American Indians/Alaska Natives Living in Cites Not Served by an Urban Indian Health Program Funded by the Indian Health Service

The purpose of this report is to present findings on the health status and health needs ofAmerican Indians and Alaska Natives (AI/ANs) in six urban areas not currently served byurban Indian health programs funded by the Indian Health Service (IHS). In accordancewith requirements of Title V, Section 504, of the Indian Health Care Improvement Act, ahealth needs assessment was conducted in six U.S. cities to determine the health status andhealth needs of AI/AN residents in these urban areas.Several methods were used to conduct the assessment including: 1) analysis of 1990 Census population data; 2) analysis of city-specific mortality data; 3) meetings with AI/AN community leaders; 4) meetings with local health officials; and 5) analysis of selected health indicators, Health Risk Appraisals, and Community Health Assessment data.Heart disease is the leading cause of death among urban AI/ANs. Certain cardiovascular risk behaviors such as smoking, obesity, and lack of exercise, are more prevalent among assessment participants than among the U.S. general population. Accidents are the third leading cause of death among urban AI/ANs. Injury associated risk factors include lack seat belt use, drinking and driving, and binge drinking. Twelve percent of assessment participants report they are diabetic. Leading problems reported by participants when seeking health care include cost, lack of health insurance, and lack of AI/AN health providers. Lack of knowledge of available local health services and the perception that mainstream health providers don\u27t understand their health needs are also problems reported by participants.The study produced recommendations in the following areas: 1) steps needed for local urban AI/AN organizations to pursue Title V funding through the Indian Health Care Improvement Act for additional urban Indian health programs; 2) increase awareness on the part of the city, county, and state health officials of the need to improve the accuracy of mortality and morbidity statistics for AI/ANs living in urban areas; and 3) increase awareness on the part of health department and community health center administrators of the need for health services among their community\u27s AI/AN population

Assessment of the health care needs of the urban Indian population in the State of Arizona.

