JOURNAL OF WOMEN’S HEALTH Volume 15, Number 8, 2006 © Mary Ann Liebert, Inc.
Health Behaviors among American Indian/Alaska Native Women, 1998–2000 BRFSS SONAL R. DOSHI, M.P.H., M.S.,1 and RUTH JILES, Ph.D.2
ABSTRACT Background and objective: Minority populations, including American Indians and Alaska Natives (AI/AN), in the United States generally experience a disproportionate share of adverse health outcomes compared with whites. The prevalence of risk behaviors associated with these adverse health outcomes among AI/AN women is not well documented, especially for those who live outside areas serviced by Indian Health Service. We sought to describe the prevalence of selected health risk behaviors among AI/AN women, document the disparities between AI/AN women and all U.S. women, and demonstrate the efforts needed for AI/AN women to reach Healthy People 2010 goals. Methods: Age-adjusted prevalence estimates for selected sociodemographic characteristics, current smoking, obesity, lack of leisure time physical activity, and binge drinking were calculated using Behavioral Risk Factor Surveillance System (BRFSS) data from 1998 to 2000, combined. Comparisons were made between prevalence estimates for AI/AN women and all women who participated in the BRFSS and Health People 2010 goals. Results: The prevalences of current smoking (27.8%) and obesity (26.8%) were significantly higher among AI/AN women than among all U.S. women. AI/AN women did not meet Healthy People 2010 goals for current smoking, obesity, leisure time physical activity, or binge drinking. Conclusions: These data highlight both disparities in health risk behaviors between AI/AN women and all U.S. women and improvements needed for AI/AN women to meet Healthy People 2010 goals. This project demonstrates the overwhelming need for culturally appropriate and accessible prevention programs to address health risk behaviors associated with the leading causes of death among urbanized AI/AN women.
INTRODUCTION
M
UNITED STATES generally experience a disproportionate share of adverse health outcomes, in contrast to whites. To address and eliminate health disparities found among racial and ethnic U.S. populations, the nation developed health goals for eliminating health disparities by the year 2010. INORITY POPULATIONS IN THE
Healthy People 2010 (HP2010) outlines objectives that must be accomplished to eliminate these disparities.1 Native Americans as a group experience excess morbidity and mortality, in contrast to the U.S. general population.2,3 Although the term Native American is used here as a single racial category, Native Americans are actually a diverse population of American Indians and Alaska Natives
1Division of Adolescent and School Health and 2Division of Adult and Community Health, Centers for Disease Control and Prevention, Atlanta, Georgia.
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(AI/AN). This diverse group reflects geographic and tribal differences in the prevalence of health indicators, health risk behaviors, and morbidity and mortality. As a group, AI/AN experience excess mortality due to tuberculosis, chronic liver disease, motor vehicle accidents, other unintentional injuries, diabetes, pneumonia, homicide, and suicide.2,4 Although AI/AN had lower mortality rates from heart disease and cancer than the U.S. population, these two diseases are the leading causes of death among AI/AN and continue to increase at a higher rate than among the U.S. population as a whole.4,5 National data about health determinants among AI/AN are limited, but there is evidence that AI/AN have a higher prevalence of cigarette smoking and being overweight, and they have a lower prevalence of use of preventive services.5–8 Using data from the Behavioral Risk Factor Surveillance System (BRFSS) from 1992 through 1995, Denny and Taylor6 reported that AI/AN were more likely than whites to report fair or poor perceived health, current smoking, lack of seatbelt use, physician-diagnosed diabetes, obesity, and not visiting a physician because of inability to pay. Other studies using BRFSS data indicated that AI/AN men were more likely to binge drink and be current smokers; AI/AN women were more likely than AI/AN men to be obese and less likely to participate in leisure time physical activity.6,9 Despite the widespread knowledge of gender differences in health behaviors and morbidity, comparatively little data exist on health behaviors among AI/AN women. This study seeks to describe the selected health risk behaviors among AI/AN women that place them at risk for the leading causes of excess mortality. To document the disparities between AI/AN women and non-AI/AN women, comparisons were made between these groups. To demonstrate the efforts needed to reach national goals, health behaviors among AI/AN women and HP2010 goals were compared.
