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RESEARCH AND PRACTICE

Leading Causes of Death and All-Cause Mortality in American Indians and Alaska Natives I David K. Espey, MD, Melissa A. Jim, MPH, Nathaniel Cobb, MD, Michael Bartholomew, MD, Tom Becker, MD, PhD,

Don Haverkamp, MPH, and Marcus Plescia, MD, MPH

American Indians and Alaska Natives (AI/ANs) in the United States have long endured a legacy of injustice and discrimination with multiple negative manifestations, including alarming health disparities and inadequate health care. In the early decades of the Indian Health Service (IHS), improvements in the health of AI/AN populations were significant, principally as a result of sanitary water supplies, control of tuberculosis and other infectious diseases, and improved nutrition.' Starvation is no longer an issue in AI/AN communities; rather, the opposite is true: ohesity—a different form of malnutrition— and its attendant chronic diseases. With infant and childhood mortañty greatly reduced, more AI/AN people are developing cancer, diabetes, heart disease, and stroke.

In the efforts to better characterize and track the health status of AI/AN populations—a critical step to address health disparities—we see a recurrent theme of inadequate and in- accurate data, most often related to race mis- dassiñcation that occurs in many health-related databases. Accurate health surveillance data are essential to address health disparities and to plan, implement, and evaluate disease preven- tion and control activities. Previous reports have indicated less favorable health status of AI/AN people compared with the general population of US Whites,^'^ Among health status indicators, mortality data provide es- sential infonnation for measuring the health of a population. Patterns of mortality in spe- cific demographic subpopulations, including race and ethnic groups, may reflect differ- ences in socioeconomic status and access to medical care or the prevalence of subpopulation-spedfic risk factors.'* However, the goal of producing reliable mortality esti- mates for AI/AN populations has been ham- pered by the misclassification of race that frequentiy occurs in vital statistics data^

We sought to provide an overview of lead- ing causes of death and trends in all-cause

Objectives. We present regional patterns and trends in all-cause mortality and leading causes of death in American Indians and Alaska Natives (AI/ANs).

Methods. US National Death Index records were linked with Indian Health Service (IHS) registration records to identify AI/AN deaths misdassified as non- AI/AN, We analyzed temporal trends for 1990 to 2009 and comparisons between non-Hispanic AI/AN and non-Hispanic White persons by geographic region for 1999 to 2009, Results focus on IHS Contract Health Service Delivery Area counties in which less race misclassification occurs.

Results. From 1990 to 2009 AI/AN persons did not experience the significant decreases in all-cause mortality seen for Whites, For 1999 to 2009 the all-cause death rate in CHSDA counties for AI/AN persons was 46% more than that for Whites. Death rates for AI/AN persons varied as much as 50% among regions. Except for heart disease and cancer, subsequent ranking of specific causes of death differed considerably between AI/AN and White persons.

Conclusions. AI/AN populations continue to experience much higher death rates than Whites, Patterns of mortality are strongly influenced by the high incidence of diabetes, smoking prevalence, problem drinking, and social de- terminants. Much of the observed excess mortality can be addressed through known public health interventions, (Am J Public Health. 2014;104;S303-S311. doi:10.2105/AJPH,2013.301798)

mortality for the AI/AN population—particu- larly those residing in areas served by the IHS— using national mortality data that have been linked to the IHS patient registration data to improve race classification,

METHODS

Detañed methods for generating the analytic mortality files are described elsewhere in this supplement,® An abbreviated description follows.

Data Sources

Population estimates. We used county-level population estimates produced by the US Census Bureau as denominators in the rate calculations. To manage multiple-race data collected since 2000, the National Center for Health Statistics (NCHS), in coUaboration with the US Census Bureau, developed a technique of bridging race categories into single-race annual population estimates,^ The National Cancer Institute makes further refinements

regarding race and county geographic codes, makes adjustments for population shifts as a result of Hurricanes Katrina and Rita in 2005, and provides public access to these estimates on the Institute's Web site,̂ '® During preliminary analyses, we discovered that pop- ulation estimates significantiy overestimated AI/AN persons of Hispanic origin,'° Therefore, to avoid underestimating mortality in AI/AN populations, we limited analyses to non- Hispanic AI/AN persons. We chose non- Hispanic Whites as the most homogeneous referent group. For conciseness, the term "non-Hispanic" is omitted henceforth when discussing both groups.

