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AHRQ Research and Other Activities Relevant to American Indians and Alaska Natives


  U.S. Department of Health and Human Serviceswww.hhs.gov/ 



AHRQ Research and Other Activities Relevant to American Indians and Alaska Natives 


Preventive Care


The main health challenges currently faced by AI/AN people are the health conditions and chronic diseases related to lifestyle issues such as obesity, physical inactivity, poor diet, substance abuse, and injuries. Preventive health initiatives for AI/AN populations have been undertaken to create healthier communities, improve quality of life, decrease health care utilization, control disability, and improve productivity. Initiatives include developing, coordinating, implementing, and disseminating effective health promotion and chronic disease prevention programs through collaboration with key stakeholders and by building on individual, family, and community strengths and assets.


·         Simple, effective methods to promote increased physical activity yield positive results 


Studies of geographically diverse American Indian tribes consistently show low levels of leisure-time physical activity, less frequent exercise, and a higher proportion of sedentary persons. Researchers found that physical activity among American Indian elders (aged 50-74) can be promoted in a brief, inexpensive manner in primary care. The study randomly divided 125 American Indians into 2 groups, with the first group receiving basic instruction in daily physical activity monitoring and the second group receiving instruction in daily physical activity monitoring augmented with a pedometer to track and record their total daily step counts. At the end of the 6-week study, participant fitness was measured by performance in a 6-minute walk test. Both groups showed similar results. The researchers suggest that the act of self-monitoring can raise awareness of modifiable health habits, create an external environmental reminder to increase personal responsibility, improve self-efficacy, and provide ongoing feedback on progress.


Source: Sawchuk C, Charles S, Wen Y, et al. A randomized trial to increase physical activity among native elders. Preventive Medicine 2008; 47:89-94. (Grant HS10854).


·         Improving preventive services recommendations and reminders 


To improve the quality of preventive services recommendations and reminders, in 2009 AHRQ commissioned a gap analysis to compare its recommendations in the electronic Preventive Services Selector (ePSS) tool, to the preventive health reminders currently in use in the IHS's Resource and Patient Management System (RPMS). The analysis found that the majority of the recommendations in the ePSS tool are not currently contained in the RPMS, and the ones that are have slightly different logic definitions. However, the RPMS does contain sufficient data elements so that the AHRQ recommendations can easily be built into the Best Practice and Health Maintenance sections of the existing RPMS Health Summary. (AHRQ Contract).


·         AHRQ provides support for prevention and care management services 


An interagency agreement has allowed AHRQ to provide funding to the IHS to support the improvement of the delivery of prevention and care management services through the IHS Chronic Care Initiative (CCI). This agreement uses the CCI's key strategy, the Collaborative Innovations in Planned Care for the Indian Health System (IPC-IHS). The IPC collaborative will focus on the self-management support component of the Chronic Care Model and provide training in the 5 A's model of behavior change (Assess, Advise, Agree, Assist, Arrange) and motivational interviewing for teams. The collaborative also supports primary care practices to improve chronic illness and preventive care for AI/ANs. The 2-year project will help to answer questions about what elements can be integrated into the IHS electronic health record (EHR) to prompt and document self-management support. Another area to be explored is what key measures should be collected from the EHR to drive performance improvement. (AHRQ and IHS Interagency Agreement).


Quality of Care


A primary interest of AHRQ is improving the quality of health care in the United States. Improving quality of care for AI/ANs poses various challenges. Overall, AI/ANs receive worse care than whites for more than 40 percent (9 of 22) of core quality measures and better care for nearly 25 percent (5 of 22) of core quality measures, according to AHRQ's 2009 National Healthcare Quality Report. The Agency has funded several studies aimed at improving care quality for AI/ANs.


·         Project seeks ways to improve CAHPS® and enhance its impact 


The Yale CAHPS® team is conducting a Quality Indicators (QI) project with the Eastern Shoshone and Northern Arapaho Tribes of the Wind River Indian Reservation in Wyoming and with the Assinniboine and Sioux Tribes of the Fort Peck Indian Reservation in Montana. The Yale team has worked with the Tribal Health Directors at Wind River and the IHS leadership team to develop a modified version of the CAHPS® 3.0 instrument. This instrument is being used to collect data to identify specific areas for targeted QI interventions. Baseline data has been collected and reported to the Tribal-IHS Working Group. This team is now developing a detailed plan for the QI initiative which will be presented to the Tribal Health Directors and IHS for review. At the Fort Peck Indian Reservation, the Tribal Health Director is interested in conducting QI interventions at the tribally operated dialysis unit. The team, with input from the Tribal Health Director, has developed a modified version of the CAHPS® In-Center Hemodialysis Survey that will be used to collect baseline data through which to identify the specific QI initiative to be implemented. It is anticipated that a QI project will also be conducted with the Fort Peck IHS Service Unit. (Principal Investigator: Paul D. Cleary, Yale University; Grant HS16978, 9/01/07-8/31/12).