MATERIALS AND METHODS The BRFSS is an ongoing random digit-dialed telephone survey that collects information about adult health behaviors related to the leading causes of morbidity and mortality. Conducted by state health departments in collaboration with the
Centers for Disease Control and Prevention (CDC), the survey was initiated in 1984 and includes all 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, and Guam. Data are collected monthly at the state level through telephone interviews with adults aged 18 and older. Respondents are randomly selected by means of a multistage cluster design, and it is believed that the probability of an individual being sampled in multiple subsequent years is small, although that has not been determined. The BRFSS is described in detail elsewhere.10 The BRFSS includes a relatively small number of AI/AN annually. To increase the precision of national estimates, we combined data over 3 years, 1998–2000, for all 50 states and the District of Columbia. Instability in estimates over time precluded the use of more recent BRFSS data in these analyses. A total of 286,482 women were sampled during the 3-year period, and 4,633 (1.6%) self-identified as AI/AN. The 1998 BRFSS included 1,088 (1.2%) AI/AN women among a total of 88,192 women. In 1999, there were 1,410 (1.5%) AI/AN women among a total of 94,679 women. In 2000 there were 2,148 (2.0%) AI/AN women among the 109,680 women who participated in the survey.
Variable definition Respondents were categorized as American Indian or Alaska Native if they identified themselves as such during the BRFSS interview. AI/AN respondents were not asked their tribal affiliation or if they resided on a reservation. In addition to demographic information, this study addressed four health behaviors related to the leading causes of disability and death: smoking, obesity, no leisure time physical activity, and binge drinking. Persons who indicated that they had smoked 100 cigarettes in their lives and also smoked at the time of the interview were identified as current smokers. Self-reported height and weight were used to compute body mass index (BMI). Obesity was defined as a BMI of 30.0. For this study, prevalence estimates for obesity were calculated for women aged 20 years as per HP2010 targets.1 Persons who reported no leisure time physical activity (e.g., running, calisthenics, golf, gardening, or walking) in the month prior to the survey were classified as having no leisure time physical activity. Respondents who reported having five or more drinks on at least one occasion in
HEALTH BEHAVIORS AMONG AMERICAN INDIAN/ALASKA NATIVES
the past 30 days were defined as binge drinkers. For all 3 years, all respondents were asked about current smoking status and self-reported height and weight. In 1998 and 2000, respondents were asked if they participate in physical activities during their leisure time. In 1999, all respondents were asked about binge drinking activity.
Statistical methods Each state’s yearly BRFSS sample is weighted to the respondent’s probability of selection and to the age-specific and sex-specific or race-specific, age-specific, and sex-specific population from the most current census data for the state.11,12 These weighted data were used to estimate the prevalence of risk factors for each state’s population. Because of the relatively limited sample size of the AI/AN, multiple years of data were aggregated for these analyses to increase the precision of the prevalence estimates. To make comparisons between AI/AN and non-AI/AN, prevalence estimates were age-adjusted to the 2000 census, using direct standardization.13,14 Unadjusted prevalence estimates were used for comparisons among AI/AN women. Prevalence estimates and 95% confidence intervals (CIs) were computed for all four health behaviors. Standard Z-tests were calculated to compare age-adjusted health risk behaviors for AI/AN women with HP2010 goals for all four health behaviors in this study. Confidence intervals were used to determine statistically significant differences in risk behaviors. Analyses were performed using SAS version 8.2 (SAS Institute, Cary, NC) and SUDAAN version 8.0.2 (Research Triangle Institute, Research Triangle Park, NC) to calculate standard errors and 95% CI for prevalence estimates.