Death records. Each state compiles death certificate data and sends them to the NCHS, where they are edited for consistency. The NCHS makes this infonnation available to the research community as part of the National Vital Statistics System and includes underlying and multiple cause-of-death fields, state of residence, age, sex, race, and ethnicity," NCHS and the Census Bureau use the same bridging

Supplement 3, 2014, Vol 104, No, S3 | American Joumai of Public Health Espey ei al. | Peer Reviewed | Research and Practice | S303

RESEARCH AND PRACTICE

algorithm to assign a single race to decedents with multiple races reported on the death certificate.'̂

The IHS patient registration database was linked to the National Death Index to identify AI/AN decedents who had received health care in IHS or tribal facilities and were mis- classified as non-Native.^ After this linkage, IHS AI/AN records identified as those of deceased individuals were linked to the 1990 to 2009 annual National Vital Statistics System mortality files as an additional indicator of AI/AN ancestry. These files were combined with corresponding annual bridged race in- tercensal population estimates to create an analytic file in SEER*Stat version 8.0.4'^ (called the AI/AN Mortality Database, or AMD). Race for AI/AN deaths in this artide is assigned as reported elsewhere in this supple- ment.^ In short, the AMD combines race dassification by NCHS on the basis of the death certificate and information derived from data linkages between the IHS patient registration database and the National Death Index. For 1990 to 1998, we coded the underlying cause of death according to the International Classi- fication of Diseases, Ninth Revision {ICD-9)}'*'

For 1999 to 2009, we used the International Classification of Diseases, 10th Revision (ICD-

lOf}^ Trend analyses spanning ICD-9 and ICD-10 reporting years took into accotmt comparability of cause of death recodes be- tween the 2 revisions.'® To present the leading cause of death in rank order—as established by death cotmts—we used the method devel- oped by NCHS based on the recode for 113 selected causes '®'^

Geograpiiic Coverage and Time Periods

Most analyses in this artide are restricted to IHS Contract Health Service Delivery Area (CHSDA) counties, which, in general, contain federally recognized tribal reservations or off- reservation trusts or are adjacent to them.'® Linkage studies have indicated less misdassifi- cation of race for AI/AN persons in these coimties.̂ -'® The CHSDA cotmties also have higher proportions of AI/AN persons in re- lation to the total population than do non- CHSDA counties, with 64% of the US non- Hispanic AI/AN population residing in the 637 cotmties designated as CHSDA (these counties represent 20% of the 3141 coimties in the

United States). Although less geographically representative, analyses restricted to CHSDA counties are presented for death rates in this article for the purpose of offering improved accuracy in interpreting mortality statistics for AI/AN populations. Trend analyses shovra in Figure 1 span 1990 to 2009, whereas rates and rate ratios (RRs) presented in the tables are

limited to 1999 to 2009 to reflect a more recent time period and consistent cause of death coding in ICD-10.

The analyses were completed for all regions combined and by individual IHS region: Northern Plains, Alaska, Southern Plains, Southwest, Padfic Coast, and East.'® Identical or similar regional analyses have been used for

1600-1

1400-

1200 O § 1000- o 2 800-

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400-

200-

1600-1

1400-

1200- O § 1000- O ° 800- 01 ro 600-

ÜC

400

200

O-

Averaqe Percent Change AI/AN Males (-0.2) White Males (-1.3=)

Trend Comparison

Not parallel I»

AI/AN male rate

- A I / A N male trend

White male rate

- W h i t e male trend

Year

Annual Percent Change AI/AN Females (0.5=) White Females (-0.5")

Trend Comparison

Not parallel I"

• AI/AN female rate

^ A I / A N female trend

• White female rate

—White female trend

Year

Note. Ai/AN - American Indian/Alaska Natives. Analyses are limited to persons of non-Hispanic origin. AI/AN race is reported

from death certificates or tiirough iinkage with the IHS patient registration database.

'The annuai percentage change in rates during 1990-2009 was significant at a - .05.

"The difference in average annuai percentage change between AI/AN and Whites during the past 10 years (2000-2009) was

significant at a = .05.

FiGURE 1-Annuai age-adjusted aii-cause deatii rates and Joinpoint trend iines for Ai/AN

and Wiiite (a) maies and (b) femaies: Contract Heaitii Service Deiivery Area counties, United

States, 1 9 9 0 - 2 0 0 9 .

