BUILDING HEALTHY HEARTS FOR AMERICAN INDIANS AND … · The logo for the Building Healthy Hearts...

O f f i c e o f P r e v e n t i o n , E d u c a t i o n , a n d C o n t r o l

N A T I O N A L I N S T I T U T E S O F H E A L T HN A T I O N A L H E A R T , L U N G , A N D B L O O D I N S T I T U T E

BUILDINGHEALTHY HEARTS FORAMERICANINDIANS ANDALASKA NATIVES:A BACKGROUND REPORT

National Heart, Lung, and Blood Instit

ute

The logo for the Building Healthy Hearts forAmerican Indians and Alaska NativesInitiative depicts the drum as a focal pointin tribal traditional life. The drum is a livingthing to be treated with deep respect, andthe act of drumming is connected to theheartbeat. The shape of the drum representsthe circle of life, reminding us that we areall linked with one another. The drumstickssymbolize the four directions, which in turnare associated with the four stages of life:east, the newborn; south, the adolescent;west, the adult; and north, the elder. Thefour directions are also tied to four colors.east represents the early morning white light(often shown as white corn, symbolizing themale and father of the family), south theblue sky of noon, west the yellow of sunset(often shown as yellow corn, symbolizing thefemale and mother of the family), and norththe black of night.

Strengthen theHeart Beat

The NHLBI anniversary logo represents 50 years of success;people doing science to improve the health of people.

FO R AD M I N I S T R AT I V E US E ON LY

NOV E M B E R 1998

NAT I O NA L IN S T I T U T E S

O F HE A LT H

National Heart , Lung,

and Blood Inst i tute

BUILDINGHEALTHY HEARTS FORAMERICANINDIANS ANDALASKA NATIVES:A BACKGROUND REPORT

i

TABLE OF CONTENTS

Foreword ............................................................................................................iii

Acknowledgments................................................................................................v

Introduction ..........................................................................................................1

Limitations of the Data ........................................................................................3

U.S. Census Data ........................................................................................3

National Health Surveys ..............................................................................3

Mortality Data and Surveys ..........................................................................3

Indian Health Service....................................................................................4

Differences in Data Collection ....................................................................4

Sociodemographics of American Indians and Alaska Natives ............................5

Definition of American Indian and Alaska Native..........................................5

Population Density ........................................................................................5

Composition and Geographic Distribution ....................................................6

Age................................................................................................................7

Education ......................................................................................................7

Income and Employment ............................................................................8

Access to Health Care..................................................................................9

Cardiovascular Disease Among American Indians and Alaska Natives ............11

Cardiovascular Disease Mortality ..............................................................11

Risk Factors................................................................................................12

High Blood Cholesterol............................................................................12

High Blood Pressure ..............................................................................13

Cigarette Smoking ..................................................................................15

Physical Inactivity ....................................................................................17

Diabetes Mellitus ....................................................................................18

Obesity.....................................................................................................19

Dietary Consumption Practices of American Indians and Alaska Natives..21

Alcohol Consumption ..............................................................................22

ii

American Indian and Alaska Native Culture and Perceptions of Health ..........25

Social Structure. ........................................................................................25

Concept of Time..........................................................................................26

Harmony With the Environment..................................................................26

Oral Communication.. ................................................................................26

Traditional and Contemporary Methods of Healing ....................................27

Community-Based Health Promotion and Disease Prevention Programs for American Indians and Alaska Natives ........................................29

Strong Heart Study ....................................................................................29

PATHWAYS ................................................................................................30

Checkerboard Cardiovascular Curriculum..................................................30

Zuni Diabetes Project. ................................................................................31

Southwestern Cardiovascular Curriculum ..................................................32

NIDDK Diabetes Prevention Program ........................................................32

Nutrition Assistants Program ......................................................................33

Food Distribution Program on Indian Reservations. ..................................33

Wings of America........................................................................................33

Recommended Strategies for Effective Programs ............................................35

Theoretical Models ............................................................................................41

PRECEDE Model........................................................................................41

Health Belief Model ....................................................................................42

Social Learning Theory ..............................................................................42

Theory of Reasoned Action ........................................................................43

Stages of Change Model ............................................................................43

Needs and Opportunities ..................................................................................45

Design and Assessment Phase..................................................................45

Planning Phase ..........................................................................................46

Implementation Phase ................................................................................47

Evaluation Phase........................................................................................47

Conclusion ........................................................................................................49

Resources..........................................................................................................51

References ........................................................................................................53

iii

FOREWORD

As we embark upon the new millennium ofhelping people improve their health throughresearch, research training, and educationactivities, the National Heart, Lung, and BloodInstitute (NHLBI) is committed to eliminatingdisparities in health status particularly amongminority communities. Since 1972, TheNHLBI has translated and disseminatedknowledge to the community to promote pub-lic health and prevent and control heart, lung,and blood diseases and sleep disorders.Through its national education programs andInitiatives, the NHLBI seeks to increase publicawareness and professional practice, set policyagendas, and generally improve the quality oflife for all Americans. These programs includethe National High Blood Pressure EducationProgram, the National Cholesterol EducationProgram, the National Heart Attack AlertProgram, the National Asthma Education andPrevention Program, the NHLBI ObesityEducation Initiative, and the National Centeron Sleep Disorders Research.

Cardiovascular disease (CVD) is the leadingcause of death for all Americans, includingAmerican Indians and Alaska Natives(AI/AN). More AI/AN men and women overage 45 die from CVD than any other disease.CVD is the second leading medical cause ofdeath after cirrhosis for Indian men andwomen ages 15-44. However, it is a relativelyrecent phenomenon among native populations.The prevalence of CVD has increased as morepeople adopt Western lifestyles characterized

by high-fat, high-calorie diets and low levelsof physical activity. Complicating efforts tocombat risk factors is the lack of access manyNative Americans have to clinical preventiveservices and health education.

Through research and clinical studies we havedetermined that many of the risk factors thatinfluence the prevalence and severity of CVDcan be reduced by lifestyle changes. These riskfactors include high blood pressure, high bloodcholesterol, cigarette smoking, physical inac-tivity, obesity, and diabetes. Today, AI/ANstruggle with the health burden of CVD and itsassociated risk factors. For example, diabeteshas risen to epidemic proportions in somecommunities, and many other communities arefighting the battle against obesity and highblood pressure.

Although significant improvements have beenmade in the Nation’s overall health, the gainsare not equally shared by ethnic and racialminorities. By virtually every health statusindicator--life expectancy, mortality, morbidity,use of and access to health resources--minori-ties fare poorly. These groups continue to suf-fer more acutely from disability and disease,and they share a disproportionate burden com-pared with the general population. TheInstitute’s priority is to determine better meth-ods to reduce the disproportionate burden ofheart, lung, and blood disease and sleep disor-ders in minority populations.

iv

This challenging quandary has led the NHLBIto establish an outreach project called BuildingHealthy Hearts for American Indian andAlaska Natives. This project seeks to promotehealthy lifestyles and reduce the prevalence ofCVD and its associated risk factors by devel-oping and implementing CVD prevention andcontrol strategies designed specifically forAI/AN.

The Institute thanks all those who have con-tributed to this background report which pro-vides an overview of the cardiovascular healthstatus of AI/AN. This report will serve as ablueprint in the development of the project.The success depends on the involvement of allcommunities--this support has been givenenthusiastically. Together, we will continue tostrengthen the heart beat of this generation andgenerations to come.

Claude Lenfant, M.D.DirectorNational Heart, Lung, and Blood Institute

v

PRIMARY AUTHOR

Mimi Lising, M.P.H., PresidentialManagement Intern

REVIEWERS

National Heart, Lung, and Blood Institute

Matilde Alvarado, R.N., M.S.N.

Robinson Fulwood, M.S.P.H.

Gregory J. Morosco, Ph.D., M.S.P.H.

Eileen Newman, M.S., R.D.

Frederick Rohde, M.A.

NHLBI Ad Hoc Committee on MinorityPopulations

David Baines, M.D.

Mary Helen Deer-Smith, R.N.

Michelle Tangimana, M.S.

Indian Health Service

Karen F. Strauss, M.S., R.D.

National Institute on Alcohol Abuse andAlcoholism

Patricia Mail, M.P.H.

SPECIAL ACKNOWLEDGEMENTS

Cheryl Contreras, M.P.I.A.

Carlos Crespo, DrPH, M.S., FACSMAmerican University

Phyllis Fife, Ed.D.Native American Management Services, Inc.

Valentina Herrera Native American Management Services, Inc.

Pamela E. Iron Tribal Outreach Specialist American Indian Resource Center

Kurt Schweigman

Thomas K. Welty, M.D., M.P.H

Special appreciation to individuals who shareda wealth of knowledge and expertise throughinterviews.

ACKNOWLEDGEMENTS

1

INTRODUCTION

The American Indian and Alaska Native popu-lation is the smallest self-identified, racial-eth-nic group in the United States, numberingabout 2 million people. They are widely dis-persed across the Nation, belonging to morethan 547 tribes and speaking more than 200distinct languages. As a population, AmericanIndians and Alaska Natives generally areyounger, have less education, and tend to bepoorer than other populations in the UnitedStates. Many are employed in agriculture,craft, and repair service occupations; few workin managerial and professional specialty occu-pations. In this report, “native” and “nativepeople” are used to refer to both AmericanIndians and Alaska Natives.

Cardiovascular disease (CVD) is the leadingcause of death for all Americans, includingAmerican Indians and Alaska Natives. Moremen and women over 45 years old die fromCVD than any other disease. CVD is a rela-tively recent phenomenon in the AmericanIndian and Alaska Native population. As morenative people adopt Western lifestyles charac-terized by a high-fat, high-calorie diet and lowlevels of physical activity, the prevalence ofCVD increased in many native communities.

Today, American Indians and Alaska Nativesstruggle with the health burden of CVD and itsassociated risk factors. Diabetes has risen toepidemic proportions in some populations, andmany others are fighting the battle againstobesity and high blood pressure. Because

native people generally earn less than the aver-age American and tend to live in remote, rurallocations, some may have limited access toclinical preventive services, health education,and prevention efforts. All these factors actsynergistically to place native people at veryhigh risk for chronic diseases.

In 1990-92, CVD accounted for proportionallymore deaths among American Indian andAlaska Natives age 45 to 64 than among peo-ple of the same age group in the general popu-lation. As this population ages, the absolutenumber of elderly and chronically ill people inthis group is likely to increase.

Because of the diversity of this population,health promotion efforts to improve the healthstatus of American Indians and Alaska Nativesshould be tailored to the needs of specific tar-get communities. Native people are character-ized not by their homogeneity, but rather bytheir heterogeneity. Tribes differ markedly intheir health and disease patterns and behaviorsas well as in the sociocultural aspects of theirlives. For example, whereas heart diseaseaccounted for 15.9 percent of all deaths in1990-92 in the Tucson area, it accounted for32.4 percent of total deaths in Oklahoma(Indian Health Service, 1996).

Although manifestations of health and diseasepatterns and societal norms vary, AmericanIndians and Alaska Natives share a number ofcultural values that can be effectively incorpo-rated into health promotion activities.

2

Organizing community-based programs at thelocal level and involving community membersin all phases of program design, implementa-tion, and evaluation will ensure that programsare culturally sensitive, relevant, and appropri-ate.

This report attempts to provide a comprehen-sive picture of CVD in the American Indianand Alaska Native population. It is organizedinto eight sections.

◆ Limitations of the Data. This section dis-cusses the limitations of the data availableon the health status of Native people.

◆ Sociodemographics of American Indiansand Alaska Natives. This section presentsthe demographic characteristics of nativepeople in the United States. These attributesinclude population density, composition andgeographic distribution, age, education,income and employment, and access tohealth care.

◆ Cardiovascular Disease Among AmericanIndians and Alaska Natives. This sectiondiscusses CVD mortality and provides infor-mation on each of the major cardiovascularrisk factors—high blood cholesterol, highblood pressure, cigarette smoking, physicalinactivity, diabetes mellitus, obesity. Thissection also discusses the dietary and alco-hol consumption practices and the effects ofthese risk factors on native people.

◆ Native Culture and Perceptions ofHealth. This section describes the knowl-edge, beliefs, and behaviors of AmericanIndians and Alaska Natives as well as theirperceptions of health. Specific topicsinclude social structure, concept of time,harmony with the environment, oral com-munication, and traditional and contempo-rary methods of healing.

◆ Community-Based Health Promotion andDisease Prevention Programs forAmerican Indians and Alaska Natives.This section highlights several existing pre-vention and intervention programs targetedto native communities.

◆ Recommended Strategies for EffectivePrograms. This section presents recom-mended strategies for designing community-based health promotion programs for Amer-ican Indians and Alaska Natives, based onthe success of existing programs. Discuss-ions with program planners and other influ-ential people who work directly with thispopulation offer insight into various strate-gies.

◆ Theoretical Models. This section discussesfive theoretical models that can be incorpo-rated into the development of health promo-tion programs targeting native people.

◆ Needs and Opportunities. This sectionoffers recommendations for transformingneeds in health promotion and disease pre-vention and control programs into opportu-nities to improve the heart health of Amer-ican Indians and Alaska Natives. The rec-ommendations are based on the existing epi-demiological literature, evaluations of cur-rent health promotion and disease preven-tion programs, and telephone interviewswith people working to improve nativehealth. The recommendations provide aframework on which to build effective healthprograms that increase the awareness of car-diovascular risk factors and their impact onheart health in native communities.

3

A paucity of data exists on the health status ofAmerican Indians and Alaska Natives. Thelack of adequate representation of this popula-tion in national surveys and databases leavesresearchers and program planners to relyalmost exclusively on studies that focus onspecific regions and tribes. The heterogeneitythat characterizes native tribes, however, limitsgeneralizations to all native peoples based ondata on a particular tribe. Researchers must beaware of these and other limitations to thedata. This section briefly highlights the bound-aries that exist in making conclusions based onthe data on native people.

U.S. CENSUS DATA

Historically, American Indians and AlaskaNatives have not been well represented innational surveys. Only recently has the U.S.Bureau of the Census included AmericanIndians living in the Indian Territory and onreservations in population counts. In anattempt to include all native people in the cen-sus, the Census Bureau established liaisonswith more than 300 tribal governments.Unfortunately, many households on AmericanIndian reservations and in Alaska Native vil-lages were still excluded. In addition, manynative people did not participate in the censusdue to their migration patterns between ruraland urban areas or in protest to the U.S.Government’s treatment of indigenous peoples.

The 1980 census estimated that racial minori-ties were undercounted by approximately 6percent. The estimated undercount of minori-ties in the 1990 census was at least as high(National Cancer Institute, 1993).