RESULTS Sociodemographic characteristics of AI/AN women and non-AI/AN women are shown in Table 1. Compared with non-AI/AN women, AI/AN women were younger overall, fewer were married or widowed, they reported lower educational attainment and lower household incomes, and more reported their health status as fair or poor. More AI/AN women than nonAI/AN women reported having no healthcare coverage and experiencing difficulty in seeing a physician because of cost in the past 12 months.
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Table 2 shows unadjusted prevalence estimates for current smoking, obesity, no leisure time physical activity, and binge drinking among AI/AN women by demographics characteristics. Current smoking was reported by 28.9% (95% CI 26.4%-31.4%) of AI/AN women. Those aged 65 reported significantly less current smoking than any other age group. AI/AN women who were members of unmarried couples reported the highest rate of current smoking (56.4%, 95% CI 43.1%-69.7%). More than one fourth (26.7%, 95% CI 23.9%29.5%) of AI/AN women were identified as obese. AI/AN women in the youngest age group (20–24 years) had the lowest obesity rate (11.7%, 95% CI 7.2%-16.2%), and the highest obesity prevalence was among those who indicated their health was fair, significantly higher than those reporting excellent or very good health. There were differences in the proportion of AI/AN women who reported engaging in leisure time physical activity by age, educational levels, and income. Among AI/AN women, the lowest prevalence of no leisure time physical activity was among those aged 18–24 (17.7%, 95% CI 11.6%–23.8%). Based on 1999 estimates, 10.4% (95% CI 6.8%12.4%) of all AI/AN women reported binge drinking in the 30 days prior to the survey.
Comparisons to all U.S. women Age-adjusted prevalence estimates for AI/AN and non-AI/AN women are compared in Table 3. A higher prevalence of current smoking was seen among AI/AN women (27.8%, 95% CI 25.2%30.4%) than non-AI/AN women (20.8%, 95% CI 20.6%-21.0%). Additionally, AI/AN women had a higher incidence of obesity (26.8%, 95% CI, 24.0%29.6%) than non-AI/AN women (19.3, 95% CI 19.0%-19.6%). There was no significant difference between AI/AN women and non-AI/AN women with regard to engagement in leisure time physical activity and binge drinking.
Comparisons to Healthy People 2010 objectives We compared age-adjusted prevalence estimates for current cigarette smoking, obesity, no leisure time physical activity, and binge drinking among AI/AN women and HP2010 goals in Figure 1. Among AI/AN women, the prevalence of cigarette smoking was 2.8 times higher than HP2010 goals. The prevalence of obesity among
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DOSHI AND JILES TABLE 1.
AGE-ADJUSTED CHARACTERISTICS OF AI/AN WOMEN COMPARED WITH ALL NON-AI/AN WOMEN, 1998–2000, BRFSS
Demographics Age groups 18–24 25–34 35–49 50–64 65 Marital status Married Divorced/separated Widowed Never married Member of unmarried couple Education Less than high school High school or GED Some post-high school College graduate Income $0–14,999 $15,000–24,999 $25,000–34,999 $35,000–49,999 $50,000–74,999 $75,000 Unknown Health insurance status Has healthcare coverage No healthcare coverage Self-reported health status Excellent Very good Good Fair Poor Difficult to see doctor due to cost Yes No
Non-AI/AN women adjusteda % 95% CIb
AI/AN women adjusted % 95% CI
NA NA NA NA NA
NA NA NA NA NA
56.8 13.4 10.9 16.3 2.6
0.3 0.2 0.2 0.2 0.1
50.4 18.1 11.5 16.4 3.6
2.9 2.3 1.8 1.5 1.0
13.5 33.3 28.1 25.1
0.2 0.3 0.3 0.3
23.8 32.4 26.6 17.2
2.8 2.8 2.5 2.5
11.7 17.2 13.9 15.4 13.2 11.8 16.8
0.2 0.2 0.2 0.2 0.2 0.2 0.2
18.6 21.9 15.9 12.6 10.0 5.9 15.1
2.3 2.5 2.3 1.9 2.0 1.5 2.1
86.7 0.2 13.3 0.2 21.9 33.4 29.1 11.4 4.2
80.4 2.1 19.7 2.1
0.2 0.3 0.3 0.2 0.1
19.4 25.9 31.1 16.8 6.8
12.1 0.2 87.9 0.2
2.7 2.6 2.7 2.3 1.3
18.6 2.3 81.4 2.3
aWeighted bCI,
and age-standardized to the 2000 U.S. women’s population (Census 2000). confidence interval.