S304 I Research and Practice | Peer Reviewed | Espey et a/. American Journal of Public Heaith | Supplement 3, 2014, Voi 104, No. S3

RESEARCH AND PRACTICE

other health-related publications focusing on AI/AN

Statistical Methods All rates, expressed per 100 000 population,

were directly age adjusted using SEER*Stat software version 8.0.4 to the 2000 US stan- dard population (Census P25-1130) and using 11 age groups (< 1, 1-4, 5-14, 15-24, 2 5 - 34, 35-44, 45-54, 55-64, 65-74, 75-84, and > 85 years) in accordance with a 1998 US Department of Health and Human Services recommendation.^^ Readers should avoid comparison of these data with published death rates adjusted using a different standard population.

Using the age-adjusted death rates, we calculated standardized RRs for AI/AN popu- lations using White rates for comparison. We calculated RRs using SEER*Stat and confi- dence intervals (CIs) for age-adjusted rates and RR on the basis of methods described by Tiwari et al.̂ ^ using SEER*Stat version 8.0.4.

We assessed temporal changes in annual age-adjusted death rates, including the annual percentage change for each interval, with join- point regression techniques using statistical software developed by the National Cancer Institute (Rockville, MD).̂ ^ Statistical signifi- cance was set at P< .05. Trend analyses spanned the entire period covered by AMD 1990 to 2009. We also conduded pairwise comparisons to determine the parallelism of trends. Once 2 groups were determined to have parallel or nonparallel trends, we tested the average annual percentage change for the 2 groups, using the past 10 years, to determine whether they were statistically different

RESULTS

All-cause death rates by geographic region and sex comparing AI/AN with White persons in CHSDA counties only and all counties combined are presented in Table 1. In general, death rates for AI/AN persons were greater in CHSDA cotmties than in all coimties com- bined, whereas for Whites, death rates changed very little in relation to CHSDA groupings, hi subsequent results as well as in the discussion, "death rates" refers to analyses restrided to CHSDA counties only. For all regions com- bined, AI/AN death rates for both sexes

combined were nearly 50% greater than rates in Whites. The highest rates were noted in the Northern Plains and the Southern Plains, whereas the lowest were in the East and the Southwest. Comparisons of all-cause death rates in AI/AN populations with those in Whites ranged from near parity in the East region (RR= 1.04; 95% CI = 1.01, 1.07) to nearly 2 times higher in the Northern Plains region (RR= 1.90; 9 5 % CI= 1.87, 1.93). Eor AI/AN and White populations, all-cause death rates were substantially lower for women than for men in all regions combined and in individual regions.

When examined by age, disparities in all- catise mortality were most evident in yotmger age groups, particularly ages 25 to 44 years (Table 2). This pattern was apparent across all IHS regions, and it was particularly prominent in the Northern Plains and Alaska, where all-cause death rates for AI/AN persons in this age group were more than 3 times higher than that for Whites.

Table 3 ranks the leading causes of death for AI/AN persons by sex and IHS region and all regions combined in CHSDA counties for 1999 to 2009 and compares the death rates with those for Whites residing in the same areas. Key patterns for all regions combined are presented briefly; see Table 3 for region- specific cause-of-death rankings.

For AI/AN men, the leading 2 causes of death were diseases of the heart and cancer- ranked similarly in Whites. Though modestly elevated for AI/AN persons compared with Whites (22% and 1 1 % greater, respectively) in relative terms, in absolute terms these differ- ences are substantial and exceed the death rates for many other causes of death. The next 3 leading causes of death in AI/AN males- unintentional injury, diabetes, and chronic liver disease—were not similarly ranked in Whites (4th, 6th, and 1 Oth, respectively) and the rates were several times higher in AI/AN persons compared with Whites. Of the remaining 10 leading causes of death in AI/AN males, we noted discrepandes in ranking for several catises of death, and RRs were significantly higher for all listed leading causes of death. Of particular note is homidde (9th in AI/ANs and 19th in Whites; RR = 4.85; 95% 0 = 4.58, 5.13).