·         Project to improve race and health status data for Pacific Northwest States 


The Improving Data and Enhancing Access-Northwest Project seeks to more accurately characterize health status and clinical outcomes data for Northwest tribal people, while working to minimize and eventually eliminate racial misclassification errors in State surveillance data systems. To identify and correct racial misclassification, the project will conduct record linkages with an array of health-related data systems in a three-State region. Ultimately, it will disseminate results and develop concrete methods by which other States and Tribal Epidemiology Centers may implement similar programs. AHRQ is providing support for this project through funding received from the American Recovery and Reinvestment Act of 2009. (Principal Investigator: Victoria Warren-Mears, Northwest Portland Area Indian Health Board; Grant HS19972, 9/30/10-9/29/13).


·         Medical home model for Alaska Natives to be assessed for impact on patient care delivery 


The Southcentral Foundation (SCF), a tribally owned organization, implemented a patient-centered medical home (PCMH) in 1999 and 2000 in Anchorage, Alaska. The SCF PCMH has three key characteristics: patient-selected family match to a primary care team, patient-driven care, and advanced access. In this project, the University of Alaska and the SCF are partnering to determine the impact of the PCMH transformation on the characteristics and quality of patient care delivery, and to assess changes in health care delivery, such as quality and safety efforts, efforts to bring evidence to the point of care, use of information systems, and costs. This PCMH model could have national implications for improving the health of the AI/AN population and may also be relevant to other practices serving diverse populations with multiple health disparities. (Principal Investigator: David L. Driscoll, University of Alaska at Anchorage; Grant HS19154, 7/01/10-6/30/12).


·         Electronic clinical data to assist in assessing comparative effectiveness of quality improvement efforts 


Over the past decade, the IHS has developed a national information technology infrastructure that allows for the routine, reproducible measurement of ambulatory quality of care across a spectrum of conditions for AI/AN communities. This infrastructure represents a model for evaluating the use of a nationally integrated health information system to conduct comparative effectiveness research (CER) and ultimately identify the most capable quality improvement activities. This project will use electronic clinical data from the IHS national health information systems to create a longitudinal database linking quality of care measures for diabetes, cardiovascular disease, and cancer screening over a 9-year period. A second objective will be to conduct two comparative analyses to determine the effectiveness of delivery system interventions, such as the use of an advanced EHR, and a chronic care model (Improving Patient Care) to assess health care quality and outcomes for diabetes, cardiovascular care, and cancer screening. AHRQ is providing staff support to IHS in this project with funding received from the American Recovery and Reinvestment Act of 2009.


·         Study links funding levels of tribal health programs to outcomes 


Tribally Operated Health Programs (TOHPs) provide care nationally to more than one-third of the 1.8 million AI/ANs who obtain services from the IHS. Many unnecessary hospitalizations can be prevented with access to comprehensive effective ambulatory care. This study found that higher IHS funding levels for TOHPs in California were associated with lower rates of hospitalization for ambulatory care-sensitive conditions (HASCs) by the AI/ANs who used them. On average, IHS funding pays for less than 49 percent of the medical care provided by TOHPs in California. For TOHPs with funding less than 60 percent of what the Federal government pays for Federal employee medical care (benchmark), the HASC rate dropped 12 percent for every 10 percent increase in funding. Even when adjusted for confounding characteristics, the funding effect was between 9 and 11 percent. The authors concluded that additional funding of tribal program health care is likely to improve outcomes of care for the AI/AN population.


Source: Korenbrot C, Kao C, Crouch JA. Funding of tribal health programs linked to lower rates of hospitalization for conditions sensitive to ambulatory care. Medical Care 2009 Jan; 47(1):88-96.