NATIONAL HEALTH SURVEYS

In the health arena, the types of data availablefor U.S. whites and African Americans areunavailable for American Indians and AlaskaNatives. Native people have not been over-sampled in most health and nutrition surveys,particularly the National Health and NutritionExamination Surveys (NHANES). The fewexisting studies on the health of AmericanIndians and Alaska Natives generally havebeen conducted in specific geographic regionsand among different tribes. Given the widevariation in biological, sociodemographic, andsociocultural characteristics among this popu-lation, as well as the lack of sufficient totalnumbers to provide generalizable and accurateaggregate data, caution must be taken not togeneralize specific data to all native people inthe United States.

MORTALITY DATA AND SURVEYS

Other factors limiting the accuracy of availabledata on native people include racial misclassi-fication, blood quantum (percentage ofAmerican Indian or Alaska Native heritage),and tribal enrollment. For mortality data,States submit death certificates to the NationalCenter for Health Statistics for inclusion in

LIMITATIONS OF THE DATA

4

national mortality analyses. Unfortunately,people completing an individual’s death infor-mation may assume the decedent’s race byvisual observation and without verification.This racial misclassification can lead to misin-formation in the State and national databases,resulting in potentially erroneous conclusions.

Hahn and colleagues examined racial classifi-cation from birth and death certificates from1983 to 1985 for American Indian and AlaskaNative infants in 33 reservation states. Theyconcluded that misclassification of race onbirth and death certificates tended to occurabout 50 percent of the time (National CancerInstitute, 1993). Race and ethnicity questionson surveys also pose a classification problem.The number of people identifying themselvesas American Indian or Alaska Native dependson whether the survey allows identificationthrough ancestry, blood quantum, or tribalenrollment.

INDIAN HEALTH SERVICE

The Indian Health Service (IHS) databasesreflect only a segment of the entire AmericanIndian and Alaska Native population. The IHSprovides health services to all American Indianand Alaska Native persons residing in IHS ser-vice areas. Only native people who have usedIHS services within the last 3 years are includ-ed in the “user population” that is calculatedby the IHS. Health information on people whohave never used IHS facilities and people whouse private practitioners and Veterans Admin-istration facilities is not included in the IHSdatabase.

In addition, data on native people who live inurban areas and obtain their health care fromsources within the city are not usually provid-ed to the IHS for inclusion in its database(National Cancer Institute, 1993). Data report-ing may be further hampered in the future as

American Indian tribes begin to assume moreresponsibility for their own health servicedelivery and health services for AmericanIndians and Alaska Natives as a whole popula-tion become less cohesive.

DIFFERENCES IN DATA COLLECTION

Inconsistencies in data collection protocolsamong existing studies limit the ability tocompare data accurately. Many studies do notfollow a standard definition of risk factors. Forexample, obesity has been variably defined,and low- and high-density lipoprotein choles-terol values may or may not be included in theanalysis or definition of hypercholesterolemia.In addition, measurement of risk factors differssubstantially among studies.

In testing for diabetes, some studies do notdistinguish between insulin-dependent diabetesmellitus and non-insulin-dependent diabetesmellitus and they do not use glucose tolerancetesting to screen for undiagnosed diabetescases. Risk factors like physical inactivity, andcigarette smoking are also difficult to quantifyor standardize. Furthermore, studies differ intheir age standardization methods, makingvalid comparisons difficult (Ellis and Campos-Outcalt, 1994). Standardization of methodolo-gy and analysis of risk factors in future studieswould facilitate comparison between groups.

5

SOCIODEMOGRAPHICS OF AMERICAN INDIANS

AND ALASKA NATIVES

DEFINITION OF AMERICAN INDIANAND ALASKA NATIVE

The Bureau of the Census uses self-identifica-tion to classify persons as American Indians orAlaska Natives and to identify tribal member-ship. The Census Bureau’s definition ofAmerican Indian or Alaska Native is “a personhaving origins in any of the original peoples ofNorth America and who maintains culturalidentification through tribal affiliations orcommunity recognition.” Blood quantum,which indicates the percentage of AmericanIndian or Alaska Native heritage, is not alwaysa clear indication of American Indian orAlaska Native status. Persons who have one-sixteenth of native blood may mark AmericanIndian or Alaska Native on the censusalthough they may live a mainstream lifestyle.It should be noted, however, that persons iden-tifying themselves as American Indian orAlaska Native may not necessarily have one-sixteenth blood quantum.

POPULATION DENSITY

American Indians and Alaska Natives totalabout 2 million people in the United States.This population comprises the smallest self-identified racial group in the United States,less than 1 percent of the U.S. population.Between 1980 and 1990, the number of peoplewho identified themselves as AmericanIndians or Alaska Natives increased by 38 per-cent. The increase during this period was duenot only to natural causes, but also to changes

in people’s self-identification from other racesto American Indian or Alaska Native. In addi-tion, improvements were made in methodolo-gy for counting people who live on reserva-tions, on trust lands, and in Alaska Native vil-lages (U.S. Bureau of the Census, 1993).Projections estimate that the American Indianpopulation will reach 4.6 million by the year2050.

The Bureau of Indian Affairs currently recog-nizes more than 547 tribes of native people inthe United States (Indian Health Service,1995a). Members of these tribes speak morethan 200 distinct languages and are widely dis-persed across the United States.

Cherokee 369,035Navajo 225,298Chippewa 107,321Sioux 105,988Choctaw 86,231Pueblo 55,330Apache 53,330Iroquois 52,557Lumbee 50,888Creek 45,872

TRIBE POPULATION

Source: U.S. Bureau of the Census, 1990.

TEN LARGEST AMERICAN INDIAN TRIBES

6

COMPOSITION AND GEOGRAPHICDISTRIBUTION

In the 1990 census, American Indians com-prised about 96 percent of the entire nativepopulation. About 19 percent identified them-selves as Cherokee, 12 percent as Navajo, 6percent each as Chippewa and Sioux, and 5percent as Choctaw. The next five largesttribes were Pueblo, Apache, Iroquois, Lumbee,and Creek. Most tribes had fewer than 10,000members in 1990.

Native people were the first inhabitants ofNorth America. Most credible scholars believethat approximately 25,000 years ago,American Indians and Alaska Natives crossedthe Bering Strait from Siberia and settled theentire Western Hemisphere over a period of10,000 to 15,000 years.

Migration was common, but contact withEuropean explorers and settlers forced twomajor periods of mass migration. First, thetransmission of infectious diseases from earlyEuropean settlers devastated the AmericanIndian population. Many surviving Indiansresettled in smaller, more widely separatedgroups. Second, a series of legislative acts waspassed, forcing American Indians to settle intolocations specified by law.

The Indian Removal Act of 1830 forcedAmerican Indians to move to territories westof the Mississippi River. By 1887, mostAmerican Indians were resettled on reserva-tions or in the Indian territory of Oklahoma.After World War II, Congress passed theIndian Relocation Act of 1956. AmericanIndians once again migrated, this time to urbanareas, where they were encouraged to enhancetheir economic opportunity and assimilate intomainstream society even more than before(Centers for Disease Control and Prevention,1992).

Today, nearly half of the American Indian pop-ulation resides in the West, 30 percent in theSouth, 18 percent in the Midwest, and 6 per-cent in the Northeast. More than half of theNative population are located in seven States:Alaska, Arizona, California, New Mexico,North Carolina, Oklahoma, and Washington;the largest proportion resides in Oklahoma.

The Alaska Native population consists ofEskimos, American Indians, and Aleuts. Of thenearly 86,000 Alaska Natives living in Alaska,more than one-half of these are Eskimo,approximately one-third are American Indian,and slightly more than one-tenth are Aleut.The two main Eskimo groups living in Alaskaare the Inupiat, who live in the north andnorthwest parts, and the Yupik, who live in thesouth and southwest parts. The primaryAmerican Indian tribes living in Alaska areAthabascan, Tlingit, Tsimshian, and Haida.

There are 314 Federal reservations and trustlands, 217 Alaska Native village statisticalareas, 12 Alaska Native regional corporations,and 17 tribal jurisdiction statistical areas in theUnited States. Contrary to the popular beliefthat most American Indians and AlaskaNatives live on reservations or in small vil-lages, only about 22 percent of the AmericanIndian and Alaska Native population live onreservations and historic trust lands and 15percent live in tribal or village statistical areas.The rest, 63 percent, live in urban centersaround the country. For Alaska Natives, how-ever, only about one-third live in urban areas,primarily Anchorage, Fairbanks, and Juneau.The other two-thirds of the Alaska Native pop-ulation live in one of more than 200 rural vil-lages with populations of 50 to 1,000 people.Alaska Natives also live in the continentalUnited States, especially the NorthwesternStates and California (National CancerInstitute, 1993).

7

AGE

In general, American Indians and AlaskaNatives are a much younger population thanother racial groups, due in part to their highfertility rates. The American Indian medianage in 1990 was 26 years, which is 7 yearsyounger than the median age of 33 years forthe general population (U.S. Bureau of theCensus, 1993). Thirty-four percent of Nativepeople are younger than age 18, compared toapproximately 25 percent of the U.S. generalpopulation. In addition, only 6 percent of thispopulation were older than age 65, comparedto 13 percent of all races in the United States(U.S. Bureau of the Census, 1990). Figure 1displays the age distribution of AmericanIndians and Alaska Natives.

EDUCATION

Overall, American Indians have less educationthan the general population. According to 1990census data, 66 percent of American Indiansover age 25 have completed high school andabout 9 percent possess a bachelor’s degree orhigher. In comparison, in the general popula-tion, 75 percent of persons over age 25 havecompleted high school and 20 percent have abachelor’s degree or higher, as shown in figure2. Approximately 85 percent of AmericanIndian youth attend public schools, 10 percentattend Bureau of Indian Affair (BIA) schools,and 5 percent attend private schools.

In addition, Alaska Natives are less likely tohave graduated from high school or collegethan the general population in Alaska. Sixty-

0

10

20

30

40

50

26.0

35.0 33.0 34.2

25.6 25.0

5.9

12.9 12.5

Median Age Under 18 years Over 65 years

American Indians and Alaska Natives

White

General population

Per

cent

Source : U.S. Bureau of the Census, 1993.

FIGURE 1. AGE DISTRIBUTION OF AMERICAN INDIANS AND ALASKA NATIVES

8

three percent of Alaska Natives over age 25completed high school or higher comparedwith 87 percent of the entire State population.In addition, only 4 percent of Alaska Nativeshad a college degree or higher compared with23 percent of the statewide population.

INCOME AND EMPLOYMENT

American Indians and Alaska Natives tend tobe poorer than other populations in the UnitedStates. In 1989, 31 percent of native peoplelived at or below the poverty level. This ismore than twice the number of poor people inthe total U.S. population (13 percent) andalmost three times the number of whites livingat or below the poverty level (12 percent).Twenty-one percent of Alaska Native familieslive below the poverty line, compared to 7 per-cent of all families in Alaska.

The median family income in 1990 forAmerican Indians was $21,750, whereas themedian family income for the total U.S. popu-lation was $35,225. Alaska Natives alsoearned less than other people in Alaska (figure3). Although Alaska has the highest medianfamily income ($46,581 a year) in the UnitedStates, the median family income amongAlaska Natives was only $26,695, which isonly 57 percent of the median income for theState. In Alaska, Aleut families earned anaverage of $36,472 followed by AmericanIndians at $29,339, and Eskimos at $23,257.

American Indians residing on reservations andtrust lands are the poorest segment of theAmerican Indian and Alaska Native popula-tion. In 1989, 51 percent were living below thepoverty level. The per capita income in 1989ranged from slightly more than $3,000 per per-

0

20

40

60

80

100

65.6

87.6

75.2

9.4

26.420.3

High school graduate College graduate

Per

cent


White

General population


FIGURE 2. EDUCATIONAL ATTAINMENT OF AMERICAN INDIANS AND ALASKA NATIVES

9

son to nearly $5,000 per person. One-fifth, or20 percent, of the housing units on reserva-tions and trust lands lacked complete plumbingfacilities, compared with 6 percent of allAmerican Indian households in the UnitedStates.

Overall, 62 percent of American Indians age16 and older were in the labor force in 1990.The majority of American Indians wereemployed in agriculture, craft, and repair ser-vice occupations—namely, operators, fabrica-tors, and laborers. A smaller proportion ofAmerican Indians and Alaska Natives than ofthe total population worked in managerial andprofessional specialty occupations.

ACCESS TO HEALTH CARE

The Indian Health Service is an agency withinthe U.S. Department of Health and Human

Services. The IHS is responsible for providingcomprehensive health services to members offederally recognized American Indian andAlaska Native tribes. An individual is eligiblefor services if he or she is “regarded as Indianby the community in which he [or she] lives asevidenced by such factors as tribal member-ship, enrollment, residence on tax-exemptland, ownership of restricted property, activeparticipation in tribal affairs, or other relevantfactors in keeping with general Bureau ofIndian Affairs practices in the jurisdiction.”The 1990 census identified more than 2 mil-lion people of Indian heritage; approximately1.41 million of this group are eligible for IHSservices (Indian Health Service, 1996). MostAmerican Indians and Alaska Natives who donot receive IHS health services reside in urbanareas.

31.2

11.713.1

$21,751

$40,884

$35,225

Percent below poverty line Median family income

Per

cent

Dol

lars


White

General population


FIGURE 3. AMERICAN INDIAN AND ALASKA NATIVE ECONOMIC INDICATORS

10

The goal of the IHS is to raise the health statusof American Indians and Alaska Natives byproviding them preventive, curative, rehabili-tative and environmental health services.Tribes are offered opportunities for maximuminvolvement in developing and managing pro-grams to meet health needs. Health servicesare delivered directly through IHS facilities,through IHS contractual arrangements withproviders in the private sector, and throughtribally operated programs and urban Indianhealth programs.

The IHS health services delivery system ismanaged through 12 regional units called areaoffices, which cover all or parts of 33 Statesknown as Reservation States. These areaoffices provide administrative support to 72local service units, which are the basic healthorganizations for a geographic area served bythe IHS. As of October 1994, these 72 IHS-operated service units administered 40 hospi-tals and 119 health centers, school health cen-ters, and health stations.

Some of the health programs are operated bytribes, and a limited number of projects serveAmerican Indians living in urban areas. In1994, 71 tribally operated service units admin-istered 9 hospitals and 342 health centers,health stations, and Alaska village clinics.Thirty-four Indian-operated urban projectsranged from information referral and commu-nity health services to comprehensive primaryhealth care services.

American Indians and Alaska Natives obtaintheir health care through a variety of sources,not just through the IHS, tribally operated ser-vice units, and urban projects. Many haveemployer-sponsored medical benefits and useprivate practitioners and third-party payment.Native people not living in the 33 reservationStates must either use alternative health careresources or travel great distances to obtain

IHS services. In addition, the transitorylifestyle of many American Indians whomigrate between reservations and cities insearch of employment may contribute to thelack of health care access for this migrant pop-ulation.