For AI/AN females, cancer was the leading cause of death followed by heart disease, the

converse of White females. As in males, both causes of death were modestly elevated in AI/AN relative to White females (17% and 22%, respectively), a substantial difference in absolute terms. The 3rd through the 6th leading causes in AI/AN females—uninten- tional injuries, diabetes, stroke, and chronic liver disease—were ranked differently in Whites (6th, 8th, 3rd and 12th, respectively), with notable rate disparities for tinintentional injury (RR = 2.43; 95% CI = 2.36, 2.51), di- abetes (RR = 4.04; 95% CI = 3.91, 4.18), and chronic liver disease (RR= 5.36; 95% CI = 5.14, 5.60). Of the remaining leading causes of death in AI/AN females, only 1—chronic lower respiratory diseases—was not elevated in comparison with White females. Homidde was more than 3 times higher and kidney disease and septicemia were more than 2 times higher in AI/AN versus White females.

Figure 1 summarizes trends in all-cause mortality in CHSDA counties from 1990 to 2009 for all regions combined for AI/AN and White males and females. All-cause death rates remained stable for AI/AN males, whereas for White males, death rates declined 1.3% per year. A pairwise comparison deter- mined that the 2 trends are not parallel, with a significant difference between the average annual percentage change for AI/AN and White males. AI/AN females experienced an increase of 0.5% per year, whereas the rate for White females decreased by a sinular annual percentage. We found that these aU-cause mortality trends for AI/AN and White females were also nonparallel.

DISCUSSION

Key findings in this article provide infor- mation that may be useful to the public health, health care, and health policy com- munities serving AI/AN populations. First, AI/AN all-cause death rates are substantially greater than those for Whites, most notably in the Northern Plains and the Southern Plains. Second, the most prominent dispar- ities for all-cause death rates are concen- trated in the younger age groups. Third, the significant decrease in all-cause death rates experienced over the past 2 decades by the White population was not shared by the AI/ AN population. Finally, the leading specific

Supplement 3, 2014, Voi 104, No. S3 | American Journai of Pubiic Heaith Espey et al. \ Peer Reviewed ¡ Researcti and Practice | S305

RESEARCH AND PRACTICE

TABLE 1-Death Rates for All Causes, by IHS Region and Sex for American Indians/Alaska Natives Compared With Whites, All Ages: United States, 1999-2009

IHS Region and Sex

Northern Plains

Totai

Male

Female

Alaska

Total

Male

Female

Southern Plains

Total

Male

Female

Southwest

Total

Male

Female

Pacific Coast

Total

Male

Female

East

Total

Male

Female

All regions

Total

Male

Female

AI/AN Count

23 331

12 709

10622

8616

4771

3845

30 421

15 946

14475

33 325

18836

14489

20 779

10 875

9904

6172

3231-

2941

122 644

66 368

56 276

AI/AN Rate

1461.8

1748.8

1243.4

1218.6

1431.6

1041.2

1313.1

1568.7

1116.3

1017.8

1251.4

828.1

1091.5

1238.3

971.1

828.7

939.1

735.4

1165.9

1381.8

991.5

CHSDA Counties

White Count

786 392

386 164

400228

23 621

13 600

10 021

358 711

175 778

182 933

669 622

347 628

321994

1459 406

721856

737 550

1 559 313

750611

808 702

4 857 065

2 395 637

2 461428

White Rate

770.6

927.4

649.2

738.2

856.8

627.3

928.7

1102.2

790.9

789.7

926.2

670.4

796.0

933.7

683.8

795.7

957.7

671.0

798.8

948.8

678.6

AI/AN;White RR (95% Ci)

1.90* (1.87, 1.93)

1.89* (1.84, 1.93)

1.92* (1.88, 1.96)

1.65* (1.61, 1.70)

1.67* (1.61, 1.74)

1.66* (1.60, 1.73)

1.41* (1.40, 1.43)

1.42* (1.40, 1.45)

1.41* (1.39, 1.44)

1.29* (1.27, 1.30)

1.35* (1.33, 1.37)

1.24* (1.21, 1.26)

1.37* (1.35, 1.39)

1.33* (1.30, 1.36)

1.42* (1.39, 1.45)

1.04* (1.01, 1.07)

0.98 (0.94, 1.02)

1.10* (1.06, 1.14)

1.46* (1.45, 1.47)

1.46* (1.44, 1.47)

1.46* (1.45, 1.47)