·         Collaboration creates community health information exchange network 


This project includes a collaborative partnership among 12 agencies, including a rural acute care hospital, a large American Indian tribal entity, an IHS hospital, a community health center, a health department, and a community consortium. The total patient population is 250,000 in 14 counties in rural northeastern Oklahoma. The project includes three components for improving quality of care. The first, Healthfinder, is an electronic and telephone resource to assist consumers in locating health providers and social services. It also assists providers in meeting community needs. Healthfinder (www.okhealthfinder.com) includes a special section to assist AI/ANs in finding tribal and IHS resources. The second component implements an integrated community health information exchange network to facilitate provider coordination and transfer of critical patient information. The network is using Hastings Indian Medical Center, an IHS facility, and the Cherokee tribe, the second largest tribe in the country, as initial connections with the goal of allowing all IHS and Native American tribes to connect quickly and inexpensively through the network.The last component explores areas for the most cost-effective prevention strategies and adopts common objectives for prevention interventions and outcome measurement. This project builds on an earlier 1-year planning grant (HS15364) by the same investigator. (Principal Investigator: Mark Jones, Tahlequah City Hospital; Grant HS16131, 9/30/05-9/29/08)


·         Study seeks strategies to improve performance based on priority issues 


In addition to supporting the development of a sustainable research infrastructure for the Montana/Wyoming Tribal Leaders Council, Black Hill State University, and the Black Hills Center for American Indian Health, this project funded a study aimed at designing, implementing, and evaluating the effectiveness of a structured process in which tribal members and IHS providers jointly developed strategies to improve performance based on priority issues identified through a consumer survey. Investigators developed a targeted research agenda that addressed tribally identified priority issues, such as hepatitis C, West Nile virus, and methamphetamine use. (Principal Investigator: Gordon Belcourt, Montana/Wyoming Tribal Leaders Council; Grant HS14034)


·         Database developed to assist in health care planning 


This grant enabled the development of a shared resource database for tribes to use in health care program planning and application development. It includes area- and tribal-specific data, "best practices" papers, and links to resources on health topics of interest to the tribes. It is currently being maintained by the Rocky Mountain Tribal Epi-Center. Principal Investigator: Gordon Belcourt, Montana/Wyoming Tribal Leaders Council (Grant HS14034)


Research Considerations


When researchers study AI/AN people, they need to be able to understand, appreciate, and use culturally appropriate strategies. For example, they need to understand AI/AN cultural values and language barriers that alter perceptions of informed consent to research participation. By demonstrating cultural competence, researchers can avoid stereotypes and biases that can undermine their efforts. It also promotes a focus on the positive characteristics of a particular group. Cultural competence acknowledges and incorporates at all levels the importance of culture, the assessment of cross-cultural relations, vigilance toward the dynamics that result from cultural differences, the expansion of cultural knowledge, and the adaptation of services to meet culturally unique needs.


·         Project to improve the quality of race and ethnicity data in hospital discharge and emergency department databases in New Mexico 


New Mexico's Improving the Quality of Race and Ethnicity Data Project will contribute to reducing racial and ethnic health and health care disparities by improving the reliability of race, ethnicity, and tribal affiliation hospital data in the State. Guided by a State advisory committee, between 5 and 10 pilot hospitals will field test training materials that will be developed for the project. These will include hospital procedure, data collection, patient education, and train-the-trainer materials. Hospital discharge records will be linked with birth certificate records and IHS records to track improvements. New Mexico expects to establish a model for the collection, reporting, and appropriate dissemination of tribal identifier data which will be informally disseminated to other States and through a published manuscript. AHRQ is providing support for this project through funding received from the American Recovery and Reinvestment Act of 2009. (Principal Investigator: Michael Landen, New Mexico State Department of Health; Grant HS20033, 9/30/10-9/29/13).


·         Coding problems inhibit ability to study American Indian acute inpatient hospital data 


Reliable coding of race and ethnicity by hospitals represents a critical step toward assessing and addressing racial and ethnic disparities in acute inpatient care. The authors examined the reliability of race and ethnicity classifications by different hospitals who admitted the same patients in a large, diverse State. The rates of coding agreement for American Indians were very low (19 percent), compared with whites (91 percent) and blacks (88 percent). There was a similar pattern for hospital data and death certificates with agreement of only 27 percent for American Indians. The authors concluded that coding agreement is too low for American Indians (as well as persons born in American Indian and selected Hispanic subgroups) for these groups to be studied using this data.