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CARDIOVASCULAR DISEASE AMONG

AMERICAN INDIANS AND ALASKA NATIVES

CARDIOVASCULAR DISEASE MORTALITY

Cardiovascular disease is the leading cause ofdeath in the United States regardless of gender,race, or ethnicity. For CVD deaths in the totalpopulation, the 1992 age-adjusted death ratewas 180.4 deaths per 100,000 population. Theage-adjusted death rates for the two majorcomponents of CVD—coronary heart diseaseand stroke—were 144.3 and 26.2 respectively.Only recently has CVD been prevalent amongAmerican Indians and Alaska Natives.

Although overall mortality rates for nativepeople are lower than those of the general pop-ulation, CVD is now the leading cause ofdeath for this population. The CVD death ratefor native people is 132.8 deaths per 100,000population. The mortality rate for coronaryheart disease (CHD) in native people is 107.1cases per 100,000 population. The mortalityrate for stroke, the fifth leading cause of deathfor this population, is 19.1 cases per 100,000population (Plepys and Klein, 1995) (figure 4).Mortality rates for both CHD and cerebrovas-

0

50

100

150

200

132.8

173.0 180.4

107.1

139.0 144.3

19.1 24.2 26.2

Cardiovascular disease Coronary heart disease Stroke

Per

100

,000


White

General population

Source: Plepys and Klein, 1995.

Note: Age-Adjusted to U.S. 1940 Standard population.

FIGURE 4. AGE-ADJUSTED CVD MORTALITY AMONG AMERICAN INDIANS AND ALASKA NATIVES

12

cular disease is higher for native people resid-ing in the IHS service area: in 1990-92, theCHD mortality rate was 114.2 cases per100,000 population and the stroke mortalityrate was 23.0 cases per 100,000 population(Indian Health Service, 1996).

RISK FACTORS

Population-based studies have led to the iden-tification of risk factors for cardiovascular dis-ease. Although some risk factors such as age,gender, and family history cannot be con-trolled, others can be prevented and managedby altering one’s lifestyle, thus reducing therisk of cardiovascular disease. Modifiable riskfactors include high blood cholesterol, highblood pressure, smoking, physical inactivity,diabetes, obesity, and heavy alcohol consump-tion. The following section discusses the mostcommon modifiable risk factors for cardiovas-cular disease and their effects on AmericanIndians and Alaska Natives.

High Blood CholesterolCholesterol is a waxy substance that the bodymanufactures to make hormones, vitamin D,and bile acids. The body produces enoughcholesterol to fill its needs, but cholesterol alsois taken into the body through the diet. Overtime, extra cholesterol and fat circulating in theblood can accumulate on the inner walls of thearteries that supply blood to the heart. Thesedeposits narrow the arteries, slowing or evenblocking the flow of blood to the heart andincreasing the risk of cardiovascular disease.

The National Cholesterol Education Programhas defined ranges for blood cholesterol levelsas desirable, borderline-high, and high bloodcholesterol. For adults, a blood cholesterollevel lower than 200 mg/dL is desirable. Acholesterol level between 200 and 239 mg/dLis considered borderline-high, and high bloodcholesterol is defined as 240 mg/dL or greater

(National Cholesterol Education Program,1993).

Two specific kinds of blood cholesterol arelow-density lipoprotein (LDL) cholesterol andhigh-density lipoprotein (HDL) cholesterol.LDL cholesterol, sometimes called “bad” cho-lesterol, causes cholesterol to accumulate inthe walls of the arteries. The more LDL thatexists in the blood, the greater the risk forheart disease. Conversely, HDL cholesterol hasbeen dubbed “good cholesterol” because ithelps the body remove the cholesterol from theblood. Unlike total and LDL cholesterol, moreHDL cholesterol in the blood reduces the riskfor heart disease.

Although the mean total cholesterol levels ofAmerican Indians and Alaska Natives are gen-erally lower or comparable to the levels ofother U.S. populations, variation occursbetween regions. Data from the Strong HeartStudy, a study of 12 tribes in Arizona, NorthDakota, Oklahoma, and South Dakota indicat-ed that 30 to 40 percent of all AmericanIndians had cholesterol levels greater than 200mg/dL. Twenty five percent of the ArizonaPima Indians had blood cholesterol levels at orabove 200 mg/dL compared with 47 percent ofthe North Dakota and South Dakota partici-pants. Furthermore, the high blood cholesterolrates for American Indians were lower thanthose of the U.S. general population. Theprevalence of high blood cholesterol (≥ 240mg/dL) among men of all races in the UnitedStates is 28 percent and 34 percent for women.In the Strong Heart Study the prevalence ofhigh blood cholesterol was 8.6 percent formales and 12.7 percent for females (Welty etal., 1995) (figure 5).

Thirty-four percent of Navajo men age 25 to74 had elevated total cholesterol levels com-pared to 28 percent of men of the same agegroup studied in the 1976-80 National Health

13

and Nutrition Examination Survey (NHANESII). Younger Navajo women had total choles-terol concentrations similar to those forwomen younger than age 55 from theNHANES II, but the cholesterol levels weresignificantly lower among older Navajowomen. Interestingly, the prevalence of totalcholesterol concentrations greater than 240mg/dL was 17.5 percent in Navajo women,which was about half the prevalence rate ofwomen studied in the NHANES II (32.9 per-cent) (Sugarman et al., 1992).

High Blood Pressure Blood pressure is the force of the blood push-ing against the walls of the arteries. Severalfactors affect blood pressure, including theamount of blood flowing through the arteries,the rate of blood flow, and the resiliency of thearterial walls. High blood pressure, also calledhypertension, occurs when there is resistance

to blood flow through the arteries and the heartexerts extra pressure to carry blood to vitalorgans and muscles. High blood pressure notonly increases the risk of heart attack andstroke, but it is also closely linked to conges-tive heart failure, chronic occlusive peripheralvascular disease, aortic aneurysm, and renalfailure. It is often called the “silent killer”because many people are not aware of theirsymptoms until damage has already been doneto the heart, brain, or kidney.

Blood pressure is reported in two numbers.The first number, systolic blood pressure,denotes the point of greatest pressure, whenthe heart contracts and pumps blood throughthe arteries. The second number, diastolicblood pressure, represents the point of lowestpressure when the heart relaxes between beats.A reading of 120/80 mm Hg is consideredoptimal blood pressure (National High Blood

0

10

20

30

40

8.6

28.0

12.7

34.0

Men Women

American Indians*

General population

Per

cent

High blood cholesterol ≥ 240 mg/dL.

*American Indians from Arizona, Oklahoma, North Dakota, and South Dakota.

Source: Welty et al., 1995; NHANES III.

FIGURE 5. HIGH BLOOD CHOLESTEROL AMONG AMERICAN INDIANS, 45 TO 74 YEARS OLD

14

Pressure Education Program, 1993b). Personsare considered to have hypertension if theirsystolic blood pressure measures 140 mm Hgor higher, their diastolic blood pressure mea-sures 90 mm Hg or higher at two or more vis-its over one to several weeks, or they are cur-rently taking medication for high blood pres-sure (National High Blood Pressure EducationProgram, 1993a).

The risk of cardiovascular morbidity, disabili-ty, and mortality increases progressively withincremental increases in blood pressure. Evenpersons with high-normal blood pressure (sys-tolic blood pressure of 130 to 139 mm Hg ordiastolic blood pressure of 85 to 89 mm Hg)are considered at increased risk for disease(National High Blood Pressure EducationProgram, 1993a). However, data show thateven a slight decrease in blood pressure levelscan substantially reduce cardiovascular risk.

For example, a downward shift of only 2 mmHg in the average national systolic blood pres-sure might reduce the annual mortality fromstroke, heart disease, and all causes by 6, 4,and 3 percent, respectively (National HighBlood Pressure Education Program, 1993b).

The incidence of high blood pressure isincreasing in native populations. Hypertensionaccounts for 42 percent of all IHS ambulatoryvisits, exceeded only by upper respiratoryinfections, otitis media, and diabetes (NationalHeart, Lung, and Blood Institute, 1996b). Animportant aspect of high blood pressure amongAmerican Indians and Alaska Natives is itsstrong association with diabetes and the appar-ent synergistic increase in morbidity when thetwo occur together (National Heart, Lung, andBlood Institute, 1996b). Figure 6 shows theprevalence rates of high blood pressure(≥ 140/90 mmHg or taking antihypertensive

0

20

40

60

80

100

39.043.0

37.7 38.0

Men Women

Per

cent

High blood pressure = 140/90 mm Hg or taking antihypertensive medication.

*American Indians from Arizona, Oklahoma, North Dakota, and South Dakota.

American Indians*

General population

Source: Welty et al., 1995; NHANES III.

FIGURE 6. HIGH BLOOD PRESSURE AMONG AMERICAN INDIANS, 45 TO 74 YEARS OLD

15

medication) among male and female StrongHeart participants.

The prevalence of hypertension varies by theregion and by tribe. Studies show that YaquiIndians of Arizona, the urban Chippewa ofMinnesota, and the Cree and Ojibwa tribes allhad higher systolic blood pressure than whites,and all but the Chippewa had higher diastolicblood pressure than their white counterparts(Ellis and Campos-Outcalt, 1994). Data fromthe Strong Heart Study revealed that AmericanIndians age 45 to 74 living in Oklahoma andArizona had higher rates of hypertension (42to 47 percent) than the country as a whole (38to 43 percent) for similar age groups in 1988-91 (Welty et al., 1995).

Pima Indians appear to have a higher preva-lence of high blood pressure than otherAmerican Indian and Alaska Native tribes.One study indicates that, in 1992, more than40 percent of male and more than 30 percentof female Pima Indians had hypertension,compared to less than 20 percent of male andapproximately 15 percent of female AmericanIndians and Alaska Natives served by theIndian Health Service (National Heart, Lung,and Blood Institute, 1996b).

Some native people, however, have hyperten-sion prevalence rates lower than other U.S.populations. The mean systolic and diastolicblood pressure of Yupik Eskimos was lowerthan whites in the 1988-91 NHANES(NHANES III), except for Yupik females age30 to 40, who had diastolic blood pressure lev-els similar to African Americans in theNHANES III (National Heart, Lung, andBlood Institute, 1996b). Among Strong HeartStudy participants living in North Dakota andSouth Dakota, only 27 percent of men and 28percent of women had hypertension in 1988-91, compared to 43 percent of men and 38 per-cent of women of all races in the United States(Welty et al., 1995).

The level of hypertension awareness was highin Strong Heart Study participants with highblood pressure. About 75 percent of partici-pants were aware that they had hypertension,and more than 50 percent of the persons withhypertension were treating and controlling it.This level of awareness was comparable tothose of white and African American partici-pants with hypertension in the NHANES III(Welty et al., 1995).

Cigarette SmokingCigarette smoking is an independent risk fac-tor for cardiovascular disease and acts syner-gistically with other risk factors such as highblood pressure and high blood cholesterol. Theestimated number of preventable deaths in theUnited States from coronary heart diseasealone related to smoking is more than 90,000deaths each year, and an additional 37,000deaths from CHD are attributed to passivesmoking each year. Cigarette smoke is estimat-ed to be responsible for more than 20 percentof all CHD deaths in men age 65 and olderand for approximately 45 percent of deaths inmen younger than age 65 (McBride, 1992).The risk for CHD attributable to smoking inwomen is similar. In the Nurses’ Health Study,more than 50 percent of the risk for prematurefatal and nonfatal CHD was attributable tosmoking (McBride, 1992).

Cigarette smoking contributes greatly to thedevelopment and progression of atherosclero-sis in coronary arteries, thrombosis, and acuteand chronic CHD events. Exposure to smokecauses coronary blood vessels to constrict,which may promote endothelial injury andlead to plaque development or progression andlocal thrombosis. Smoking also increases thestickiness of blood platelets, promoting theiradhesion to the lining of the arteries andincreasing the likelihood of a clot forming inthe narrowed arteries. The degree of risk ofsmoking is related to the number of cigarettes

16

smoked, and heavier smoking is associatedwith even higher risk of death and myocardialinfarction (McBride, 1992).

In smokers, a combination of factors sets thestage for a heart attack. Smoking increasesoxygen demand by raising the heart rate, bloodpressure, and peripheral arterial resistance. Inaddition, carbon monoxide in smoke binds tohemoglobin in red blood cells, thereby reduc-ing the oxygen-carrying capacity of the blood.This altered ability of coronary vessels to reg-ulate blood flow, coupled with a decreasedoxygen-carrying capacity, can produceischemia and possibly sudden death. Onestudy examining the effects of smoking inCHD patients revealed 33 percent moreepisodes of ischemia per day and a significant-ly longer duration of ischemia in smokingpatients. Cohort and population studiesdemonstrate that cigarette smoking substantial-ly increases the risk of sudden death(McBride, 1992).

Cigarette smoking is also associated withchanges in the lipoprotein distribution.Nicotine elevates very-low-density lipoproteincholesterol while reducing high-densitylipoprotein cholesterol. These combinedeffects may promote endothelial cell injuryand reduce vascular repair mechanisms.

Cigarette smoking cessation, however, is relat-ed to a marked decrease in CVD, includingreduced cardiac arrest, coronary death, andmyocardial infarction. Studies of both men andwomen consistently suggest a large reductionof cardiovascular risk following 1 year ofsmoking cessation and a gradual return over 5to 10 years to risks similar to those of peoplewho never smoked.

Passive smoking is also an important risk fac-tor for heart disease morbidity and mortality.Evidence from numerous studies links envi-

ronmental tobacco smoke (ETS) to heart dis-ease mortality and accounts for 70 percent ofall deaths due to ETS. Evidence also indicatesthat nonsmokers are more sensitive to smoke,including cardiovascular effects, and that pas-sive smoke contains a higher concentration ofgas constituents, including carbon monoxide(McBride, 1992).

Smoking has long been part of the culture ofmany American Indian tribes. Men smoketobacco and the dried leaves, roots, and barkof other plants on ceremonial and social occa-sions. For tribes like the Chippewa, tobacco isconsidered a gift from the spirit and thus has“magic power.” It increases the efficacy of arequest and makes an obligation or agreementmore binding (Gillum et al., 1984).

Today, many American Indians and AlaskaNatives smoke and no longer solely for spiri-tual reasons. Studies have shown a higherprevalence of smoking among AmericanIndians than whites; however, there are sub-stantial regional variations. The national smok-ing prevalence rates for 1987-91 among nativepeople were 33 percent for men and 27 per-cent for women, compared to 26 percent forwhite men and 23 percent for white women.