AI/AN Count

31188

16 812

14 376

8616

4771

3845

35130

18 391

16 739

35 366

19 916

15 450

27 339

14 379

12 960

24 738

13 095

11643

162 377

87 364

75 013

AI/AN Rate

1242.9

1484.9

1064.5

1218.6

1431.6

1041.2

1159.6

1359.5

1001.1

1000.0

1218.4

821.5

953.5

1088.3

842.9

595.7

691.7

518.3

964.4

1135.2

827.3

All Counties

White Count

3 843 218

1846 384

1996834

23621

13600

10 021

1 758152

858 447

899 705

1052 569

536 547

516 022

2 711044

1 327 483

1 383 561

12 136 547

5 872 696

6 263 851

21525151

10 455157

11 069 994

White Rate

787.1

947.8

666.6

738.2

856.8

627.3

859.7

1018.7

733.6

776.8

909.7

664.2

781.0

916.5

671.4

824.8

988.2

698.3

812.2

969.1

689.9

AI/AN;White RR (95% CI)

1.58* (1.56, 1.60)

1.57* (1.54, 1.60)

1.60* (1.57, 1.63)

1.65* (1.61, 1.70)

1.67* (1.61, 1.74)

1.66* (1.60, 1.73)

1.35* (1.33, 1.36)

1.33* (1.31, 1.36)

1.36* (1.34, 1.39)

1.29* (1.27, 1.30)

1.34* (1.32, 1.36)

1.24* (1.22, 1.26)

1.22* (1.21, 1.24)

1.19* (1.16, 1.21)

1.26* (1.23, 1.28)

0.72* (0.71, 0.73)

0.70* (0.69, 0.71)

0.74* (0.73, 0.76)

1.19* (1.18, 1.19)

1.17* (1.16, 1.18)

1.20* (1.19, 1.21)

«oie. AI/AN - American Indians/Alaska Natives; CHSDA» Contract Health Service Deliveiy Areas; CI = confidence interval IHS = Indian Health Service; RR - rate ratio. All analyses viiere limited to decedents of non-Hispanic origin. AI/AN race is reported from death certificates or through linkage with the IHS patient registration database. Rates are per 100 000 people and were age adjusted to the 2000 US standard population (11 age groups; Census P25-1130). RRs were calculated in SEER*Stat (version 8.0.4) before rounding of rates and may not equal RRs calculated from rates presented in table. States and years data excluded because Hispanic origin was not collected on the death certificate; LA; 1990; NH; 1990-1992; OK; 1990-1996. IHS regions are defined as follows; Alaska'; Northern Plains (IL, IN,' IA,' M l , ' MN,' MT,' NE,' ND,' SD,' Wl,' WV); Southern Plains (OK,' KS,' TX'); Southwest (AZ,' CO,' NV,' NM,' U f ); Pacific Coast (CA,' ID,' OR,' WA,' HI); East (AL,' AR, CT,' DE, FL,' GA, KY, LA,' ME,' MD, MA,' MS,' MO, NH, NJ, NY,' NC,' OH, PA,' RI,' SC,' TN, \fF, VA, WV, DC). Percentage regional coverage of AI/AN persons in CHSDA counties to AI/AN persons in all counties; Northern Plains = 64.8%; Alaska - 1 0 0 % ; Southern Plains = 76.3%; Southwest = 91.3%; Pacific Coast = 71.3%; East = 18.2%; total US = 64.2%. Source. AI/AN Mortality Supplement Database (1990-2009). 'Identifies states with > 1 county designated as CHSDA. * P < . 0 5 .

cause-of-death and age-at-death dispeirities indicate potential areas of intervention that can improve the mortality disparities in this population.

Despite these findings, it is important to acknowledge the substantial progress made over the past century by targeting resources towcird AI/AN communities and by placing great emphasis on public health

interventions, such as immunization, sanita- tion, and maternal and child health pro- grams, as integral parts of the IHS.' None- theless, these data paint an unfavorable aiid disturbing picture of the mortality disparity in the AI/AN population, affecting particu- larly the younger age groups. After dramat- ically improving AI/AN mortality for much ofthe 20th century, the situation changed in

the 1980s,^^ and death rates have either stagnated or worsened since 1990, as reported here. Kunitz^^ suggested that this reversal of trend is a result of the increasing burden of diabetes and lung cancer as well as inadequate funding for IHS and tribal health programs. A few common factors are likely responsible for most of these death rate disparities.