This study (1) determined the present health status of the urban Indian population in the State of Arizona, and determined the extent of use and availability of all health resources for that population, (2) identified the health needs of the population and the barrier's that exist in addressing those needs, and (3) provided accurate and timely information that will serve as an objective base for decision making in addressing the identified needs and problems.A needs assessment approach was used with an overall framework represented by the model: Health Status (minus-) Health Resources Used (plus+) Barriers/Health Resources Not Used (equals=) Health Needs. The study also incorporated the PRECEDE model developed by Lawrence Green of the University of Texas and the Needs Assessment for Prevention Planning developed by the Alcohol, Drug Abuse and Mental Health Administration of the PHS. The study used data compiled on the Phoenix Service Unit for Phoenix and the Pima County urban census tract mortality data for Tucson. Interview data and other sources were also used.The health status of urban Indians in Arizona is poor, and three of the six major causes of death - accidents, alcoholism, homicide - are complex problems with which medical technology has had little success. Heart disease, cancer and diabetes, the other leading causes of death are chronic conditions requiring long-term health monitoring. Urban Indian reported high prevalence of vision problems (40.5%), overweight (37.3%), dental (30.7%), and back problems (21.7%). Mental health problems affected many in the Indian community - 14.5% reported anxiety and depression and 13.5% reported fatigue and exhaustion. Infant mortality rates for urban Indians are well above the rate of the Arizona general population and the overall Arizona Indian population. The urban Indian infant mortality rate exceeds the 1990 U.S. Surgeon General's Objective for the nation by 60%. Health risk factor levels are high among the Arizona urban Indian community. High blood pressure readings in the Indian males combined with the low numbers taking blood pressure medication point to the importance of screening and follow-up for heart health risks. Levels of obesity, binge drinking and diabetes are also elevated within the urban Indian community in Arizona. Other health risks of urban Indians include high driving speeds, driving while intoxicated, and sedentary life-styles. The major source of health care for urban Indians is the IHS. Other sources such as county medical facilities, community health centers, and private providers are rarely used. Over 40% of the urban Indian community went to the emergency room for health care during 1988. However, many of these visits represent inappropriate use of the emergency facilities. Social services in the metropolitan areas are under-utilized by the Indian community. Indian-specific programs with the exception of alcohol-related services and Women, Infants, and Children (WIC) nutrition services are not available. Both WIC and the alcohol-related programs are among the few used by the Indian community, indicating that services geared toward Indian people will have greater utilization than those not culturally specific. American Indians living in urban areas with limited access to phones and transportation are best reached by the "word-of-mouth" about services. American Indian staff in urban health programs, particularly the Community Health Representatives, provide an important link to the urban Indian community. They are able to outreach through their work in both homes and community health. They can follow the movement of clients through their family and friends within the community. Most of the urban health programs provide transportation services that enable urban Indians to access services they would otherwise forego. Barriers to care were identified in the categories of socioeconomic factors, lack of health insurance, complexity of Medicaid program requirements, limited availability of services for low-income Indians in urban areas, and limited accessibility and acceptability of services for urban Indians. The combination of poor health status, underutilization of services, and numerous barriers to services leave the urban Indian community with service requirements for medical items, prescriptions, emergency care, pediatric care, and overnight hospital stays. In addition, culturally sensitive mental health programs are needed based on the high prevalence of anxiety, depression, and exhaustion within the community. There is a critical need for basic preventive, family-centered medical services, and for comprehensive perinatal care. Because of the high number of young children, there is a great need for well-child clinics focusing on preventive medicine. Clinics providing culturally-specific services need to be incorporated into the health plan for the urban Indian community. Low-cost ambulatory clinic facilities with eye and dental care are needed. Prevention programs targeting diabetes, alcohol and drug abuse, sexually transmitted diseases, violence, and accidental injuries should be established to assuage the high costs of such conditions among urban Indian communities in Arizona. Transition programs for new residents in each urban area would help bring Indians into the service stream and avoid the downward spiral into despairing poverty. Indian-specific mental health services are needed to deal with the high rate of homicide and suicide among Indian youth, the high rates of alcohol and substance abuse, and reported mental health problems. In policy terms, there is a need for a Medicaid education program and a coalition of efforts among the tribes, IHS, state, and private agencies. Arizona should be addressed as a contract care state since legislation has been already passed; but no funding has been allocated to carry out the legislation. The role of the Phoenix Indian Medical Center needs to the clarified to establish whether it functions as a referral hospital (as originally intended) or as an outpatient clinic (as it is currently utilized but without adequate resources). The IHS needs to explore the feasibility of shared service in Arizona between urban Indian health care delivery programs and local service units. Full-time urban Indian positions at the state and federal levels need to be established

Evaluating Community-Based Translational Interventions Using Historical Controls: Propensity Score vs. Disease Risk Score Approach.

Many community-based translations of evidence-based interventions are designed as one-arm studies due to ethical and other considerations. Evaluating the impacts of such programs is challenging. Here, we examine the effectiveness of the lifestyle intervention implemented by the Special Diabetes Program for Indians Diabetes Prevention (SDPI-DP) demonstration project, a translational lifestyle intervention among American Indian and Alaska Native communities. Data from the landmark Diabetes Prevention Program placebo group was used as a historical control. We compared the use of propensity score (PS) and disease risk score (DRS) matching to adjust for potential confounder imbalance between groups. The unadjusted hazard ratio (HR) for diabetes risk was 0.35 for SDPI-DP lifestyle intervention vs. control. However, when relevant diabetes risk factors were considered, the adjusted HR estimates were attenuated toward 1, ranging from 0.56 (95% CI 0.44-0.71) to 0.69 (95% CI 0.56-0.96). The differences in estimated HRs using the PS and DRS approaches were relatively small but DRS matching resulted in more participants being matched and smaller standard errors of effect estimates. Carefully employed, publicly available randomized clinical trial data can be used as a historical control to evaluate the intervention effectiveness of one-arm community translational initiatives. It is critical to use a proper statistical method to balance the distributions of potential confounders between comparison groups in this kind of evaluations