Data from the Strong Heart Study show thatsmoking rates in some regions may be evenhigher. In North Dakota and South Dakota, 53percent of men and 45 percent of womensmoked (Welty et al., 1995). In a cross-sec-tional study of Pascua Yaqui Indian adults age25 to 65 in Arizona, 43 percent of men and 24percent of women reported smoking (Campos-Outcalt et al., 1995). Among Alaska Natives,47 percent of men and 39 percent of womensmoke (Department of Health and SocialServices, 1996). Overall, men tended to smokemore cigarettes than women in all age groups(Campos-Outcalt et al., 1995).

17

These high rates are not indicative of allAmerican Indian and Alaska Native popula-tions, however. A study conducted on adultPima Indians in Arizona indicated a very lowprevalence of cigarette use; less than 1 percentsmoked (Nelson et al., 1990). The Strong HeartStudy also confirmed these low rates of smok-ing in the Southwest. The prevalence of smok-ing among American Indians in Arizona was30 percent of men and 13 percent of women.

The use of cigars, pipes, and smokeless tobac-co appears to be uncommon among adults.Fewer than 5 percent of the Strong HeartStudy participants smoked cigars or pipes, andsmokeless tobacco use was rare (Welty et al.,1995). However, higher rates of smokelesstobacco use have been reported in AmericanIndian children and adolescents, especiallythose living on reservations (National CancerInstitute, 1993).

Although adult American Indian men smokemore than women, data from an IndianAdolescent Health Survey reveal the opposite.This survey, administered to 13,454 students inseventh through twelfth grade, revealed thatfor every grade level after the seventh grade,females were more likely to be daily cigarettesmokers than males, rising from 9 percent injunior high school to 18 percent in highschool. The percentage for males increasedfrom 8 percent in junior high school to 15 per-cent in high school. However, daily use ofsmokeless tobacco was higher for males thanfemales, with 17 percent of high school malesusing smokeless tobacco compared to 8 per-cent of females.

Data from the 1990 Great Alaska Spit-OutTobacco Use Survey, completed by 1,555Alaskan schoolchildren, showed that theprevalence of both cigarette smoking and useof smokeless tobacco was 16 percent each(National Cancer Institute, 1993). A study by

Beauvais (1992) showed that cigarette use washighest for American Indian youth living onreservations compared to nonreservationIndian youth and white youth. Up to 74 per-cent of eighth graders and 80 percent oftwelfth graders living on reservations smokecigarettes. Smoking prevention programs needto focus on native youth before they beginusing tobacco.

Physical InactivityEvidence indicates that physical inactivity isan independent risk factor for heart disease.People who are physically inactive are almosttwice as likely to develop heart disease thanthose who are more active (National Institutesof Health, 1995). Physical activity may protectagainst the development of CVD and may helpcontrol high blood cholesterol, high bloodpressure, diabetes, and obesity. Several studieshave shown that exercise training programssignificantly reduce overall mortality as wellas death caused by myocardial infarction.

The NIH Consensus Statement on PhysicalActivity and Cardiovascular Health recom-mends a minimum of 30 minutes of moderate-intensity physical activity on most, and prefer-ably all, days of the week for all children andadults. In addition to formal exercise pro-grams, occupational, nonoccupational, anddaily living tasks such as brisk walking, homerepair, and yardwork have similar cardiovascu-lar and health benefits if performed at a levelof moderate intensity with an accumulatedduration of at least 30 minutes per day. Therecommended daily duration may be brokenup into shorter bouts of activity of at least 10minutes each.

A sedentary lifestyle has replaced a traditionalAmerican Indian lifestyle of long ago, whenhunting, fishing, and gathering was a way oflife. Isolation, a high unemployment rate,extreme weather conditions, and a lack of

18

recreational facilities all contribute to televi-sion being used as a means of entertainmentand occupying idle time. American Indians inthe Strong Heart Study reported watching tele-vision an average of 3 hours per day. A seden-tary lifestyle was common among the threegroups, with Arizona Indians being the leastactive. In all centers, 38 percent of men and 48percent of women reported no activity duringthe past week and 17 percent of men and 20percent of women reported no activity duringthe past year (Welty et al., 1995).

Diabetes MellitusDiabetes mellitus is a group of disorders char-acterized by high blood glucose levels. Type I,or insulin-dependent diabetes mellitus(IDDM), is an autoimmune disease that is rareamong American Indians and Alaska Natives.It occurs when the insulin-producing beta cellsin the pancreas are destroyed. People with typeI diabetes must have daily insulin injections tosurvive. Type II, or non-insulin-dependent dia-betes mellitus (NIDDM), occurs when bodycells become resistant to insulin and do notmetabolize glucose properly. Type II diabetesis more common among adults, especiallythose who have a family history of diabetes,are overweight, are older than age 40, and areof African American, Latino, or AmericanIndian descent. Many people with type II dia-betes are able to control their blood sugarthrough weight control, regular exercise, and ahealthful diet. Some may need insulin injec-tions or oral medications to lower their bloodsugar (National Institute of Diabetes andDigestive and Kidney Diseases, 1992).

Type II diabetes, once rarely diagnosed amongAmerican Indians, has reached epidemic pro-portions in many American Indian and AlaskaNative communities. Although NIDDM has agenetic component, with rates highest in full-blooded American Indians, the incidence andprevalence of the disease has increased dra-

matically as native people adopt Westernlifestyles, with accompanying increases inbody weight and diminished physical activity.

A 1987 Special Medical Expenditure Surveyof American Indians and Alaska Natives eligi-ble for IHS services showed that the age- andsex-adjusted diabetes rate in individuals olderthan age 19 was 12 percent, compared with 5percent in the general population. However,the prevalence of diabetes varies considerablybetween regions. Only 4 cases of diabetes per1,000 population were found among the Inuitof the Northwest Territories, whereas the PimaIndians of Arizona have a prevalence of 500cases per 1,000 population, the highest rate ofNIDDM in the world (National Institute ofDiabetes and Digestive and Kidney Diseases,1995b).

Among Alaska Natives, the prevalence of dia-betes was 16 cases per 1,000, but prevalencevaried by ethnic group: 27 cases per 1,000among Aleuts, 22 cases per 1,000 amongAlaskan Indians, and 9 cases per 1,000 amongAlaskan Eskimos (Schraer et al., 1988).Among participants of the Strong Heart Study,65 percent of Arizona Indian men and 71 per-cent of Arizona Indian women had diabetes. InOklahoma, North Dakota, and South Dakota,33 percent of men and approximately 40 per-cent of women had diabetes. Diabetesappeared to be more prevalent among womenthan men (Welty et al., 1995).

Diabetes and its complications are a majorcause of morbidity and mortality in nativepopulations. The age-adjusted diabetes deathrate for American Indians in 1984-86 was 2.7times the rate for the general population. Thisreflects only cases in which diabetes was theprimary cause of death, not those in which itwas a contributing cause. The NationalMortality Followback Study also found thatAmerican Indian and Alaska Native heritage

19

was underreported on death certificates by 65percent. When the 1986-88 relative mortalityrates were adjusted for underreporting of her-itage, the diabetes mortality for native peoplewas 4.3 times the rate for whites (NationalInstitute of Diabetes and Digestive and KidneyDiseases, 1995a).

A New Mexico study demonstrated thatAmerican Indians experienced 3.6 times thediabetes death rates of whites, and a mortalitystudy on Canadian Indian reservations in sevenprovinces found the risk of death from dia-betes to be 2.2 times higher for CanadianIndian men and 4.1 times higher for CanadianIndian women than the rates for the Canadianpopulation as a whole (National Institute ofDiabetes and Digestive and Kidney Diseases,1995a). Detailed mortality studies in Pimasduring 1975-84 found that the age- and sex-adjusted death rate from diabetes was 11.9times greater than the 1980 death rate for allraces in the United States (National Institute ofDiabetes and Digestive and Kidney Diseases,1995a).

The health burden from NIDDM comes pri-marily from complications. Kidney disease,cardiovascular disease, stroke, eye disease, andamputations caused by nerve disease are someof the long-term complications that arise fromNIDDM. Between 1983 and 1986, kidney dis-ease resulting in end-stage renal diseaseoccurred in Indians at nearly six times the rateseen among U.S. whites. Researchers havefound that Pima Indians have more than 20times the rates of new cases of kidney failureas the general U.S. population, and diabetes isresponsible more than 90 percent of the time(National Institute of Diabetes and Digestiveand Kidney Diseases, 1995a).

Cardiovascular disease is two to four timesmore common in people with diabetes. In fact,cardiovascular disease is present in 75 percentof diabetes-related death. Diabetes is related to

lipoprotein metabolism, atherosclerosis, obesi-ty, and hypertension. Diabetes is an indepen-dent risk factor for CHD, and the risk is dou-bled when high blood pressure is present(National Heart, Lung, and Blood Institute,1994).

Studies of specific tribes clearly suggest thatdiabetes is a major risk factor for cardiovascu-lar disease in all Native populations. AmongNavajos, half of all diagnosed myocardialinfarctions documented from 1976-79 to 1984-86 occurred in people with diabetes. In onestudy, nearly one-third of all participants withdiabetes also had cardiovascular disease. Ofthose age 60 and older, who constitute nearlyhalf of the population with diabetes, 33 per-cent of the women and nearly 60 percent ofthe men were afflicted. Age-adjusted rates forpersons with diabetes were 5.2 times those ofpersons without diabetes for heart disease,10.2 times for cerebrovascular disease, and 6.8times for peripheral vascular disease (Hoy etal., 1995). In Pima Indians, a tribe with lowcoronary heart disease rates, all CHD deathsduring 1975-84 occurred in persons with dia-betes. The study found that a longer durationof diabetes was associated with an increasedincidence of fatal CHD in Pima Indians(Nelson et al., 1990). In Strong Heart Studyparticipants, diabetes was the strongest riskfactor for CVD, especially among women(Howard et al., 1995).

ObesityThe prevalence of overweight and obesity areusually measured using body mass index(BMI), which is a ratio relating body weight toheight. Overweight is defined as a BMI of 25to 29.9 kg/m2. Obesity is defined as a BMI of30. Waist circumference is positively correlat-ed with abdominal fat content. Adults with aBMI of 25 to 34.9 kg/m2 are considered to beat greater risk for obesity-related factors iftheir waist measurement is greater than 40

20

inches for men and 35 inches for women(National Heart, Lung, and Blood Institute,1998).

Obesity is associated with an increased risk forhigh blood pressure, diabetes, and high bloodcholesterol. Even mild to moderate overweightis associated with a substantial elevation incoronary risk. However, weight loss canreduce cardiovascular risk. Data from theCoronary Artery Risk Development in YoungAdults (CARDIA) study show that weight loss(initial loss of 5 pounds without regain ofmore than 5 pounds over 5 years) decreasesblood pressure and raises HDL cholesterol lev-els (National Heart, Lung, and Blood Institute,1994).

In the early 1900s, obesity was rare amongAmerican Indians and Alaska Natives; how-ever, by the late 1960s, high rates of obesitywere reported in some tribes. In the 1987National Medical Expenditure Survey, 34 per-cent of American Indian males were over-weight compared to 24 percent of males in thegeneral population. Similarly, 40 percent ofAmerican Indian females were overweightcompared to 25 percent of females in the gen-eral population. The prevalence of obesity inAmerican Indians was also high—14 percentfor males and 17 percent for females—com-pared with whites—9 percent for males and 8percent for females (Broussard et al., 1991). In1993, 48 percent of American Indian andAlaska Native adults were overweight(National Center for Health Statistics, 1995).

Data from the Strong Heart Study showed thatthe prevalence of overweight exceeded nation-al averages by 16 to 36 percent in 1988-91.The highest rate of overweight was amongArizona Indians; 41 percent of the men wereobese and 26 percent were overweight. Forwomen, 50 percent were obese and 30 percentwere overweight. The waist-to-hip ratio indi-

cated that central obesity, another major riskfactor for heart disease, predominates in bothsexes (Welty et al., 1995).

In another study, the prevalence of overweightwas 34 percent and 56 percent among Eskimomen and women, respectively, and 29 percentand 55 percent among Alaskan Indian men andwomen. A recent study of Navajo adults indi-cates that 51 percent of women and 33 percentof men are overweight (Broussard et al.,1995).

The prevalence of obesity was also evidentamong American Indian children, even thoseas young as 5 years old. A study of AmericanIndian children age 0 to 4 participating in pub-lic health programs revealed that they weremore likely to be overweight than children ofthe same age in the general population. In1988, 11 percent of American Indian childrenunder 5 years old were overweight comparedto 8 percent of their counterparts in the generalpopulation (Broussard et al., 1991). A 1990national survey of 9,464 American Indianschoolchildren age 5 to 18, excluding NavajoIndians, showed that the overweight preva-lence was high for all ages and for both sexes.According to this survey, the overall preva-lence of overweight was 39.3 percent(Jackson, 1993).

Genetic predisposition is an important deter-minant of obesity. Studies of twins andadoptees have shown that body fat is transmit-ted genetically to a moderate extent. One studyestimates that about 25 percent of the variationin body fat is genetic, and much of the varia-tion is due to environmental factors such aslevel of physical activity and diet (NationalHeart, Lung, and Blood Institute, 1994).

Neel’s “thrifty gene theory,” proposed in 1962,may partially explain the propensity forAmerican Indians and Alaska Natives to beoverweight and obese (Neel, 1962). This theo-

21

ry postulates that, in order for populations tosurvive alternating periods of feast and famine,people developed a thrifty gene to allow themto store fat when food was abundant so thatthey would not starve in times of famine. Withthe introduction of a lifestyle characterized bya high-fat diet, less physical exercise, and acontinuous and ample food supply, this genebegan to work against them, continuing tostore calories in preparation for food scarcity.This thrifty gene that once protected peoplefrom starvation also might contribute to theirretention of unhealthy amounts of fat (NationalInstitute of Diabetes and Digestive and KidneyDisorders, 1995a).

DIETARY CONSUMPTION PRACTICES OFAMERICAN INDIANS AND ALASKA NATIVES

Over the last 30 years, the traditional foods—such as corn, buffalo, and venison—consumedby Native people have been replaced byprocessed and commercially prepared foods.Although there are tremendous gaps in knowl-edge about the contemporary consumptionpractices of American Indian tribes and AlaskaNative communities, a few studies shed somelight on this area. A food frequency surveyconducted on Mvskoke Indians in Oklahomashowed that their diets were generally high infat, calories, and sugar (Russell et al., 1994).Respondents stated that they ate processedmeats, hamburger, snack chips, and sweet rollson a regular basis. Meat was typically fried,and vegetables were usually cooked in baconfat or butter. They rarely relied on hunting,fishing, and butchering livestock and usuallyate traditional food only at tribal celebrations(Russell et al., 1994).

