Health Disparities and Community-Based Research for AI/AN People

This review article, published in Diversity and Equality in Health and Care, examines health disparities faced by American Indian/Alaska Native (AI/AN) populations in the United States. The authors, Jones, Weaver, Panahi, and Kamimura, highlight the "invisible minority" status of AI/AN individuals, who experience significant health inequalities compared to other racial/ethnic groups. The paper addresses concerns about nutritional challenges, chronic health conditions like diabetes and cardiovascular disease, and proposes strategies to reduce these disparities. It reviews the impact of federal programs, tribal consultation, and the use of Community-Based Participatory Research (CBPR) to improve health outcomes. The article emphasizes the importance of culturally competent approaches, increased AI/AN stakeholder involvement, and addressing lifestyle issues, particularly for AI/AN people living in urban areas. The paper provides an overview of the historical context, nutritional challenges, and chronic health conditions, while also highlighting the role of CBPR in addressing health disparities and the importance of considering the diversity within AI/AN communities. The article concludes by emphasizing the need for more research and culturally tailored interventions to improve the health and well-being of AI/AN populations.

Diversity and Equality in Health and Care (2018) 15(2): 66-70
Review Article
 2018 Insight Medical Publishing Group
Global Health Care Concerns
Indigenous Peoples’ Health in the United State
Review of Outcomes and the Implementation o
Community-Based Participatory Research
Miranda Jones, Shannon Weaver, Samin Panahi, Akiko Kamimura*
University of Utah, Salt Lake City, UT, USA
ABSTRACT
The American Indian/ Alaska Native (AI/AN) population is
considered an “invisible minority” because their health concerns
are not addressed equitably compared to other racial/ ethnic
minority populations. AI/AN individuals face high rates of
nutritional challenges and chronic health conditions including
diabetes and cardiovascular disease. The purpose of this paper is
to review concerns about AI/AN health disparities and to propose
strategies to reduce these disparities. This work is achieved by
reviewing the evidence for health disparities experienced by
AI/AN populations. The U.S. government has been working
to improve health disparities for AI/AN individuals, through a
number of federally run programs. We propose that one important
strategy is to use a community-based participatory research
approach (CBPR) to reduce health disparities. Because of the
beneficial component of local-level input, CBPR is a powerful
tool for addressing health disparities experienced by AI/AN
populations. We further propose that CPBR should be focused
on tribal consultation in policymaking, an increase in AI/AN
stakeholders, and reducing health disparities in lifestyle issues for
AI/AN people living in urban areas, and reservations.
Keywords: Native American; diet; physical activity;
chronic health conditions; community-based participatory
research
Introduction
American Indian/ Alaska Native (AI/AN) refers to
individuals having origins in any of the original peoples of
North and South America (including Central America) and who
maintain tribal affiliation or community attachment [1]. Between
five to six million people in the United Sates (U.S.) identify as
AI/AN [1]. This racial group comprises two percent of the total
U.S. population [2]. Twenty-two percent of AI/AN individuals
live on reservations that are legal designations for land managed
by recognized AI/AN tribes [2]. In 2010, approximately 70%
of AI/AN people lived in urban areas, representing an increase
from 38% in 1970 and 60% in 2000 [3]. The AI/AN population
can be thought of as an “invisible minority” as their health
concerns are not addressed equitably compared to other racial/
ethnic minority populations [4].
While the U.S. government offers urban Indian health
programs, which provide health care services to AI/AN people,
only 25% of AI/AN people receive health care services through
urban Indian health programs [5]. AI/AN people living in urban
areas are particularly underserved because: 1) AI/AN individuals
in urban areas might have less understanding of traditional
practices as relocation to urban areas has disrupted traditional
culture, while there are no other structures in place to provide
support; and 2) there is an absence of sovereign governing bodies
to provide valuable support for identification and safeguarding
individual rights to health care access [4]. For these reasons,
the awareness of the potentially unique health concerns is
important when considering the federal government’s role in
tribal consultation planning and implementation.
The Department of Health and Human Services (HHS)
strives to provide AI/AN populations comprehensive quality
care. It is vital that the federal government maintains a
relationship with the 567 federally recognized tribes they serve.
In the past, some federal policies have negatively affected health
outcomes for indigenous people of the U.S. [5]. For example,
in 1890, the federal government disrupted tribal culture by
preventing indigenous people from leaving reservations in
search of food [6,7]. Tribes were forced to rely on food rations
provided by the federal government, which consisted of sugar,
lard, and other nutritionally problematic foods. AI/AN people
used these commodities to create a cultural staple, which is
known as “frybread” [8-10]. Frybread is the product of federal
government intervention and has negatively impacted health
outcomes in tribal communities [11]. Mitigating historical
trauma and existing inequality is a key focus of the ongoing
relationship between these two sovereign governments.
As a result of the challenging history between AI/AN
people and the federal government, it is vital that the federal
government works to ensure cultural competency. The Indian
Health Service, a part of HHS, is understaffed and underfunded
which compounds the already inadequate consultation for
AI/AN individuals. [13]. In order to ensure that the federal
government positively affects indigenous communities, it is
critical to review how tribal consultation is being improved by
including indigenous stakeholders in every part of the policy
process (research, discussion, implementation, and review).
The timeline (Figure 1) provides key legislation and executive
orders relevant to the HHS tribal consultation policy and their
relationship with AI/AN people [14].
The purpose of this paper is to review concerns about AI/
AN health disparities and to propose strategies to reduce