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TABLE 2-Death Rates for All Causes, by IHS Region and Age for American indians/Aiasita Natives Compared With Whites, Maies and Femaies: CHSDA Counties, United States, 1999-2009

Ai/AN White

IHS Region and Age

Northern Plains 0-24 y

25-44 y

45-64 y

65-84 y

> 8 5 y

Alaska

0-24 y

25-44 y

45-64 y

65-84 y

> 8 5 y

Southern Piains

0-24 y

25-44 y

45-64 y

65-84 y

> 8 5 y

Southwest 0-24 y

25-44 y

45-64 y

65-84 y

> 8 5 y

Pacific Coast

0-24 y

25-44 y

45-64 y

65-84 y

> 8 5 y

East

0-24 y

25-44 y

45-64 y

65-84 y

> 8 5 y

Count

2592

3459

7115

8064

2101

1116

1382

2253

2937

928

1880

3322

8461

12050

4708

3425

6221

8920

10368

4391

1434

2754

6430

7787

2374

431

756

1938

2350

697

Rate

170.8

458.4

1385.3

6032.6

18 584.7

192.8

442.0

1025.0

4751.4

17 040.0

112.1

357.4

1179.4

5310.1

20388.0

136.0

440.1

956.8

3697.1

13938.8

114.6

330.2

942.9

4571.3

15236.5

89.9

238.6

769.3

3526.3

10 573.4

Count

16 996

28 235

119 707

356 653

264 801

1091

2160

6822

9789

3759

8062

15 420

64 425

168 348

102 456

14190

30 684

122 589

320 538

181 621

25 902

56 985

248 186

665 484

462 849

26 451

59 545

245 921

720 164

507 232

Rate

61.0

125.8

520.2

3274.3

15 021.1

63.1

144.3

489.4

3296.8

12 810.1

78.0

186.4

736.4

3869.4

16 309.3

64.5

165.3

615.3

3200.0

14 583.9

56.7

140.5

578.7

3383.5

14 854.0

59.2

145.2

582.6

3360.8

14 793.5

Ai/AN;White RR (95% C

2.80 (2.69, 2.92)

3.64 (3.51, 3.77)

2.66 (2.60, 2.73)

1.84 (1.80, 1.88)

1.24 (1.18, 1.29)

3.06 (2.81, 3.33)

3.06 (2.86, 3.28)

2.09 (2.00, 2.20)

1.44 (1.38, 1.50)

1.33 (1.24, 1.43)

1.44 (1.37, 1.51)

1.92 (1.85, 1.99)

1.60 (1.57, 1.64)

1.37 (1.35, 1.40)

1.25 (1.21, 1.29)

2.11 (2.03, 2.19)

2.66 (2.59, 2.74)

1.56 (1.52, 1.59)

1.16 (1.13, 1.18)

0.96 (0.93, 0.98)

2.02 (1.92, 2.13)

2.35 (2.26, 2.44)

1.63 (1.59, 1.67)

1.35 (1.32, 1.38)

1.03 (0.98, 1.07)

1.52 (1.38, 1.67)

1.64 (1.53, 1.77)

1.32 (1.26, 1.38)

1.05 (1.01, 1.09)

0.71 (0.66, 0.77)

Social Determinants

Social determinants of heaith—defined by the World Health Organization^® as "the cir- cumstances in which people are bom, grow up. Uve, work and age, and the systems put in place to deal with illness"—are often the most difficult

Continued

to address. They also offer the potential for greatest impact.^'' On average, AI/AN persons are more likely than Whites to be poor, be unemployed, and have a lower level of educa- tional attainment.̂ ®'̂ ^ Many live in rural areas where employment is often seasonal and

dangerous, such as wildland firefighting and commercial fishing.^° These factors all con- tribute to a high incidence of deaths resulting from unintentional injury.^' These social fac- tors combined with the culttiral devastation most tribes experienced in the past 150 years resulted in understandably high homicide and suicide rates.''^ Abuse of alcohol and other drugs compounds the problem of injury, both intentional and unintentional, and contributes to high rates of death from chronic Uver disease.'̂ ^^^^ Approaches to improving social determinants usually focus on economic de- velopment and education and seek to support a culture of empowerment and self-efficacy. Community participation is particularly im- portant to address prominent issues such as health disparities and could be more widely implemented in AI/AN populations. Involving the community utilizes inherent strengths and assets and increases the likelihood that changes can be sustained. Successful ap- proaches include community-based participa- tory research, community-oriented primary care, and the development of peer educator systems.