Source: Fiscella K. and Meldrum S. Race and ethnicity coding agreement between hospitals and between hospital and death data. Med Sci Monit 2008; 14(3):SR9-SR13. (Grant HS10910).


·         Individual consent in research can clash with community values 


Reflecting on a decade of research among American Indians in the Southwest, the author studied the biomedical ethics of individual autonomy, which can be incompatible with the culture mores of strong family, community, and group decisionmaking. The author suggests that alternative approaches to informed consent and ethics are called for.


Source: Smith-Morris, CM. Autonomous individuals or self-determined communities: The changing ethics of research in Indian country. Human Organization 2007 Fall;66(3);327-336. (Grant HS10802)


·         AI/ANs difficult to reach by mail 


The researchers sent a calendar with preventive health information to one group and no health information to the control group via first class mail to 5,633 patients who had been seen at a clinic during the past 2 years. Based on initial mailings and in-person location efforts, an estimated 61 percent of patients received the calendars. The mail verification process was significantly less likely to identify addresses for patients who were AI/AN and those who were seen more than 3 months before the study. In fact, AI/ANs were about half as likely as non-AI/ANs to have accurate addresses. The results suggest that it is difficult, but possible, to use the U.S. Postal Service to reach patients seen at an urban Indian health facility.


Source: Duffy D, Goldberg J, Buchwald D. Using mail to reach patients seen at an urban health care facility. J Health Care Poor Underserved 2006 Aug;17: 522-31. (Grant HS10854)


·         Nearly half of urban AI/ANs travel back to their reservation yearly 


Of the more than two million AI/ANs living in the United States today, only 25 percent reside on reservations, while 60 percent live in cities. Those who live in cities often travel to reservations, yet little is known how this travel may be related to health. Researchers surveyed more than 500 AI/AN adults at a primary care clinic in Seattle about time spent visiting a reservation during the past year, and the person's sociodemographic, cultural, and clinical characteristics. Thirty-four percent of respondents had spent up to 30 days traveling, 14 percent had spent more than 30 days traveling, and 52 percent had not traveled to reservations. Strong Native American cultural identification, presence of lung disease, absence of thyroid or mental problems, and greater dissatisfaction with care were independently associated with more travel to reservations. Reservation visits were not consistently linked to self-reported health outcomes, nor could the researchers determine how often respondents traveled to the reservation for health care. The findings underscore the importance of considering the role of culture as well as residence and patterns of travel in both research and clinical care involving AI/ANs.


Source: Rhoades DA, Manson SM, Noonan C, Buchwald D. Characteristics associated with reservation travel among urban Native American outpatients. J Health Care Poor Underserved 2005 Aug;16(3):464-74. (Grant HS10854)


·         Strictly translated informed consent documents promote mistrust 


Interpreters and a Navajo language consultant developed a translation in Navajo of a standard consent form for participating in a study. After using the form for 4 months, the researchers learned that the formal consent process often led to confusion and mistrust of the research. The researchers stress that cross-cultural communications and translations increase effectiveness.


Source: McCabe M, Morgan F, Curley H, et al. The informed consent process in a cross-cultural setting: Is the process achieving the intended result? Ethn Dis 2005 Spring;15(2):300-4. (Grant HS10637)


Research Infrastructure Development


A major AHRQ goal is to build research infrastructure and enhance opportunities for AI/AN investigators in health services research.


·         Partnerships formed to foster research and research training 


In addition to building the research capacity for the Native American Research Center for Health (NARCH), this multiyear project aimed to identify which health care characteristics of tribal health program service systems are associated with preventable hospitalizations. AHRQ became a partner in the NARCH program in 2005, supporting the California Rural Indian Health Board's NARCH grant. This program—which aimed to develop opportunities for conducting research and research training that respond to the needs of AI/AN communities—was predominantly funded by the National Institutes of Health and managed by the IHS. The centers created partnerships between AI/AN organizations and research-intensive institutions. Further information on the NARCH grants can be found at http://www.ihs.gov/MedicalPrograms/Research/narch.cfm.