Data from the Strong Heart Study (1989-91)showed that mean food energy intakes of par-ticipants were below the recommended dailyallowance. Mean total fat intakes as a percent-age of calories were consistently above 30 per-

cent of calories, and mean intakes of dietaryfiber were below the recommended intake of20 to 30 grams per day for healthy adults(Federation of American Societies forExperimental Biology, 1995). This study alsorevealed numerous variations in diet amongthe three communities. The Pima Indians ofArizona had the highest fat and cholesterolconsumption, but also the highest fiber intake,compared to the other two sites. TheOklahoma group overall consumed a widervariety of foods and more fruits and vegeta-bles, both fresh and canned; however, theyalso ate more beef, bacon, hot dogs, and fats(National Heart, Lung, and Blood Institute etal., 1993).

A dietary survey of Pima Indians in Arizonashowed that their diet has been influenced bymainstream American foods, Mexican foods,and the food distribution programs operatingin the community. For example, the typicalAmerican-style breakfast of eggs, bacon orsausage, and fried potatoes is common, as areMexican-style dishes such as tacos, tamales,menudo (entrails soup), and chorizo (sausage).Staples derived from the food commodity pro-grams including canned meats, vegetables, andAmerican cheese are reflected in typical dishessuch as “cheese crisp” (melted cheese on a tor-tilla) and corned beef with gravy or potatoes.Hamburger and pork chops are the most wide-ly used meats, and the traditional Pima intakeof legumes is evident in the combination ofpinto beans with many foods. Pimas also eatwhite bread, flour tortillas, and fry bread (atype of biscuit dough formed into balls andfried). Traditional desert foods such as “wildspinach,” tepary beans, and cholla (cactus) areeaten infrequently and more by the older agegroups or at community gatherings.

The sodium intake in Pima Indians is close tothe recommended level for adults and is gener-

22

ally lower than the mean intake for the generalpopulation. However, Pima Indians consumetoo much of their fat as saturated fat and toolittle as polyunsaturated fat, according to therecommendations of the National CholesterolEducation Program. Moreover, the averagecholesterol intake is far above the maximumrecommended level of 300 mg per day (Smithet al., 1996).

A 1987-88 assessment of the dietary intakes ofAlaska Native adults from 11 communitiesrevealed that they consumed more protein, fat,carbohydrates, iron, and vitamins A and C thanthe general population; however, they alsoconsumed less calcium, fruits, and vegetables(Nobmann et al., 1992). Alaska Natives main-tain a heavy reliance on traditional foods andeating practices, consuming high amounts offish and shellfish. The percentage of fat con-sumed was 35 to 39 percent, greater than therecommended level of below 30 percent. Themajor contributors of fat were fish, agutuk(Eskimo ice cream), beef, seal oil, whale blub-ber, chicken, butter, and margarine. Agutuk,beef, and butter contribute to the saturatedfatty acid intake and may be an important con-tributor to the static rate of heart diseaseamong Alaska Natives. Berries and seaweedare typical fruits and vegetables eaten byAlaska Natives; however, they generally con-sumed only one or two fruits or vegetables perday, much less than the recommended five perday. Dark green, yellow, and cruciferous veg-etables were eaten very infrequently(Nobmann et al., 1992).

Alcohol ConsumptionAlthough considerable evidence shows thatmoderate alcohol consumption (defined as nomore than one drink per day for most womenand no more than two drinks per day for mostmen) decreases the risk of death from coro-nary artery disease, numerous studies haveshown an association between chronic heavy

drinking and high blood pressure, cardiomy-opathy, arrhythmias, and stroke (NationalInstitute on Alcohol Abuse and Alcoholism,1993).

Many epidemiological studies have identifieda positive association between alcohol intake(three or more drinks or roughly 40 grams ofalcohol per day) and the level of blood pres-sure. Data from cross-sectional studies showthat as much as 5 to 7 percent of the overallprevalence of hypertension can be attributed toan alcohol intake of three or more drinks perday (National High Blood Pressure EducationProgram, 1993b). The risk for hypertensionamong individuals drinking three or moredrinks per day was 50 percent higher thanamong nondrinkers; the risk among individu-als consuming six or seven drinks per day was100 percent higher. A recent study also demon-strated that the mean systolic and diastolicblood pressure was 6.6 and 4.7 mm Hg higher,respectively, among daily drinkers than amongindividuals who drank less than once a week(National Institute on Alcohol Abuse andAlcoholism, 1993).

Studies show that chronic alcohol consump-tion also is associated with increased risk ofstroke, cardiomyopathy, and arrhythmias.Heavy drinking (about five drinks per day)increases by fourfold the risk of hemorrhagicstroke and may contribute to an estimated 20to 30 percent of cardiomyopathy cases.Furthermore, the high incidence of suddendeath in alcoholics may be explained in partby alcohol-related arrhythmias (NationalInstitute on Alcohol Abuse and Alcoholism,1993).

Alcohol-related morbidity and mortality arehigh in most American Indian populations,causing high rates of premature loss of life.For men age 45 to 64, cirrhosis is the secondleading cause of death among American

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Indians and Alaska Natives. The mortality ratedue to cirrhosis is about twice as high fornative men as for white men (Centers forDisease Control and Prevention, 1992). Fornative people in the IHS service area, the mor-tality rate is more than three times that ofwhites (Indian Health Service, 1996).

In 1990-92, the age-adjusted alcoholism mor-tality rate for the IHS service area populationwas 37.2 cases per 100,000 population. Whenthe three IHS areas with problems in underre-porting of American Indian race on death cer-tificates were excluded, the age-adjusted mor-tality rate increased to 52.6 cases per 100,000population. This was 674 percent higher thanthe general population rate of 6.8 cases per100,000 in 1991. These rates vary by region,however. The mortality rate was 89.3 deathsper 100,000 population in the Aberdeen area(North Dakota and South Dakota), comparedto 9.2 deaths per 100,000 population in theOklahoma area (Indian Health Service,1995b).

The 1990 national rates showed that amongAmerican Indians and Alaska Natives age 45or older, 63 percent of men and 41 percent ofwomen currently use alcohol (Welty et al.,1995). Data from the Strong Heart Study,however, showed that participants drank lessthan these given rates: 55 percent of men and32 percent of women were current alcoholdrinkers (Welty et al., 1995). On the otherhand, the rates of heavy drinking (14 or moredrinks per week) and binge drinking (5 ormore drinks per occasion) were higher amongStrong Heart Study participants who had con-sumed alcohol during the past year than wasreported in national surveys (Welty et al.,1995). Heavy drinking and binge drinkinghave been associated with many adverse healthevents, including sudden death.

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AMERICAN INDIAN AND ALASKA NATIVE

CULTURE AND PERCEPTIONS OF HEALTH

An understanding of American Indian andAlaska Native cultures is essential to creatingprograms that are relevant, appropriate, andacceptable to the target population. Culture isthe integrated pattern of knowledge, beliefs,and behaviors that colors the way one sees theworld and serves as a framework within whichindividuals function throughout their daily life.It is the set of values that helps define the rela-tionship of individuals to their environmentand to other individuals (Paniagua, 1994).

Although the American Indian population isvery diverse, some parallels exist in the basicbeliefs and values many American Indiansshare. Unlike mainstream U.S. culture, whichstrongly values individualism and the nuclearfamily, American Indians and Alaska Nativesare characterized by a strong family and com-munity structure. They also value harmonywith the environment and traditional methodsof healing.

SOCIAL STRUCTURE

American Indians and Alaska Natives strivefor integration within the family, clan, andtribe. In contrast to the mainstream Anglo-American culture of nuclear family, AmericanIndians value the extended family above theself. The familial structure is usually intergen-erational and includes members of the specificclan and tribe as well as individuals from thecommunity who have made significant contri-butions to the family’s survival. Fathers (orolder adults) “manage” the American Indian

family rather than control it, unlike Asian orHispanic fathers who often control their fami-lies by authority or machismo. AmericanIndian women are highly esteemed becausethey give the gift of life. They typically serveas the caretakers of the family and often placethe needs of family members before their own.Mutual respect between wives and husbands,between parents and children, and betweenfamily members and relatives is looked uponhighly (Paniagua, 1994).

Every person in the family is viewed as a sig-nificant component of the family structure, andthe family provides security and protection forpeople of all ages. Elders are cherished fortheir wisdom and knowledge. They know allthe rules necessary for social order and areexpected to help educate the young about trib-al customs, history, and morals. Children areviewed as blessings from the creator and areincluded in almost every tribal activity(National Cancer Institute, 1993).

Although strong family relationships areemphasized, American Indians and AlaskaNatives also foster a sense of independenceamong family members, particularly amongchildren and adolescents. For example,American Indian children are rarely tolddirectly what to do and are often encouragedto make their own decisions. Few rules arepreferred among American Indians and AlaskaNatives; if rules exist, they should be flexibleand loosely written (Paniagua, 1994).

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Native culture consists of gift offerings andsharing one’s self, time, and energy with thefamily, clan, and tribe. The self is often sec-ondary with respect to the role of the tribe.Like Latinos and Asians, native people rejectthe traditional sense of individualism becauseit leads to competition among family membersand tribe members. Rather, they emphasize thevalue of collectivism and working together toachieve common goals among all members ofthe tribe (Paniagua, 1994). This sentimentfrom a Lakota woman is typical of the waynative people perceive their social structure:

“At the core of tribal nations is not theindividual but the family. Withoutrespect for families and children, noneof us will survive. We need to give peo-ple a sense of belonging. That’s whatmakes a nation strong” (Katz, 1995).

CONCEPT OF TIME

Many American Indians and Alaska Nativestreat time as a natural event and do not believethat time should control their natural way ofliving. Time is viewed not as a measuring tool(e.g., hours, minutes) but rather as it relates toan event or task. In the same way that materialgoods are often shared, many native peoplebelieve that time (to fulfill a given task) mustalso be shared with others. For example, punc-tuality is highly valued in mainstream Westernculture. Lack of punctuality is viewed nega-tively and shows a lack of respect for otherpeople’s time. However, for native people,being late is perceived differently and cansometimes be a sign of respect for people. Ifsomeone is stopped by a person asking a ques-tion, that person takes the time to answer it.The event, then, takes priority over the clock(Paniagua, 1994).

HARMONY WITH THE ENVIRONMENT

Generally, American Indians and AlaskaNatives have respect and reverence for theearth and all of nature, striving to live close tonature and its forces. The spiritual worldincludes not only humans but all living things.Many believe that each animal, tree, and mani-festation of nature has its own spirit and that auniversal energy links all life forms, enablinghumans to communicate spiritually with otherliving things. Care is taken not to harm or des-ecrate the earth. Even today, Pueblo Indians inTaos, New Mexico, can be seen taking shoesoff horses and walking in soft-soled shoesthemselves in the spring because they believethat the earth is pregnant at this time of yearand her body must not be harmed (Josephy,1991).

The native concept of the world is circular;there is no beginning and no end. The motionof the sun, moon, and stars across the sky iscircular as is the life path of all creatures. The“circle of life” is one of the most meaningfulsymbols in American Indian life. It symbolizesthe continuing circle of life from birth throughadolescence, adulthood, elder years, death, andthen rebirth (Indian Health Service, 1995a).The importance of the circle is evident in themajority of American Indian cultures.Religious ceremonies are performed in a cir-cle, and the shape of many traditional Indianhomes is round such as the Apache wickiup,the Navajo hogan, and the tipi of the PlainsIndians.

ORAL COMMUNICATION

American Indian and Alaska Native history isnot a written history, but a spoken one.Through the art of storytelling, most tribescommunicate their traditions, beliefs, and cus-toms to younger generations. They use Indianfolktales and myths to teach about religious,

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social, and political system, habits and beliefs,and daily codes of conduct (Josephy, 1991).This oral communication, rich with life andmeaning, is handed down through countlessgenerations and plays a principal role in estab-lishing the individual and collective nativeidentity. In some native tribes, elderly as wellas younger women see themselves as carriersof culture, using the wisdom of the ancients toadapt to a changing world. Paula Gunn Allenwrites:

“My mother told me stories aboutcooking and childbearing; she told mestories about menstruation and preg-nancy; she told me stories about godsand heroes, about fairies and elves,about goddesses and spirits; she toldme stories about the land and the sky .. . . She told me European stories andLaguna stories; she told me Catholicstories and Presbyterian stories; shetold me city stories and country sto-ries; she told me political stories andreligious stories. She told me storiesabout living and stories about dying.And in all of those stories she told mewho I was, who I was supposed to be,whom I came from, and who would fol-low me. In this way she taught me themeaning of the words she said, that alllife is a circle and everything has aplace within it.” (Katz, 1995).

TRADITIONAL AND CONTEMPORARYMETHODS OF HEALING

American Indians and Alaska Natives have tra-ditionally cherished good health and longevity.Harmony with nature is important to an indi-vidual’s health and well-being and occurssimultaneously on physical, mental, and spiri-

tual levels. A person in good health is consid-ered to be in a state of beauty or harmony. Inthis state, all parts of the body function per-fectly and feelings of well-being are felt. Aperson not in this state of harmony is consid-ered either sick or ill. Sickness is a more acutestate and can be physical, mental, social, orenvironmental in nature. Physical sicknessincludes colds, burns, skin rashes, and brokenbones. Illness, on the other hand, is consideredmore serious than sickness and comes aboutslowly, lingers for a long time, and has no dis-cernable cause (National Cancer Institute,1993).

Traditionally, many tribes incorporated healthand sickness concepts into their basic religiousprinciples. Traditional beliefs defined theirsocial origins, their relationships with thesupernatural, and the nature of the universe.Tribes believed that supernatural powersassisted them in overcoming numerous envi-ronmental and social hardships. By performingmundane behaviors according to a prescribedorder, they were guaranteed spiritual, social,and physical well-being. Trouble of any kindwas a direct consequence of either a breach ofthe “prescribed order” or evil spirits causing aperson’s disharmony. American Indian peoplerevered tribal healers because they believedthat the healer was given special powers tocontrol or counteract the negative powers fromthe human or spiritual world that caused ill-ness (National Cancer Institute, 1993).

Many American Indians and Alaska Nativescontinue to have the old attitudes about healthand illness, and traditional healing is still prac-ticed by most cultures. Traditional healing is aholistic approach that involves treating thebody, mind and spirit of the individual in addi-tion to their symptoms and physical manifesta-tions. Tribal healers use herbs and teas, as wellas prayers to spirits and ritual incantations totreat their patients’ symptoms. Oral communi-

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cation with the spirits, or “sing” is also used toprevent sickness or illness when it is knownthat an individual will come into contact withobjects or malignant forces (National CancerInstitute, 1993).

American Indians and Alaska Natives oftenincorporate both traditional healing andWestern methods of healing. They haveaccepted the Anglo doctor’s role in their heal-ing process, but relegate the doctor to the lim-ited role of “the treater of symptoms ratherthan the curer.” It is understandable, therefore,why native people go to Anglo doctors primar-ily for symptomatic treatment with antibioticsand other quick painkillers rather than for sus-tained medical care (National Cancer Institute,1993).