Akiko Kamimura67
Global Health Care Concerns
these disparities. This review describes a number of health
issues including nutritional challenges, chronic health issues,
and general health disparities faced by AI/AN people. AI/AN
individuals have an average life expectancy that is five years
less than that of the general U.S. population [15]. The health
disparities experienced by the AI/AN population are significant
enough that their health and mortality patterns are more similar
to those in developing nations than to the general United
States population [16]. This review paper contributes to the
existing data surrounding research of AI/AN people living on
reservations and in urban areas. Due to the potentially shortened
duration of life associated with high rates of chronic illnesses, it
is imperative to continue analyzing current research as well as
conduct further research surrounding AI/AN people. The U.S.
has not historically delegated adequate federal resources to care
for indigenous communities. It is of the utmost importance to
implement health promotion programs associated with the values
and in coordination with the input of these communities [13].
Nutritional challenges
Lack of fertile land for agriculture, coupled with the existence
of food deserts, presents a challenging nutritional landscape
for AI/AN people [17]. The disruption of indigenous peoples’
relationships with traditional foods and reallocated federal land
can be thought of as the heart of their disparities [18].
Chronic health conditions
Poor nutrition has ripple effects throughout the entire tribal
community, from type 2 diabetes to obesity and cardiovascular
disease. The prevalence of diabetes among AI/AN people is
16%, which is greater than any other racial/ethnic groups such
as Blacks (13%), Hispanics (13%), Asian Americans (9%), and
Whites (8%) [19]. AI/AN populations have a higher prevalence
of diabetes related mortality (34.1%) compared to non-Hispanic
whites (18.6%) [20]. The prevalence of obesity among AI/AN
people (43.7%) is much higher compared to non-Hispanic whites
(28.5%) [20]. Likewise, AI/AN people have a higher prevalence
of cardiovascular disease compared to the U.S. general
population [21]. AI/AN adults also have a lower prevalence of
engaging in regular leisure-time physical activity (18.9%) than
white adults (23.4%). These differences extend to important risk
factors for diabetes and cardiovascular disease.
Currently, there exist important health disparities in the AI/
AN population. The U.S. Department of Health and Human
Services, Office of Minority Health, published data summarizing
some key health disparities in chronic conditions (Table 1).
HHS: Brief list of current programs that impact AI/AN
communities
The federal government has been working to improve health
disparities for AI/AN individuals. Congress, in conjunction
with the Indian Health Service, established the Special Diabetes
Figure 1: Major federal laws related to AI/AN populations
American
Indian/Alaska
Native
White
American
Indian/Alaska
Native/white
ratio
Percentage of obese adults, 2015. (Obesity = Body Mass
Index of >= 30)
43.7 28.5 1.5
Percentage of adults with Diabetes, 2014
17.6 7.3 2.4
Age-Adjusted Diabetes Death Rates per 100,000 (2013)
Total 34.1 18.6 1.8
Percentages of coronary heart disease among adults, 2012
8.1 6.2 1.3
Percentage of adults who have high blood pressure, 2012
Total 24.8 23.4 1.1
Source: CDC Health Characteristics of the American India
Alaska Native Adult Population: United States. Table 4. h
www.cdc.gov/nchs/data/nhsr/nhsr020.pdf All data for pe
aged 18 and older.
Table 1: Obesity, Diabetes & Heart Disease: Age-adjusted
health disparities of AI/AN relative to white individuals.
Data from the Center for disease control [25].