·         Project studies comparative effectiveness of disease management by IHS advanced practice pharmacists 


This project seeks to create an IHS database/data infrastructure that will support the conduct of comparative effectiveness research (CER) and to conduct a CER study of a health system delivery strategy designed to improve health outcomes among AI/ANs with diabetes and CVD. The data infrastructure will help identify interventions designed to improve health outcomes and reduce documented disparities. It will be based upon 3 consecutive years of data from four IHS data sources and will include health status measures, group codes (provider, clinic, drug, pharmacy), and cost measures. Data will be included from each of the 12 IHS regions (~650,000 patients). The CER study will compare disease management by advance practice pharmacists with other health care providers within the IHS. Pharmaceutical care and the expanded role of pharmacists have been associated with many positive diabetes-related outcomes, including improved clinical measures, improved patient and provider satisfaction, and improved cost management. Within the IHS, 22 percent of pharmacists are advance practice pharmacists who are nationally credentialed and locally privileged to provide prescriptive pharmacy care and clinical monitoring for acute and chronic disease management. AHRQ is providing staff support to IHS in this project with funding received from the American Recovery and Reinvestment Act of 2009.


·         Conceptual model of academic persistence aids in training of young AI/AN professionals 


Various programs have emerged to recruit junior investigators to the social, behavioral, and health sciences. Drawing on Tinto's general theory of academic persistence focusing on the undergraduate education and IHS experience with the Native Investigator Development Program, the author presents a conceptual model that applies to individuals early in the postdoctoral or postresidency experience. This model is exemplified in the Native Investigator Development Program at the University of Colorado, Denver. All trainees in this program are either American Indian or Alaska Native. The author describes program and institutional characteristics as well as trainee processes. He concludes by describing the various benefits of the model, such as providing a common language for discussing elements of the training process and serving as a guide for assessing trainee needs.


Source: Manson SM. Professional journeys, professional paths: Persistence in navigating the crossroads of a research career. Am J of Pub Health 2009 Apr; 99 suppl 1:S20-S25. (Grant HS10854).


·         Project focuses on healthy weight and cancer outcomes for women 


This continuation grant builds upon its earlier capacity-building success during which the Montana-Wyoming Tribal Leaders Council developed a shared data resource and research infrastructure for participatory research among a majority of the 10 tribes it serves. The continuation project will further build capacity for health care research on the priority health issues identified by the tribes and continue to support culturally appropriate health programs. Three new research studies are planned: evaluation of interventions to promote healthy weight among women, examination of factors that contribute to breast and cervical cancer outcomes, and design and implementation of a "healthy reservations" model program for system-wide health improvement on reservations. (Principal Investigator: Gordon Belcourt, Montana-Wyoming Tribal Leaders Council; Grant HS14034).


Technology (Health Information Technology, Telehealth)


Health care is information intensive and increasingly dependent on technology to ensure that appropriate information is available whenever and wherever it is needed. AHRQ is assisting the IHS in enhancing its health information systems to improve quality of care and patient safety. For example, AHRQ:


  • Supported a collaborative, multimillion-dollar effort by the IHS to develop and deploy an EHR and population health management system and to investigate the effect of the system on the quality and safety of health care delivery in IHS facilities. The Resource Patient Management System's EHR permits direct provider order entry and documentation, thus increasing data quality and patient safety. It also includes elements of electronic decision support. The result of this work was the deployment of an EHR to more than 120 sites. Products the IHS developed are in the public domain and have been adopted by Federal and State agencies and community-based organizations.


  • Is maximizing functionality of the Resource Patient Management System software component, the Population Management graphical user interface, called iCare. This software application is designed to integrate multiple perspectives on clinical and community care in a single software application. Users can define their own population of patients based on primary provider, case manager, as well as a host of additional characteristics such as gender, age, diagnosis, community, or other documented data elements.


  • Provided partial funding and technical assistance for an evaluation of the deployment and impact of the Resource Patient Management System's EHR. AHRQ assisted the evaluation team at the Urban Indian Health Institute (part of the Seattle Area Epidemiology Center) and Harvard University with evaluation methodology, design, and analysis.


  • Assisted the IHS in improving outcomes in chronic illness care and preventive services through:


  • Contributing to the building of an infrastructure for quality improvement and collaborative learning.


  • Adapting and implementing the Chronic Care Model in Federal, tribal, and urban facilities.