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COMMUNITY-BASED HEALTH PROMOTION AND

DISEASE PREVENTION PROGRAMS FOR

AMERICAN INDIANS AND ALASKA NATIVES

This section highlights some key preventionand intervention programs that have beendeveloped to address the cardiovascular healthof American Indians and Alaska Natives.These programs are not meant to depict theentirety of programs available for this popula-tion but serve only as a representative sampleof existing programs.

STRONG HEART STUDY

The Strong Heart Study, aresearch study sponsored by theNational Heart, Lung, and BloodInstitute of the National

Institutes of Health, is designed to estimatemortality and morbidity from cardiovasculardisease and to determine the prevalence ofknown and suspected cardiovascular risk fac-tors in American Indians. This is the first studyof its kind to compare levels of cardiovascularrisk factors among diverse American Indianpopulations. The risk factors examined werehigh blood pressure, high blood cholesterol,diabetes, obesity, physical inactivity, smoking,and alcohol consumption. The project consist-ed of three components: death record reviews,medical record reviews for previous hospitaland clinical visits, and physical examinationsof people age 45 to 74. More than 4,500 par-ticipants from 12 tribes were examined at threesites in central Arizona, southwesternOklahoma, and the Aberdeen area of NorthDakota and South Dakota.

To accomplish this enormous task of recruitingparticipants, tribal councils and the Bureau of

Indian Affairs were consulted regarding enu-meration of the study. Significant assistancealso was provided by the Indian Health Ser-vice, the National Institute of Diabetes andDigestive and Kidney Diseases, and the U.S.Army. The Strong Heart Study made everyattempt to involve the participating communi-ties. The project provided employment oppor-tunities for American Indians in the local com-munity to serve on the staff. Community meet-ings were held periodically to apprise commu-nity members of the project’s status and anypreliminary data collected. Community mem-bers also had an opportunity to provide valu-able feedback to the investigators on the studyprocedures. The Strong Heart Study distrib-uted a quarterly newsletter as another commu-nications mechanism.

To boost recruitment efforts, evening andSaturday clinics were held to accommodateparticipants who were unavailable during theregular hours. At one site, exams were con-ducted at an apartment located within an elder-ly housing complex. The Strong Heart Studyalso participated in community events andhealth fairs. The project was invited to cohostthe First Annual Intertribal Dialysis Associ-ation and Foundation powwow in 1991.

The Strong Heart Study received overwhelm-ing support from community leaders and mem-bers in all three sites. Most of the prominentcommunity members who were eligible for theproject participated, thus setting an importantexample for other community members. Evenpeople who were not eligible for the study

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were aware of the value of the project to thecommunity. A major reason for the successand the relatively low cost of the project wasthe cooperation and partnerships developedbetween the National Heart, Lung, and BloodInstitute (the funding institute); other Govern-ment agencies; and participating tribes.

PATHWAYS

PATHWAYS is a multisite school-based obesi-ty prevention program designed to reduce theprevalence of obesity in school-aged childrenby promoting healthful eating and physicalactivity. It is the first childhood obesity pre-vention study of its kind to be executed in theUnited States under rigorous scientific meth-ods. Conducted in cooperation with sevenreservations in Arizona, New Mexico, andSouth Dakota and five universities, PATH-WAYS is a two-phase study consisting of a 3-year planning and development phase and alarger, full-scale study.

The classroom curriculum for grades 3, 4, and5 teaches children the importance of healthfuleating and physical activity; a school mealprogram and a physical activity/education pro-gram give children an opportunity to applytheir knowledge; and family involvement rein-forces children’s health behaviors. The out-come measures for this program include chil-dren’s knowledge, attitudes, and behaviorsabout health, nutrition, and physical activity;an assessment of their growth and develop-ment; their eating and physical activity pat-terns; and the nutrient content of school meals.

The first phase of the project recently has beencompleted and is awaiting complete dataanalysis before implementation of the full-scale study. Its success was based on meticu-lous attention paid to cultural sensitivity, acces-sibility to healthful food and exercise options,privacy and confidentiality of individuals, and

respect for the existing school and tribal infra-structure. The project received approval fromthe tribal councils, universities and tribalreview boards, the local Bureau of IndianAffairs, the Indian Health Service, and partici-pating school boards before it was initiated.

Every effort was made to involve key tribal,community, and school individuals in advisingthe researchers on the conduct of the study andto include American Indians among researchproject staff. Individual and group interviewswere conducted to obtain input on tailoring theprogram to suit the needs of the individualsites. The program components were pilot-test-ed, and the community had the opportunity toprovide input that was then used to revise thecomponents. The schools also participated indeveloping measurement methods for evaluat-ing the effectiveness of the program. PATH-WAYS is sponsored by the National Heart,Lung, and Blood Institute.

CHECKERBOARD CARDIOVASCULARCURRICULUM

The Checkerboard Cardiovascular Curriculumwas an intervention designed to increase car-diovascular health knowledge among fifth-grade children in rural New Mexico, primarilyPueblo and Navajo American Indians andLatinos. Students learned about cardiovascularhealth, with an emphasis on reducing high-riskbehavior, by participating in 8 to 10 weeklymeetings of about 2 hours. A team-teachingapproach was used, and lessons were taught bya graduate student, health educators, and otherhealth professionals. This culturally rich cur-riculum incorporated information on AmericanIndian traditions about running and exercise,and the traditional American Indian and Latinodiet. Children were encouraged to share storiesabout traditional philosophies of running andfitness and to interview grandparents about tra-ditional Indian life. Elders also were invited to

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classrooms to cook traditional, heart-healthyfoods and to talk about the cultural importanceof physical activity and fitness. Students werechallenged to exercise at home, and all stu-dents at one school participated in a distancerun. Efforts were made to adapt the curriculumto each culture. The project showed positiveoutcomes. Students at all schools showed asignificant gain in knowledge, many studentsincreased their exercise, and many alsodecreased their 1-mile walk or run time.Followup sessions revealed students’ interestin continuing the program (Harris et al., 1988).

ZUNI DIABETES PROJECT

The Zuni Diabetes Project, a community-basedexercise and weight control program, isdesigned to encourage weight loss andimprove glycemic control in people with dia-betes. Initiated by the Indian Health Service inJuly 1983, the project is now managed by theZuni Wellness Center, a tribally owned pro-gram. The center offers weightlifting circuittraining and a gym for basketball, volleyball,and aerobics classes. The center has expandedfrom providing 2 aerobic exercise sessions perweek to offering more than 48 sessions 5 daysa week in several sites in the Zuni community.Weekly clinics are held in conjunction with theexercise classes to monitor weight, serum glu-cose, and blood pressure. Special incentive

events are also held, such as running, walking,and bicycling programs; annual weight losscompetitions; and annual fitness challenges.Zuni aerobic instructors are employed andserve as role models. Participation in the pro-gram is promoted through personal invitations,recommendations from the medical staff, and ageneral community advertisement campaign.To increase accessibility and encourage moreparticipation, the center also provides trans-portation for the community.

In 1987, the Zuni Diabetes Project, in conjunc-tion with the Eat Right New Mexico cam-paign, held a weight loss competition in theZuni and Navajo communities. Eat Right is astatewide nutrition education and weight con-trol program implemented by the HealthnetNew Mexico health promotion organization. Atotal of 249 people completed the 10-weekprogram. Elements of the program includedteam competition, goal-setting, weekly weigh-in sessions with results posted on displayboards, exercise logs, and behavior checklists.

Results from the program were extremelypromising. Not only did 92 percent of the reg-istered participants complete the 10-week pro-gram, but most people also exceeded the pro-gram’s weight loss goal and managed to keepthe weight off after a 50-week followup peri-od. The participants’ mean blood glucose val-ues also dropped significantly, and they weremore than two times as likely to havedecreased their diabetes medication as the non-participants.

This study demonstrated that a community-based exercise program can be an effectiveway to facilitate weight loss and improvemetabolic control in a group of AmericanIndians with non-insulin-dependent diabetesmellitus. The weight loss competition provedto be an inexpensive strategy for facilitatingweight loss and behavior change. It enhanced

Traditional dancing keeps the heart strong

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and strengthened social support systems,which in turn stimulated interest and increasedcommitment among team members (Heath etal., 1991).

SOUTHWESTERN CARDIOVASCULARCURRICULUM

The Southwestern Cardiovascular Curriculum(SCC) is a multifactorial, culturally orientedcurriculum created for American Indian stu-dents in rural northwestern New Mexico.Funded by a grant from the National Heart,Lung, and Blood Institute, the curriculumincreases knowledge and promotes healthybehavior changes by teaching students lifetimeskills to promote healthy habits. The curricu-lum focuses on physiology, nutrition, physicalactivity, and the effects of tobacco use. Kidsalso engage in skill-building activities androle-playing to teach them to resist peer pres-sure and other social influences. Hardiness isemphasized as an important tradition ofAmerican Indian people. As part of an inter-generational component of the curriculum,elders from the local community lead class-room discussions on the values of traditionalfoods and the cultural importance of bothphysical and spiritual well-being. Emphasis isplaced on the traditional American Indian useof tobacco. School teachers and administratorsare trained to teach the curriculum by attend-ing a 2-day seminar.

Preliminary data from evaluation studies showthat students experience positive changes inhealth knowledge, attitudes, and behavior. Thecurriculum helped schools meet their goals forthe Healthy Kids for the Year 2000 programand the school-related objectives of the U.S.Department of Health and Human Services foreducating children about nutrition, physicalactivity, and tobacco. The educators’ trainingworkshop increased teachers’ knowledge andskills in health and multicultural education,

and food service employees were given addi-tional training in selecting and preparinghealthful foods.

NIDDK DIABETES PREVENTION PROGRAM

The National Institute of Diabetes andDigestive and Kidney Disorders (NIDDK) hasimplemented a multicenter clinical study todetermine if diabetes can be prevented ordelayed. In preparation for this multicenterstudy, the NIDDK conducted a pilot studywith two groups of Pima Indians who are freeof diabetes and have normal glucose tolerancetests. The two groups were called Pima Actionand Pima Pride. The Pima Action group mem-bers participated in discussions on healthy tra-ditional behaviors involving nutrition andexercise and were encouraged to eat a low-fat,high-fiber diet that included beans, fruits, andvegetables. They were also prompted to exer-cise 3 hours a week in leisure and occupation-al activities and to record their activities in ajournal. Most participants exercised or workedin groups when possible to maintain motiva-tion and morale. Program staff met with studyvolunteers at 3-, 6-, and 12-month intervals tomeasure their progress.

Whereas members of the Pima Action groupfocused on weight loss, the Pima Pride groupparticipants focused on discovering ancestralvalues and lifestyles and determining their rel-evance to their own lives. These participantsattended presentations by community membersand others to learn more about their ancestors’healthy diets and lifestyles.

Results from these pilot studies have beenpromising; participants are eager to makehealthy lifestyle changes. Upon completion ofdata analysis for the pilot study, theresearchers plan to develop an interventionincorporating several other treatments and thebest aspects of the Pima Pride and Pima

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Action programs (National Institute of Dia-betes and Digestive and Kidney Disorders,1995a).

NUTRITION ASSISTANTS PROGRAM

The Indian Health Service, in collaborationwith the U.S. Department of Agriculture(USDA), has developed the NutritionAssistants Program to prepare paraprofession-als in nutrition education. These paraprofes-sionals are chosen from reservation communi-ties to serve as role models and educators forother community members. Through homevisits and community activities, these nutritionassistants teach people to prepare and storefood in healthy ways. One week of formaltraining and followup training sessions areprovided, which are adapted to suit thelifestyles of people living in American Indiancountry. College credit is offered in some sitesfor nutrition assistants taking the classes. Theadvantage of using paraprofessionals is theircultural sensitivity and their ability to relate tothe target audience because they are membersof the target audience.

FOOD DISTRIBUTION PROGRAM ON INDIANRESERVATIONS

The Food Distribution Program on IndianReservations (FDPIR) provides food com-modities to low-income American Indian andAlaska Native families living on or near reser-vations. It is an alternative to the Food StampProgram for people who do not have easyaccess to food stores. The program is adminis-tered by the USDA in cooperation with Stateagencies. The USDA provides food to theState agencies, which are responsible for foodstorage and distribution, eligibility certifica-tion, and nutrition education. Families receivemonthly packages of basic supplemental foodssuch as canned meat and fish products, cannedfruits and vegetables, dried beans, dairy prod-

ucts, grain products, fats, and sugar (U.S.Department of Agriculture, 1994).

In 1986, the USDA revised the food packageby lowering the levels of fats and sugar in thefood and increasing the nutrient and energycontent. The agency recently launched twopilot programs to add frozen ground beef andfresh fruits and vegetables as alternatives tocanned products in the food package. Theseproducts have never been available before dueto the lack of transportation and storage facili-ties. However, the USDA partnered with theU.S. Department of Defense, an agency able toprocure fresh produce and deliver it directly totribes. In addition, a significant nutrition edu-cation component has been created thatincludes culturally appropriate fact sheets andrecipes detailing storage, handling, and prepa-ration of the new foods. Nutrition and cookingdemonstrations are being designed and imple-mented by individual tribes to meet the specif-ic needs of each area. Both pilot programshave met with huge success and are beingexpanded to include additional sites. The pro-vision of these new products will allow FDPIRparticipants—who do not have access to inex-pensive or good quality fresh fruits, vegeta-bles, and meat—to enhance the nutritionalbenefits in their diet and enjoy a greater vari-ety in their food choices (U.S. Department ofAgriculture, 1993, 1996).

WINGS OF AMERICA

Wings of America, established in 1988, is anAmerican Indian youth development programof the Earth Circle Foundation, Inc., based inSanta Fe, New Mexico. In partnership withAmerican Indian communities, the programuses running as a catalyst to empowerAmerican Indian youth to identify with theirheritage and take pride in themselves, leadingto increased self-esteem, health, and wellness.Wings of America holds running and fitness

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camps for children and adolescents. Thesecamps teach life management and leadershipskills, running and fitness techniques, sub-stance abuse prevention, and good nutrition.The children are also taught traditionalAmerican Indian games. College-aged Wingsof America runners facilitate the children’scamps, and high school runners serve as peerleaders and role models.

Wings of America also sponsors teams of highschool runners to the U.S.A. Track and FieldNational Cross Country Championship eachyear. The program showcases the talents ofAmerican Indian youth at this event and offersthem a cross-cultural experience. To date,Wings of America runners have captured eightnational junior titles since 1988 and haveachieved national recognition. The program iscurrently developing model fitness and healthprograms to be implemented at the communitylevels through existing youth, health, wellness,school, and drug elimination programs. Forexample, Wings of America is working withthe eight Northern Indian Pueblo Day Schoolson the Gila River Reservation to supplementtheir health and physical fitness programs andto coordinate an all-schools track and fieldday. The program receives funding through theU.S. Department of Housing and UrbanDevelopment’s Drug Elimination Program(Wings of America, 1996).