Obesity, Inactivity, and the Metaboiic Syndrome

A combination of genetics, diet, and physical inactivity seems to predispose AI/AN individ- uals to obesity and diabetes and the metabolic syndrome,̂ *̂ "̂ ® which in turn drive the in- creased incidence of death from heart disease, stroke, chronic renal failure, and serious in- fections.̂ ^ Elsewhere in this supplement, Cobb et al.̂ ® report on the generally elevated prevalence of these risk factors, as well as self-report of history of diabetes in AI/AN persons compared with Whites, and Cho et al.*° describe the impact of high diabetes prevalence on mortality.

Tobacco and Alcohol Use

Extremely high smoking prevalence among AI/AN persons in most of the country^'' further complicates the vascular effects of the meta- bolic syndrome and contributes to increased rates of cardiovascular disease.""̂ "*^ Tobacco use also drives the high rate of death from limg cancer and alongKst of other cancers,"*'*"̂ " and it is the single most important catise of pre- ventable mortality among AI/AN populations.

Supplement 3, 2014, Vol 104, No. S3 | American Journai of Pubiic Health Espey et al, | Peer Reviewed | Research and Practice I S307

RESEARCH AND PRACTICE

TABLE 2-Contmued

Totai

0-24 y

25-44 y

45-64 y

65-84 y

> 8 5 y

10878

17 894

35117

43 556

15199

135.5

392.2

1059.0

4634.3

16 252.5

92 692

193 029

807 650

2 240 976

1 522 718

60.8

145.9

584.3

3362.0

14913.2

2.23 (2.18, 2,27)

2,69 (2,65, 2,73)

1,81 (1,79, 1.83)

1,38 (1,37, 1,39)

1,09 (1,07, 1,11)

Noie, AI/AN = American Indian/Aiaska Native; CHSDA = Contract Heaith Service Deiivery Areas; Ci - confidence interval; IHS = Indian Heaith Service; RR = rate ratio, Anaiyses were limited to peopie of non-Hispanic origin, AI/AN race is reported from death certificates or through iinkage with the IHS patient registration database. Rates are per 100 000 people and were age adjusted to the 2000 US standard popuiation (11 age groups; Census P25-1130), RR were caicuiated in SEER'Stat (version 8.0.4) before rounding of rates and may not equai rate ratios caicuiated from rates presented in tabie. iHS regions are defined as follows: Alaska"; Northern Piains (IL, IN,' IA,' Ml,= MN," MT,' NE,= ND,' SD,= Wl,' W f ) ; Southern Piains (OK,' KS,' TX°); Southwest (AZ,' CO,' NV,' NM,' U f ) ; Pacific Coast (CA,' iD,' OR,' WA,' HI); East (AL,' AR, CT,' DE, FL,' GA, KY, U , " ME,' MD, MA,' MS,' MO, NH, NJ, NY,' NC,' OH, PA,' Rl,' SC,' TN, VT, VA, WV, DC). Percent regionai coverage of AI/AN persons in CHSDA counties to AI/AN persons in aii counties; Northern Plains = 64.8%; Alaska = 100%; Southern Plains = 76.3%; Southwest - 91.3%; Pacific Coast = 71.3%; East » 18.2%; total US = 64.2%, Source, AI/AN Mortality Database (1990-2009), 'Identifies states with > 1 county designated as CHSDA. * P < , 0 5 ,

Cultural factors, such as the role of tobacco in traditional beliefs and ceremonies, make to- bacco control a challenging issue. However, substantial progress has been made in reducing tobacco use in the United States by imple- menting system, environmental, and policy changes known to decrease initiation of to- bacco use and increase successful cessation,''^ This has resulted in overall reductions in lung cancer mortality,̂ ® To achieve similar results, tribal governments should consider adopting similar approaches, taking into account the complex social and environmental determi- nants of tobacco use that may be unique to AI/AN populations. Occupational exposure to secondhand smoke is a particularly compelling area given the umited implementation of smoke-free envirorrments in casinos and gaming parlors,^^

As reported elsewhere in this supplement, mortality attiibutable to alcohol is substantially elevated in AI/AN communities relative to Whites and plays a key role in elevated death rates for multiple chronic conditions as well as injury and exposure,^^ Strategies to reduce or eliminate consumption of alcohol are critical to addressing its enormous personal and societal toll. For those unable or unwilling to avoid problem drinking, measures to make the environment less dangerous, such as improved lighting of roadways and protective custody programs, should be promoted.