·         Project seeks to improve care for minority stroke survivors 


This mentored clinical scientist development award will assist a minority researcher in helping to achieve the aims of the Stroke Telemedicine Access Recovery (STAR) Project. STAR's long-term goal is to implement an innovative, multi-disciplinary, specialty-care intervention for stroke survivors that targets early introduction to rehabilitation and assists with transitions between levels of care. The project is to take place at the Southeastern Regional Medical Center, a rural hospital serving a Lumbee Indian, African American, and white population. The first phase of the project is to observe the current rehabilitation process to be followed by implementing a multi-disciplinary consultation service using telemedicine video-conference technology. The researcher will provide pilot data to improve inpatient management, discharge disposition, and recovery phase care. (Principal Investigator: Patricia C. Gregory, University of North Carolina at Chapel Hill; Grant HS17956, 7/01/09-6/30/14).


  • Family Health History Initiative to strengthen clinical decision support tools


AHRQ is providing funding to the IHS to support the Family Health History initiative. At present, there is a paucity of EHR systems capable of capturing family health history data in a structured, standardized, and interoperable format that can be seamlessly integrated with electronic clinical decision support (CDS) tools. The IHS has taken the lead in developing the technical implementation of a system that is capable of producing a standards-based, machine-readable file that can be consumed by partner organizations across the government and private industry. The agreement outlines the scope, timeline, roles, and responsibilities of the project to be completed by the IHS. (AHRQ and IHS Interagency Agreement).


  • California implements information technology systems for rural Indian clinic health care


The California Rural Indian Health Board in September 2004 began partnering with three of its rural tribal health programs that implemented electronic health records with clinical decision support systems in an effort to reduce hospitalizations that may be preventable through improved care quality and reduced medical errors. The information technology systems that result will be used in conjunction with local hospitals to support the review of all hospitalizations for their preventability and to track the programs' medical and medication errors as well as their clinical care performance according to standardized performance guidelines. (Principal Investigator: Linda Aranaydo, California Rural Indian Health Board; Grant HS15339, 9/20/04-8/31/07)


·         Telehealth initiative sparks health information campaigns 


The authors examined the Native TeleHealth Outreach and Technical Assistance Program that transfers knowledge of health telecommunication technologies to community health professionals to empower them to use these resources in their communities. The program offered instruction on telehealth for care providers, who in turn developed culturally relevant information for recipients on health topics via CDs, videos, Web sites, and brochures.


Source: Dick RW, Manson SM, Hansen AL, et al. The native telehealth outreach and technical assistance program: A community-based approach to the development of multimedia-focused health care information. American Indian and Alaska Native Mental Health Research: J National Center 2007;14(2):49-66. (Grant HS10854)



·         Health collaborative technology assessed in Alaska's Central Kenai Peninsula  


This project assessed the status of technological resources of a federally qualified health center for uninsured and underinsured patients, a mental health clinic, a long-term care provider, and a local acute care hospital serving a population of Alaska Natives, poor patients, and patients with disabilities. The study team prepared a plan for implementing health information technologies to allow for area-wide electronic communications and connectivity with an electronic health record and a Web-based data system for patient support. (Principal Investigator: Susan Caswell, Central Peninsula General Hospital; Grant HS14902, 09/30/04-09/29/06)


·         Patients and clinicians receptive to telepsychiatry services for youth 


To address the shortage of practitioners in child and adolescent psychiatry, the use of real-time interactive videoteleconferencing to deliver psychiatric services, or telepsychiatry, has been proposed as a way to meet the needs of American Indian youth. The authors reviewed the progress of a twice-monthly telepsychiatry program for children and adolescents undertaken by the University of Colorado School of Medicine's Center for Native American TeleHealth and TeleEducation and the IHS's Rapid City Hospital. Parents said they preferred the service to the 350-mile drive they would otherwise need to make to get help for their children. Clinicians said teleconsultations helped in diagnosing and managing complicated patients and families.


Source: Savin D, Garry M, Zuccaro P, et al. Telepsychiatry for treating rural American Indian youth. J Am Acad Child Adolesc Psychiatry 2006 Apr: 45(4):484-8. (Grant HS10854)


  • Telepsychiatry clinics offer a model to increase care to rural American Indian communities


The authors describe the rural telepsychiatry clinics run by the American Indian and Alaska Native Programs at the University of Colorado Health Sciences Center through a partnership with the Department of Veterans Affairs, the IHS, and local tribal health services. This service may offer a means to increase access to care for rural American Indian communities. The clinics primarily offer assistance to American Indian veterans with PTSD. Describing the model used for developing the services, the authors trace the program development, discuss challenges in implementing services, and offer solutions. The model can guide the development of telepsychiatry services for American Indians, especially rural populations.