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This section discusses some key elements toconsider in designing community-based healthpromotion programs for American Indians andAlaska Natives. These strategies are based onfindings from intervention studies on Ameri-can Indians and Alaska Natives, experiences ofactual programs, and expert interviews. Thesehighlighted strategies are not displayed in pri-ority order and do not represent the universe ofsuccessful program strategies.

INCORPORATE COMMUNITY CULTURE,LIFESTYLE, AND VALUES.

Successful interventions are tailored to thepreferences and daily activities of the targetpopulation. For native people, the culturalvalue of family and tribe takes priority overthe self; therefore, interventions that are fami-ly-centered rather than self-centered may bebetter accepted by the community. Activitiesinvolving participation from parents, children,grandparents, and extended family are veryappealing. The special relationship betweengrandparents and grandchildren also can serveas an effective avenue for learning and healthbehavior change.

Women can be a viable channel for transmit-ting health messages to family members. Theyare often considered the educators and healersof the family. Interventions placed in the con-text of how behavior change will help theirchildren and their families are more likely tobe accepted because women value the preser-vation of the family and of generations to

come. For example, a woman is more likely toexercise and to eat less fatty food so that shewill be a live mentor for the family (NationalHeart, Lung, and Blood Institute et al., 1993).

Powwows and other tribal rituals can andshould be incorporated into programs whenev-er possible. Powwows are one of the most vis-ible expressions of “Indianness,” and aresimultaneously social gatherings, celebrations,family reunions, and occasions for spiritualrenewal (Reader’s Digest, 1995). Once begunas tribal celebrations, powwows have evolvedinto truly pan-Indian forms, blending traditionsdrawn from numerous tribes. AmericanIndians from inner cities and remote reserva-tions alike come together to celebrate theiridentity in song, dance, and costume. Thesepowwows can be found nationwide. One ofthe biggest powwows is the Red Earth Festivalheld each June in Oklahoma City (Viola,1990).

GAIN COMMUNITY SUPPORT.

Historically, numerous researchers have usedAmerican Indian and Alaska Native tribes toconduct their research studies without sharingthe information they gained with the tribesthemselves. Over time, this behavior provokedmistrust of researchers and science amongnative people. Suspicion and mistrust still per-sist today but have been somewhat remediedby researchers who have developed a workingrelationship with their target audience andhave included community members in theintervention’s planning and implementation.

RECOMMENDED STRATEGIES FOR

EFFECTIVE PROGRAMS

1

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The principle of participation is of utmostimportance to the American Indian and AlaskaNative population. When policies and priori-ties are developed at the national level butdepend on local institutions for their execu-tion, planners must make every effort to solicitactive participation, input, and even endorse-ment from the tribal leaders and the communi-ty they are working with prior to collaboratingon any research, training, or educationalefforts.

Gaining community support is essential to sus-tain an effective intervention effort.Community members add credibility and visi-bility to the project and can provide informa-tion on the cultural values, customs, and healthbeliefs and practices. They also can identifykey community leaders, communication net-works, and local experts who might be usefulto the program.

One way to organize a working group of opin-ion leaders is to establish a community or trib-al advisory board whose members can assist inplanning and implementing the program.These advisory boards typically include peoplewho will be most affected by the intervention.These people may be tribal government lead-ers, elders, medicine men and medicinewomen, primary care providers, communityhealth representatives, and members of the tar-get population.

Community members should be involved in allstages of the intervention. Early communityinvolvement in setting goals and priorities aswell as in program planning provides theopportunity for ownership, which can lead to asense of empowerment and self-determination.Community members can be enlisted to con-duct their own community needs assessment,and they can serve on focus groups to providevaluable insights into the target audience’shealth beliefs and practices. Working groups

also can help develop concepts, messages, andimages to ensure cultural relevance. Nativepeople also can work as trusted and acceptedstaff members who work directly with pro-gram participants. In addition, they can pro-vide feedback to researchers about benefits tosubjects from participating in interventions.

With training and support, these AmericanIndian and Alaska Native participants canevolve into a community-based coalition thatnot only addresses CVD prevention but otherhealth issues as well. Joanne Kauffman, in aforum addressing minority health issues, said:

“There is an awakening among Indianpeople about the importance of tribe,about the importance of community.Coalitions based on tribal culture canhelp Indian people deal with the needfor ‘spiritual wellness’ in their commu-nities . . . . The power of communities,the power of tribe, the power of agroup, I think, can make a tremendousdifference for people of color”(National Heart, Lung, and BloodInstitute et al., 1993).

DEVELOP PARTNERSHIPS WITHIN THE TARGETCOMMUNITY AND WITH OTHER FEDERAL,STATE, AND LOCAL ORGANIZATIONS.

A new program implemented within the con-fines of existing organizations in the commu-nity can utilize established infrastructures andviable local networks to reach the target popu-lation. Partnerships with local institutions whoalready affect the community will strengthenthe program’s credibility and receptivity.Program planners must be knowledgeable ofthe role and impact of the health care delivery

3

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system of the American Indian and AlaskaNative community. Both the IHS and tribalgovernments operate service units to adminis-ter to the health needs of most AmericanIndians, and Indian-operated urban units caterto the needs of urban Indians. However, con-sideration must be given to the health needs ofmany native people who do not receive theirhealth care through these channels. Partneringwith these and other health care organizationsis key to expanding the reach of the interven-tion to the target population. In addition, limi-tations in resources, abilities, and time may beoffset by cooperative arrangements with otherlocal agencies or larger organizations at theState or national levels.

Planners also should enlist traditional medi-cine men and medicine women in programdevelopment and implementation in communi-ties where they are respected and consulted.Planners should recognize existing traditionalhealth beliefs and practices, acknowledge theirpotential benefits, and attempt to work withthem rather than against or despite them.

Community health representatives (CHRs)have been a successful channel for disseminat-ing health information to American Indiansand Alaska Natives. CHRs are paraprofession-als who are trained as outreach workers toassist in providing health care, health promo-tion, and disease prevention services. TheCHR program was initiated in 1968 by theIHS to improve the health conditions of manynative communities. Many remote reservationtribes lacked accessibility to health care andhad a low acceptance level of the modernhealth care system being delivered by the IHS.The CHR program bridged the geographic andcultural gap that alienated many AmericanIndians.

CHRs are in the unique position to be moreculturally sensitive to the needs of native peo-ple because they are selected from and

employed in their own communities and areusually well-known, respected role modelsfrom their communities (Cleaver et al., 1989).Using CHRs in planning and implementing aprogram provides not only a channel to dis-seminate CVD information, but also a feed-back mechanism to gain valuable insightsabout whether the program is achieving itsgoals.

DEVELOP AND DISSEMINATE CULTURALLYAPPROPRIATE MATERIALS.

An accurate assessment of the target audi-ence’s CVD knowledge, their values andhealth beliefs, their literacy level, and theirlanguage preference is important before devel-oping educational materials or messages.Direct community input can enhance a pro-gram’s ability to design materials that addressthe specific needs of the target population.

Members of some tribes only speak traditionaltribal languages. Therefore, consider the feasi-bility of developing materials in tribal lan-guages. It is best to create materials using trib-al language from the beginning. If the English-language materials are translated, only experi-enced translators should be used. Direct trans-lations generally are not successful in commu-nicating the intended message and may offendthe target audience (National Heart, Lung, andBlood Institute, 1996a).

“All peoples and cultures relate best toand are most influenced by that whichis familiar. Achieving a goal of improv-ed health for American Indian andAlaska Native people requires the useof learning materials that are both cul-turally sensitive and relevant to locallifestyles.” (Michael H. Trujillo, M.D.,M.P.H, M.S. Assistant Surgeon General;Director, Indian Health Service).

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For American Indians and Alaska Natives, it isbest to use message concepts that incorporatetraditional Indian values that give culturalreinforcement and a sense of identity. Themeslike “love of family,” “maintaining indepen-dence,” or “remaining strong” focus on theorientation of native people toward family andcommunity and the viability of future genera-tions. Emphasis should be on integrating tradi-tional ways and lifestyles. For example, mes-sages on physical activity should emphasizethe Native traditions of running, dancing, andwalking as a means of achieving physical andspiritual fitness. Likewise, messages to pro-mote healthier diets should emphasize the tra-ditional American Indian diet that is higher incomplex carbohydrates and fiber and lower insugar and fat. Messages also should have apresent-time orientation because, for manynative people, the present is more importantthan the future. Themes that focus on thefuture may not be as effective as those thatemphasize the importance of making healthbehavior changes now (Paniagua, 1994;National Heart, Lung, and Blood Institute,1996a).

When developing educational materials, it isimportant to assess the literacy level of the tar-get population. For low-literacy audiences,written materials should use simple words,short sentences, and concrete concepts.Graphic illustrations maximize comprehensionof key messages. One-page fact sheets andshort brochures appear to be more effectivethan longer pamphlets for this audience. Formany American Indian and Alaska Nativeaudiences, television and videos are othereffective vehicles for disseminating healthmessages. Television and videos can capturereflections of life and touch the viewer’s heartin a way that the written word cannot. Anywritten or visual materials should includeimages of American Indians and Alaska

Natives and reflections of their art and music.Generic pan-Indian pictures and symbolsshould be used to reflect the diversity of theNative population. In these messages, it is ofutmost importance to place people in a posi-tive context that makes them proud of theirheritage.

The use of tribal elders as spokespersons inprogram interventions is an effective way toreach the target audience. Elders are wellrespected by all members of the community,especially the young. They are credible sourcesto teach about native traditions and to promotetraditional family teachings and practices.

The channels best suited for disseminatinginformation include powwows, Indian HealthService clinics, urban centers, reservation trad-ing posts, grocery stores, recreational centers,and trade stores. Head Start and WIC pro-grams and schools are avenues for reachingAmerican Indian and Alaska Native youth(National Heart, Lung, and Blood Institute,1987). A number of associations and networksin the radio, television, and newspaper arenasmay have access to the target audiences. Inaddition to mass media, community volun-teers, CHRs, and nutrition aides can be used toreinforce the message to the target audience.The value placed on the gift of one’s time can-not be overemphasized in the native communi-ty. Interpersonal communication is a keyaspect to the success of an intervention.

The health risk appraisal (HRA), used primari-ly in occupational settings and at health fairs,is a health survey that can be used to identifyindividuals in need of health education materi-als. An Indian-specific HRA called “Findingthe Way” was developed in 1988, based on ahealth risk appraisal developed by the CarterCenter and the Centers for Disease Control,and has been distributed throughout the IndianHealth Service. This HRA can and has been

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used in community and clinical settings tomotivate American Indians and Alaska Nativesto adopt healthier lifestyles and to take moreresponsibility for their health. For example,HRAs have been used extensively at healthfairs to provide individuals with a profile oftheir health risks and recommendations foradopting healthy lifestyles. HRAs also can beadministered to outpatients waiting for theirappointment with their health care provider.Health educators or CHRs can assist in inter-preting the survey and providing patients withappropriate health education materials. Theappraisal can be filed with the patient’s med-ical record for future reference and reinforce-ment by health care providers (Welty, 1988,1989).

REMOVE EXISTING BARRIERS.

One of the greatest barriers to participating inhealth programs is lack of accessibility.American Indians and Alaska Natives in bothrural and urban settings are typically under-served. At places that do have program sites,many people have no mode of transportationto the site. In some geographic locations,extreme weather conditions preclude programparticipation by community members. Lack oftransportation or extreme weather conditions,rather than a lack of interest on the part ofcommunity members, are some of the factorsresponsible for some programs not reachingtheir target audiences.

Planners should work in cooperation withschools to make exercise facilities availablefor native youth. Incorporating program activi-ties into the existing academic structure willimprove the chances that these activities willbe sustained long after the program fundinghas ended.

Another barrier that should be addressed in theAmerican Indian community is the lack ofaffordable grocery stores for purchasing fresh

fruits, vegetables, and meats. Programsemphasizing a return to a traditional Indiandiet would likely fail to change food behaviorsif traditional Indian foods are unavailable. TheUSDA has improved its food commodity pro-gram with the addition of fresh fruits, vegeta-bles, and meats in some Indian communities.The agency also intends to review and makerecommended changes to the food package inthe near future. Coalition-building and com-munity action is needed to influence grocerystore owners on or near reservations toincrease the variety of food products and tochange pricing policies. Another method tocircumvent this accessibility barrier is todevelop communal fruit, vegetable, and herbgardens, which are shared and maintained bymany community members. This option givesindividuals an opportunity not only to be phys-ically active, but also to commune with natureand share the fruits of their labors with othercommunity members.

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Theoretical models provide a necessary frame-work from which to develop effective healthpromotion programs. Because not all modelscan comprehensively address the specificneeds of the intended program, a combinationof models is often used. This section brieflydiscusses aspects of five models that can beincorporated into the development of healthpromotion programs targeting AmericanIndians and Alaska Natives.

PRECEDE MODEL

Green and Kreuter’s PRECEDE Model (1991)uses a multidimensional approach to addressbehavioral and environmental factors thatinfluence health behavior. The PRECEDEModel groups behavioral and environmentalfactors into three broad categories: predispos-ing, enabling, and reinforcing factors.

Predisposing factors are the knowledge, cultur-al beliefs, values, and perceived abilities of anindividual or group that facilitate or hindermotivation for change. A heightened aware-ness of one’s cardiovascular risk may be thefirst step in influencing one’s health behavior.This knowledge, accompanied by sufficientmotivation, is an essential factor in changingindividual or collective behavior. Understand-ing the target audience’s level of knowledgeabout cardiovascular disease and its risk fac-tors, their attitude toward engaging in health-promoting behaviors, and the beliefs and val-ues they place on health and disease is funda-mental to developing a culturally relevant andappropriate program.

Enabling factors are environmental conditionsthat enhance or hinder desired behavioralchanges. These factors are usually the targetsof community organization and program inter-vention. A group’s health behaviors are depen-dent on the availability, accessibility, andaffordability of the product causing the healthproblem. Similarly, their ability to adopt newhealth behaviors is limited to the degree towhich health resources are available, accessi-ble, and affordable. This issue is especiallypertinent in programs targeting AmericanIndians and Alaska Natives living on reserva-tions and in villages. The remoteness of healthcare facilities, lack of transportation, andextreme weather conditions are environmentalenabling factors that affect the availability andhinder accessibility to health care services.People in urban areas also suffer from lack ofnecessary clinical preventive services.