Access to Care

AI/AN people continue to have difficulty getting high-quality, timely health care,^°'^' Rural living and limited prehospital care pro- long the time to treatment, increasing death rates from accidents and acute iUness,̂ ^ In- sufficient funding for IHS leads to delays and deficiencies in preventive services, primary treatment, and specialist care,^° Access-to-care issues likely contribute to the observed dis- parities between AI/AN and White persons in cancer survival,"*^ heart disease mortality,*^ and diabetes mortality,'*°

Recent developments offer some cause for optimism. The Indian Health Care Improve- ment Act was permanently reauthorized in 2010, which will help modernize the IHS and improve reimbursement from Uurd-party payers,^^ After the Indian Gaming Regulatory Act in 1988, revenues from tribal gaming increased considerably. Wolf et al,̂ * studied the effect of gaming on income and health status of gaming tribes, providing evidence of a positive effect of gaming on income and on several indicators of AI/AN health, health- related behaviors, and access to health care.

Limitations Several limitations should be considered

when interpreting the results presented in this article. First, although linkage with the IHS patient registration database improves

the classification of race for AI/AN dece- dents, the issue is not completely resolved because AI/AN people who are not members of the federally recognized tribes are not eligible for IHS services and not represented in the IHS database. Additionally, some de- cedents may have been eligible for but never used IHS services, and therefore were not included in the IHS registration database. Second, substantial variation exists between federally recognized tribes in the proportion of Native ancestry required for tribal mem- bership and therefore for eligibility for IHS services. Whether and how this discrepancy in tribal membership requirements may in- fluence some of our findings is unclear, although our findings are consistent vnth prior reports. Third, the findings from CHSDA counties highlighted in this supple- ment do not represent all AI/AN populations in the United States or in individual IHS regions,® In particular, the East region in- cludes only 15,4% of the total AI/AN pop- ulation for that region. Furthermore, the analyses based on CHSDA designation ex- clude many AI/AN decedents in urban areas that are not part of a CHSDA county, AI/AN residents of urban areas differ from all AI/AN persons in poverty level, health care access, and other factors that may influence mortality trends,^^ Finally, although the ex- clusion of Hispanic AI/ANs from the analy- ses reduces overall AI/AN deaths by less than 5%, it may disproportionately exclude some tribal members who have Hispanic surnames and may be coded as Hispanic at death in states along the US-Mexico border and in other areas in the Southwest, Pacific Coast, and Southern Plains,

Conclusions

This article contains the best available data on deaths among AI/AN persons between 1990 and 2009, Using much more accurate racial ascertainment in death records, we have shown that the disparity in death rates between AI/AN and non-Hispanic White populations in the United States remains large for most causes of death, A concerted, robust public health elfort by federal, tribal, state, and local public health agencies, coupled with attention to social and economic disparities, may help narrow the gap, •

S308 I Research and Practice | Peer Reviewed | Espey et al. American Journal of Public Health | Supplement 3, 2014, Vol 104, No, S3

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About the Authors Dcwid K. Espey, Melissa A. Jim, Don Haverkamp, and Marcus Plesda are with the Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, GA.Atthe time of the study, Nathaniel Cobb was with and Michael Bartholomew is currently vith the Division of Epidemiology and Disease Prevention, Indian Health Service (IHS), Rockville, MD. Tom Becker is with Oregon Health and Sciences University, Portland. Damd K. Espey is also a guest editor for this supplement issue.

Correspondence should be sent to David K. Espey, MD, Division of Epidemiology and Disease Prevention, 1720 Louisiana Boulevard NE, Albuquerque, NM 87110 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the "Reprints" link.

This article was accepted November 8, 2013. Note. The findings and conclusions in this report are

those of the authors and do not necessarily represent the offiaal position of the CDC or the IHS.

Contrihutors D. K. Espey conceptualized the study and organized the writing and analyses. iVl. A. Jim conducted most of the analyses. N. Cobb assisted with organization, writing, and editing of the article. M. Bartholomew, T. Becker, and M. Plesda assisted with the organization and writing of the article. D. Haverkamp assisted with writing and review- ing the article and conducted trend anaiyses.

Acknowledgments We thank Steve Scoppa of IMS and Ashwini Soman of the CDC's Division of Cancer Prevention and Control for their valuable assistance creating analytic tiles and data tables.

Human Participant Protection The CDC and the IHS determined this project to constitute public health practice and not research; therefore, no formal institutional review board approvals were required.

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Supplement 3, 2014, Vol 104, No. S3 | American Journal of Public Health Espey et al. | Peer Reviewed | Research and Practice I S311

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