Source: Shore JH, Manson SM. A developmental model for rural telepsychiatry. Psychiatr Serv 2005 Aug;56(8):976-80. (Grant HS10854)


Tobacco Use


Traditional tobacco has a spiritual role in Indian culture and varies from tribe to tribe. By some estimates, American Indians have used the tobacco plant for more than 18,000 years. Traditional tobacco is still used by many tribes for prayer, ceremonies, offerings, gift-giving, or as a healing medicine. Commercial tobacco use, however, is also significant among AI/ANs. Approximately 32 percent of AI/ANs are smokers. This is the highest rate of tobacco use among every age, ethnic, and gender category in the United States. Between 1983 and 2002, adult smoking rates fell in all racial and ethnic groups except for American Indians and Alaska Natives.


·         Northern Plains American Indians smoke more than Southwest Plains Indians 


This study of Southwest and Northern Plains American Indians (ages 15 to 54) found that about half of Northern Plains men and women currently smoked (49 and 51 percent, respectively), while 19 percent of Southwest men and 10 percent of Southwest women smoked. The study did not determine use of tobacco for ceremonial purposes. However, the Northern Plains tribe bases a large part of their spiritual philosophy around the concept of the "sacred pipe," considerably more so than the Southwest tribe. Thus, the differences in smoking rates could have a cultural basis. Men and younger people were more likely to smoke in the Southwest tribe but not the Northern Plains tribe. This finding is consistent with other studies that suggest cigarette smoking among tribes of the Southwest region is on the rise, especially among younger men. The results underscore the need to consider each tribal group's unique characteristics when designing and implementing culturally sensitive smoking intervention programs in American Indian communities.


Source: Nez Henderson P, Jacobsen C, Beals J. Correlates of cigarette smoking among selected Southwest and Northern plains tribal groups: The AI-SUPERPFP Study. Am J Public Health 2005 May;95(5):867-72. (Grant HS10854)


Traditional Medicine


Many AI/ANs use traditional practices, such as herbs, to address their health care concerns.


·         Traditional herbs do not affect diabetes medication 


Many AI/ANs integrate traditional herbs with Western medicine, though there is limited data on the herbs' efficacy. During a randomized clinical trial from 2001-2003 on the Navajo Nation, 30 percent of the participants said they used herbs as medicine. Of the participants with diabetes who used traditional herbs, the study found no measurable adverse interaction with diabetes control medications.


Source: McCabe M, Gohdes D, Morgan F, et al. Herbal therapies and diabetes among Navajo Indians. Diabetes Care 2005 Jun;28(6):1534-5. (Grant HS10637)




Injury is a leading cause of death and disability for AI/AN communities. Overall, unintentional injury is the third leading cause of death among AI/ANs, and suicide and homicide are among the top 10 causes of death. Injuries and violence are especially a burden for the young AI/AN population, accounting for 75 percent of all deaths among those ages 1 to 19. Unintentional injury, suicide, and homicide are respectively the top three killers among AI/ANs 1 to 44 years old, accounting for 54 percent of all deaths. Injuries cause more deaths among AI/ANs 1 to 44 years of age than all other causes combined. Unintentional injuries account for more years of potential life lost among AI/AN than heart disease, cancer, and diabetes combined.


·         Trauma linked to alcohol problems in American Indians 


American Indians experience more traumas and alcohol disorders than the general population. Researchers interviewed 432 American Indians between the ages of 15 and 24, asking participants if they had experienced any of 16 types of traumatic events and about their use of alcohol. Overall, 21 percent had experienced one severe traumatic event, 10 percent had experienced two, and 16 percent had experienced three or more. Young adults (aged 20-24) experienced more traumatic events than adolescents (aged 15-19), as did participants in both age groups who reported that their parents used alcohol while they were growing up. More than one-fourth (26 percent) of those interviewed were diagnosed with alcohol use disorders. The odds for alcohol use disorders increased from nearly twofold for one trauma to somewhat less than fourfold for three or more traumas compared with no trauma. These results held after adjusting for age, gender, and parental alcohol use, suggesting a dose-response effect of trauma on alcohol disorders among American Indians living on or near reservations.