The Food Distribution Program on IndianReservations (FDPIR) is an example of anenabling factor that affects the dietary behav-iors of American Indians and Alaska Natives.The FDPIR was established by the U.S.Department of Agriculture (USDA) in 1977 toprovide supplemental food commodities tolow-income native families living on or nearreservations. Families receive monthly pack-ages of canned fruits and vegetables, cannedmeat and fish products, dried beans, dairyproducts, grain products, fats, and sugar. A1990 evaluation of the FDPIR showed thatapproximately 65 to 70 percent of AmericanIndians and Alaska Natives living on reserva-

THEORETICAL MODELS

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tions received either food commodities or foodstamps. However, participation in the FDPIRprogram does not guarantee nutrient-densefoods or a variety of foods, however. This pro-gram is designed as a supplemental foodsource, and recipients are expected to purchasea portion of their monthly food supply.Unfortunately, for many families, limitedaccess to grocery stores, minimal food choicesin available stores, and lack of refrigerationresult in complete dependence on commodityfoods (National Cancer Institute, 1993).

The ability to perform new skills is also anenabling factor needed to change a healthbehavior. These skills may include the abilityto measure one’s blood pressure or to performappropriate physical exercises. An assessmentof the target audience’s skills can give plan-ners valuable insight into possible programcomponents.

Reinforcing factors include the positive andnegative feedback people obtain from othersfollowing the adoption of the behavior. Thesefactors include family and social support, peerinfluence, and real or perceived positive ornegative consequences of the behavior.

Social benefits (e.g., praise, recognition) andphysical benefits (e.g., comfort, relief frompain) are factors that reinforce behavior.Reinforcing factors also include adverse con-sequences of behavior, or punishment, whichcan lead to the extinction of a positive behav-ior. Incorporating activities in a program thatreinforce positive health behaviors will morelikely lead to permanent behavior change. It isimportant to determine what the target com-munity values. For example, many native peo-ple are very family-oriented and highly valueelders and children. Family-oriented programsthat involve the participation of some or allfamily members in changing behavior may bemore successful than programs that focus onthe individual.

HEALTH BELIEF MODEL

The Health Belief Model attempts to explainhealth behavior in terms of specific belief pat-terns (Green and Kreuter, 1991). The model isbased on the following assumptions aboutbehavior change.

◆ The person must believe that he or she issusceptible to disease and that his or herhealth is in jeopardy.

◆ The person must perceive the potential seri-ousness of the condition (i.e., pain or dis-comfort, lost productivity, economic con-straints).

◆ The person must believe that the benefits ofchanging his or her behavior outweigh thebarriers. The person also must believe thatthe change is possible and within his or hergrasp.

◆ There must be a precipitating force thatcompels the person to feel the need to takeaction.

SOCIAL LEARNING THEORY

The Social Learning Theory explains humanbehavior in terms of a reciprocal interactionamong cognitive, behavioral, and environmen-tal determinants (Bandura, 1977). It suggeststhat people not only react to external influ-ences but also proactively create and regulatetheir own environment. People learn throughdirect experience, through vicarious experi-ence by observing others, and through theircognitive ability to plan goals, anticipate con-sequences, and assess their own capabilities.The cognitive process of appraising one’s ownability to perform a behavior successfully iscalled self-efficacy. Self-efficacy is an impor-tant factor in determining whether behaviorchange takes place. Self-efficacy explains howpeople set standards for themselves in chang-ing their behaviors and how mental barriers

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can hinder their ability to change. Plannersshould consider activities that foster self-effi-cacy in individuals when developing healthpromotion programs. For example, programscan include setting goals for behavior changein small increments so that participants aremore likely to succeed in their new behaviors.

THEORY OF REASONED ACTION

Lewin’s Theory of Reasoned Action holds thatthe final step in the predisposing processbefore actual action takes place is formulatinga behavioral intention (Green and Kreuter,1991). A person’s intention to perform abehavior depends on three things: (1) his orher attitudes toward the behavior, (2) his or herperception of social norms favoring the behav-ior, and (3) his or her motivation to complywith these social norms. To change a person’sbehavioral intention and thus their actualbehavior, one must change one or all of theattitudinal, normative, or motivation-to-com-ply factors.

STAGES OF CHANGE MODEL

People do not change chronic behaviors imme-diately, but instead change their habitualbehavior over time. In Prochaska andDiClemente’s Stages of Change Model, peopleare categorized into four stages of behaviorchange (Prochaska et al., 1994). The firststage, precontemplation, is a condition inwhich people have not thought of or are notinterested in change. In the second stage, con-templation, people give serious thought tochanging behavior. Action, the third stage, isthe 6-month period after an overt effort tochange has been made. Finally, maintenance isthe period from 6 months after a behaviorchange until the behavioral problem in ques-tion is completely terminated.

This model is especially relevant for programplanners and educators using information dif-

fusion strategies because it sensitizes them tothe notion that different change strategies arerequired depending on the stage of changepeople are in. For example, people in the pre-contemplation stage may need information toincrease their knowledge of cardiovascular riskfactors. People in the action phase, on theother hand, may need specific strategies thatfocus on changing behaviors.

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This section offers recommendations for trans-forming needs into opportunities regardinghealth promotion and disease prevention andcontrol programs targeting American Indiansand Alaska Natives. These recommendationsare based on the existing epidemiological liter-ature, on evaluations of current health promo-tion and disease prevention programs, and ontelephone interviews with people working toimprove the health of native people. The rec-ommendations are divided into four phases:design and assessment, planning, implementa-tion, and evaluation. These recommendationsare by no means exhaustive, but they do pro-vide a framework upon which to build effectivehealth programs that change attitudes, increaseknowledge, and adapt lifestyle behaviors rela-tive to heart health among native people.

DESIGN AND ASSESSMENT PHASE

There is a paucity of data on the health statusof American Indians and Alaska Natives.These data are necessary to develop, imple-ment, and assess effective CVD programs.Significant effort should be placed on improv-ing the representation of native people innational health surveys. More studies similarto the Strong Heart Study, which comparesgroups of American Indians, are desperatelyneeded to determine the extent of variability inthe health behaviors and disease patterns ofdifferent tribes.

An American Indian and Alaska Native taskforce or advisory board should be established

in the community prior to the development ofany health programs. The advisory board mayconsist of representatives of Federal agencies,professional organizations and nonprofit advo-cacy groups, tribal leaders, medicine men andmedicine women, and interested communitymembers. A wide representation will add cred-ibility and visibility to the project. Members ofthe advisory board can provide information oncultural values and health beliefs and prac-tices. They also can identify key communityleaders, local experts, and organizations thatmight be useful to the program.

A needs assessment survey should be devel-oped to identify the educational gaps in exist-ing CVD programs targeting American Indiansand Alaska Natives. Telephone or in-personinterviews with community leaders, nativehealth officials, and tribal elders, as well asfocus groups, will provide a clearer picture ofthe community’s perceived needs. The multi-factorial nature of CVD and the diversity ofthe native population preclude the develop-ment of an all-encompassing program target-ing all American Indians and Alaska Nativesand all cardiovascular risk factors. On theother hand, a more feasible program wouldfocus on specific risk factors and target specif-ic segments of the population. Another optionwould be to create a health promotion programthat emphasizes lifestyle changes and behav-ioral modifications in areas that crosscut allcardiovascular risk factors. The advantage offocusing on lifestyle change is that it acknowl-

NEEDS AND OPPORTUNITIES

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edges the fact that behavior is a complex pat-tern of interrelated practices that are sociallyconditioned and culturally embedded. Thesebehaviors, such as smoking and consumptionof high-fat foods, may act synergistically toproduce poor health outcomes. A holistichealth promotion approach that takes intoaccount the social norms, cultural values, andenvironmental circumstances that affect behav-ior may be particularly appropriate to nativepeople who are accustomed to holistic meth-ods of healing.

Based on the epidemiological data presented inthis background paper, the following cardio-vascular risk factors and target audiences areidentified as possible priority interventions:

◆ cigarette smoking in tribes living in theMidwestern United States and in Alaska;

◆ cigarette smoking among youth living onreservations;

◆ diabetes in all tribes, especially those in theSouthwestern and Midwestern UnitedStates;

◆ high blood pressure in tribes with a highprevalence of diabetes;

◆ obesity and physical inactivity in all tribes,with emphasis on family interventions andchildhood obesity prevention programs; and

◆ comprehensive health promotion approach-es incorporating heart-healthy lifestylechanges.

PLANNING PHASE

A network of organizations with access to thetarget audience can be one of the most effec-tive methods of reaching the greatest numberof people. When developing a CVD interven-tion program, potential partners should beinvited to serve on an information diffusionand outreach network that promotes heart

health among American Indians and AlaskaNatives. This communication infrastructurecan be a channel to disseminate, monitor, andevaluate heart health information distributed tonative groups and individuals. Federal agen-cies, professional associations, and nonprofitadvocacy groups can serve as potential part-ners. Examples include:

◆ Indian Health Service,

◆ U.S. Department of Agriculture,

◆ National Indian Health Board,

◆ National Congress of American Indians,

◆ Association of American Indian Physicians,and

◆ American Indian Health Care Association.

There is a dearth of CVD educational materi-als for American Indians and Alaska Natives.Many community health clinics and communi-ty-based programs rely on outdated, scientifi-cally inaccurate, culturally irrelevant materials.Educational materials that are accurate andhave been pretested for cultural sensitivity andliteracy level are desperately needed.

◆ Focus groups should be used to developmessage themes and concepts.

◆ Contractors, producers, and artists from thenative community should be used.

◆ Educational materials should be genericenough to be culturally relevant to mostAmerican Indian tribes. Original layout andmaster copies of the material should bemade easily available so that organizationscan adapt them to suit specific target audi-ences.

◆ Educational materials should be pretested indifferent sites, including health fairs, IndianHealth Service clinics, powwows, and annu-al conferences of professional associations.

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An effective media campaign should be usedto launch a health education program and toincrease its visibility. Information from focusgroups can help determine message conceptsand target audiences for dissemination.American Indian and Alaska Native contrac-tors with technical expertise in creating mediasuitable for the target audience should be usedin program development and identification ofmedia placement in native communities. Inaddition, media-related associations with inter-est in promoting issues of this population canbe involved in publishing or broadcastinginformation about the program. Some of theseassociations include:

◆ American Indian Library Association,

◆ Native American Journalist Association, and

◆ Native American Public BroadcastingConsortium.

IMPLEMENTATION PHASE

To build and maintain interest in the healthintervention, community members should par-ticipate actively in all aspects of the program,including the implementation phase.Traditional healers, community health repre-sentatives, nutrition aides, students pursuingallied health fields at American Indian col-leges, and other interested groups or individu-als can be recruited as either staff members orvolunteers. School boards, health boards, andcommunity youth programs can be channelsfor incorporating family activities and commu-nity events such as powwows and sportingevents into the program.

A series of professional education training pro-grams may be developed for interested healthprofessionals and paraprofessionals. Theseprograms should incorporate both Western andtraditional medicine in the areas of cardiovas-cular health for American Indians and AlaskaNatives. This “train-the-trainer” educational

method is particularly effective in promotinghealth behavior among members of the targetaudience long after the intervention has ended.In addition, many native people view healthprofessionals and paraprofessionals as rolemodels in their communities.

Annual conferences of native professionalassociations and other health-related associa-tions are another channel for disseminatingeducational information and recruiting poten-tial partners. Poster sessions and plenary ses-sions can help raise awareness about CVD andprovide an occasion to present research train-ing opportunities to American Indians andAlaska Natives. Some annual conferencesinclude:

◆ National Congress of American Indians,

◆ Association of American Indian Physicians,

◆ American Indian Science and EngineeringOrganization, and

◆ American Indian Health Care Association.

EVALUATION PHASE

A system should be devised to monitor infor-mation diffusion and education efforts. Thetracking system should provide both quantita-tive and qualitative data on process, impact,and outcome measures. The advisory commit-tee and other members of the communityshould be actively involved in designing theevaluation methodology and identifyingprocess, impact, and outcome measures.

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CONCLUSION

As a minority population in the United States,American Indians and Alaska Natives have notfully shared in the dramatic reductions in car-diovascular disease and other diseases experi-enced in recent years by the general popula-tion. CVD continues to take thousands ofNative lives each year, destroying the strengthand viability of native communities throughoutthe Nation.

Fortunately, health promotion and disease pre-vention programs are now being implementedat the community level to counteract thesedestructive forces and address the cardiovascu-lar needs of American Indians and AlaskaNatives. These interventions range from teach-ing young children to live healthy and activelifestyles to changing the health behaviors ofpeople already affected by CVD or complica-tions from cardiovascular risk factors. How-ever, much more needs to be accomplished toreduce the disproportionate burden of diseaseamong native people and to improve the healthand well-being of this generation and genera-tions to come.

According to a Sioux prophecy, the seventhgeneration since the colonization of AmericanIndian land by European settlers marks thetime that the Nation’s broken hoop will bemended and American Indians will once againlive in peace, health, and harmony. TheAmerican Indians of today are the seventhgeneration that their ancestors prayed for

(Katz, 1995). Therefore, it is appropriate andnecessary that health promotion programs becreated to mend the broken hoop of health andlongevity that American Indians and AlaskaNatives once enjoyed.

This poster is entitled “Keepers of Wisdom to

Strengthen the Hearts: American Indians and

Alaska Natives” created by Sam English

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NHLBI NATIONAL EDUCATION PROGRAMS OFFER LEADERSHIP AND INFORMATION

Since 1972, the NHLBI has taken steps to apply the latest research to the development of practicalmethods to promote successful health interventions. Through its national education programs andinitiatives, the NHLBI plays a leadership role by educating health care professionals, patients, andthe public about the prevention and treatment of heart, lung, and blood diseases and sleep disor-ders. The national programs develop and distribute patient and professional materials, includingclinical practice guidelines, and sponsor special events such as the National High Blood PressureEducation Month (May) and the National Cholesterol Education Month (September), which pro-mote awareness of heart disease risk factors and encourage regular screening.

Visit the NHLBI Web site at http://www.nhlbi.nih.gov for more information about the programs andinitiatives listed below or to access publications in electronic format.

◆ Cardiovascular InformationNational High Blood Pressure Education ProgramNational Cholesterol Education ProgramNational Heart Attack Alert ProgramNHLBI Obesity Education Initiative

◆ Sleep Disorders InformationSleep Disorders Activities

◆ Lung InformationNational Asthma Education and Prevention Program

You can also contact the NHLBI Information Center to request information about any NHLBI-sponsored program or initiative or to request a publications catalog:

NHLBI Information CenterP.O. Box 30105Bethesda, MD 20824-0105Telephone: (301) 251-1222

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P u b l i c H e a l t h S e r v i c eN a t i o n a l I n s t i t u t e s o f H e a l t hN a t i o n a l H e a r t , L u n g , a n d B l o o d I n s t i t u t e

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