Indigenous Peoples’ Health in the United States: Review of Outcomes and the Implementation of Community-Based Participatory Research68
Global Health Care Concerns
Program for Indians (SDPI) in 1997 to provide “funds for
diabetes prevention and treatment services” [22,23]. One of the
current challenges in type 2 diabetes prevention is the ongoing
need for culturally competent techniques. There is a disconnect
between traditional physiological prevention techniques and
techniques informed by consultation with AI/AN stakeholders
[24]. For example, the National Institute of Diabetes and
Digestive and Kidney Disease (NIDDK), Diabetes Prevention
Program (DPP) research showed that modest weight loss,
coming from lifestyle behavior changes could prevent the onset
and the severity of type 2 diabetes among AI/AN people. These
findings do not address the impact of culture on diet and exercise
in tribal communities [25]. These analyses reinforce that cultural
tailoring is necessary for successful diabetes intervention.
A recent effort to interdict in the issue of cardiovascular
diseases involves the “Million Hearts” Initiative [26]. The
Cardiovascular Risk Reduction Model was developed by Million
Hearts as a strategy to assess an approach toward reduction
in 10-year predicted risk of atherosclerotic cardiovascular
disease (ASCVD) [27]. Cardiovascular preventive strategies to
manage the “ABCS” (aspirin therapy in appropriate patients,
blood pressure control, cholesterol management, and smoking
cessation) have been implemented [27]. This initiative identifies
that AI/AN peoples die from heart disease at young age and
rates higher than the rest of the United States population. It is
essential to improve health care services for AI/AN people [28].
Community-based participatory research and the health
promotion approach for AI/AN populations
Many of the chronic conditions, disproportionately
experienced by AI/AN individuals, can be addressed by lifestyle
and healthy behavior changes [29,30]. These behavioral changes
could be influenced by research conducted in the local context
[30,31]. In this way, CBPR is a powerful tool for addressing
health disparities experienced by AI/AN populations and can be
an important component of tribal consultation [24]. CBPR is a
collaborative approach utilizing numerous community partners
within the research model [32,33]. Community partners, who
can be defined as individuals embedded in the local environment
where the research takes place (e.g. an AI/AN health care
provider), contribute expertise and share decision making
in the research process [24]. The CBPR framework brings
together health education, research and social action through
mutually beneficial relationships and long-term collaborative
commitment [34]. This approach recognizes the value of tribal
nations as equal partners who should inform health promotion
activities with traditional knowledge rooted in community
priorities while local stakeholders are active partners in the
health promotion research and interventions [24].
Taking a CBPR approach may also assist in health promotion
efforts in rural areas, where the majority of AI/AN people live.
One of the issues in integrating CBPR methods in indigenous
communities is the difficulty in expanding the community
capacity to sustain health intervention beyond reservations [24].
This may be due to the lack of research focused on the health of
urban-living AI/AN people. For example, less than three percent
of the research findings on AI/AN populations include data on
urban AI/AN populations [4]. It is necessary to conduct more
studies promoting research within urban AI/AN communities
[4].
While CBPR could be an important next step for improving
the lives of AI/AN people living in urban areas, there are three
challenge areas that are anticipated as potential obstacles to
overcome: 1) underrepresentation of AI/AN stakeholders in
key roles; 2) diverse populations within AI/AN communities;
and 3) geographic diversity of tribal nations. AI/AN scholars
and policy makers are severely underrepresented in key areas
needed to implement CBPR [24]. If the federal government
is going to move toward a more community-based approach,
there will need to be an increased commitment to identifying,
recruiting, and training AI/AN individuals to occupy the key
positions needed to appropriately ground this work. Moreover,
the diversity among AI/AN populations acts as a challenge to
implement CBPR. Each AI/AN sub-group needs a different
approach toward policy change, as a one size fits all approach
to complex issues is insufficient [35]. This rationale is also
appropriate for moving tribal consultation to a more community-
based health promotion approach. Creating and implementing a
community-based approach for tribal consultation that honors
this diverse set of voices will be a crucial challenge to meet in
implementation of CBPR.
Conclusion
While there have been efforts to improve health of AI/AN
people, health disparities still exist. AI/AN individuals have the
highest prevalence of type 2 diabetes, obesity, and cardiovascular
disease. AI/AN people have unique cultural needs and a historical
context that requires culturally appropriate responses. Given
the early success of CBPR focused on health concerns such as
obesity and diabetes on reservations, there is a potential that
CBPR will contribute to reducing health disparities for AI/AN
people living in urban areas. Community-based participatory
research could unify current federal tribal consultation with
research involving AI/AN stakeholders to create better health
outcomes for AI/AN people in the US. Tribal consultation and
culturally competent, participatory models are essential to ensure
that federal-level initiatives will improve health outcomes for
AI/AN communities. The disparities in health needs and access
points across rural, urban and reservation based communities
could benefit from further research. Areas for future research
include: interviewing service providers about how CBPR might
impact their patient care (especially among AI/AN populations),
investigating how CBPR has worked with other racial/ethnic
minority populations, and comparing the health outcomes of
populations that have been involved in CBPR to those that have
not. Implementing a pilot based approach would be a beneficial
step to better understand the issues specific to these diverse
community members.
Declarations of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this article.

Akiko Kamimura69
Global Health Care Concerns
Funding and Acknowledgement
The first author had an internship supported by the Hinckley
Institute at the University of Utah that addressed health
challenges for AI/AN populations. She wrote the earlier version
of this manuscript as the internship report.
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Indigenous Peoples’ Health in the United States: Review of Outcomes and the Implementation of Community-Based Participatory Research70
Global Health Care Concerns
Address of Correspondence: Akiko Kamimura, PhD, MSW,
MA. Department of Sociology, University of Utah, 380 S 1530
E, Salt Lake City, Utah 84112, USA, Tel: [phone];
Fax: [phone]; E-mail [e-mail]
Submitted: March 02, 2018; Accepted: March 19, 2018;
Published: March 26, 2018
Special issue title: Global Health Care Concerns
Handled by Editor(s): Dr. Akiko Kamimura Assistant Professor,
Department of Sociology, University of Utah, U.S.