Source: Boyd-Ball AJ, Manson SM, Noonan C, et al. Traumatic events and alcohol use disorders among American Indian adolescents and young adults. J Traumatic Stress 2006 Dec;19(6):937-47. (Grant HS10854)


·         Trauma strikes American Indians more often than the general U.S. population 


Southwest and Northern Plains American Indians more often experience trauma than the general U.S. population, according to this study of trauma exposure among two tribes. Researchers interviewed 3,084 members of two tribes about their exposure to 16 types of trauma. They compared tribal prevalence rates of trauma with a sample of the U.S. general population in the National Comorbidity Survey. Lifetime experience of any trauma was high across both tribes, ranging from 62.4 percent for male Southwest tribe members to 69.8 percent for female Northern Plains tribe members. This compares to lifetime exposure to any trauma among U.S. men and women at 60.7 percent and 51.2 percent, respectively. The researchers suggest that high rates of trauma exposure may contribute to the increasing prevalence of CVD, the leading cause of death among American Indian men and women. Similarly, trauma is closely linked to pain, which negatively affects compliance with treatment, help-seeking, and the speed of surgical recovery, all of which are often compromised in American Indians.


Source: Manson SM, Beals J, Klein SA, et al. Social epidemiology of trauma among 2 American Indian reservation populations. Am J Public Health 2005 May;95(5):851-9.  




(Grant HS10854)


Women's Health


AI/AN women have striking health concerns. They give birth to children at younger ages than do women in the general U.S. population. High birthweight births of 4,000 grams or more (vs. low birthweight births) are a relatively greater problem for AI/AN women. These women generally begin prenatal care later than other women in the United States and are more likely to exhibit risky behaviors, such as smoking or consuming alcohol, during pregnancy than their counterparts in the United States.


·         Study looks at breast and cervical cancer screening and followup 


In addition to supporting the development of a sustainable research infrastructure for the Montana/Wyoming Tribal Leaders Council, Black Hills State University, and the Black Hills Center for American Indian Health, this project funded a study for identifying factors that affect breast and cervical cancer screening and followup of abnormal findings. Investigators developed a pilot program to increase the proportion of American Indian women who receive screening tests. (Principal Investigator: Gordon Belcourt, Montana/Wyoming Tribal Leaders Council; Grant HS14034, 9/30/03-9/29/06)


·         Extremely obese American Indian and Alaska Native women may have higher bone mineral density than white counterparts 


Researchers compared baseline bone mineral density (BMD) of 139 AI/AN postmenopausal women with 1,431 non-Hispanic white postmenopausal women to determine the variability of BMD, osteoporosis, and hip fractures. The AI/AN women studied were twice as likely to be obese (body mass index of 30-39.9) or extremely obese (BMI of greater than 40) than non-Hispanic white women. The extremely obese AI/AN women had higher hip BMD than extremely obese non-Hispanic white women, but overweight AI/AN women had slightly lower spine and whole body BMD compared to non-Hispanic white postmenopausal women.


Source: Wampler NS, Chen Z, Jacobsen C, et al. Bone mineral density of American Indian and Alaska Native women compared with non-Hispanic white women: Results from the Women's Health Initiative Study. Menopause: J North Am Menopause Society 2005 Sep-Oct;12(5):536-44. (Grant HS10854)


Key Acronyms





Full Name





Agency for Healthcare Research and Quality




American Indian/Alaska Native




Consumer Assessment of Healthcare Providers and Systems




cardiovascular disease




comparative effectiveness research




electronic health record




high density lipoprotein cholesterol




Department of Health and Human Services




Indian Health Service




post-traumatic stress disorder




rheumatoid arthritis


For More Information


For further details about AI/AN projects and other activities at AHRQ, contact:


Wendy Perry
AHRQ Senior Program Analyst for AI/AN Health
540 Gaither Road
Rockville, MD 20850
E-mail: This e-mail address is being protected from spambots. You need JavaScript enabled to view it


Current as of March 2011
AHRQ Publication No. 10-P007
Replaces AHRQ Pub. No. 08-P004


Internet Citation:  


AHRQ Research and Other Activities Relevant to American Indians and Alaska Natives. Program Brief. Agency for Healthcare Research and Quality, Rockville, MD. AHRQ Publication No. 10-P007, Revised March 2011. http://www.ahrq.gov/research/amindbrf.htm