AI/AN women was 2 times higher than the HP2010 goals. The prevalence of no leisure time physical activity and binge drinking were 1.9 and 1.7 times higher than the HP2010 goal, respectively. Younger AI/AN women and those who reported excellent health met the HP2010 goals for obesity. Leisure time physical activity goals were met by AI/AN women ages 18–24 and those with incomes $75,000.
DISCUSSION This report is the first to use BRFSS data to look specifically at health behaviors of AI/AN women nationwide in the context of their socioeconomic and health status. These data show that AI/AN women engage in several behaviors (cigarette smoking, obesity, no leisure time physical activity, and binge drinking) that increase their risk of morbidity and mortality from chronic diseases.
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HEALTH BEHAVIORS AMONG AMERICAN INDIAN/ALASKA NATIVES TABLE 2.
PREVALENCE
OF
SELECTED RISK BEHAVIORS
Demographics Total Age groups 18–24 25–34 35–44 45–64 65 Marital status Married Divorced/separated Widowed Never married Unmarried couple Education Less than high school High school or GED Some post-high school College graduate Income $0–14,999 $15,000–24,999 $25,000–34,999 $35,000–49,999 $50,000–74,999 $75,000 Unknown Health insurance coverage Yes No Self-reported health status Excellent Very good Good Fair Poor Difficult to see doctor due to cost Yes No
AMONG
AI/AN WOMEN, UNADJUSTED, 1998–2000, BRFSS
Current smokinga % 95% CIe
Obesityb % 95% CI
No leisure time physical activityc % 95% CI
Binge drinkingd % 95% CI
28.9 2.5
26.7 2.8
30.7 3.2
10.4 3.2
30.2 29.3 31.1 31.6 15.1
7.4 4.8 5.2 5.5 5.8
11.7 24.1 26.1 33.7 29.3
4.5 4.7 5.2 5.9 8.6
17.7 30.3 32.4 31.3 43.6
6.1 6.3 6.4 6.8 9.6
12.2 19.1 11.8 6.0 1.7
7.3 7.8 8.5 4.7 2.1
22.6 37.6 32.3 30.9 56.4
3.3 6.2 9.5 6.2 13.3
28.4 26.6 27.8 21.4 23.6
4.3 5.3 8.0 5.9 12.1
31.6 31.5 43.7 22.5 33.7
4.8 7.0 11.2 6.1 14.7
8.0 13.4 1.4 17.4 20.7
3.6 8.4 1.8 10.5 22.7
31.8 32.8 30.7 16.2
6.1 4.5 4.9 5.0
32.3 27.8 24.8 22.1
6.5 4.4 4.4 8.4
45.1 34.5 22.4 20.5
8.0 5.5 4.9 7.3
5.6 8.6 16.8 9.3
3.9 4.0 7.8 9.5
41.7 34.7 23.5 31.2 21.2 10.9 22.4
6.8 6.1 5.5 7.2 7.2 5.6 5.9
32.7 31.3 18.9 25.7 28.9 18.9 23.4
6.2 6.1 5.4 7.0 11.2 13.1 6.2
37.6 33.4 23.7 32.4 22.2 13.8 41.5
7.5 6.5 7.4 9.7 9.4 7.4 9.2
7.7 13.5 12.1 15.2 4.7 20.2 3.5
4.3 7.6 8.0 13.2 5.7 19.8 2.5
27.9 3.0 32.9 5.1 23.6 26.6 28.8 34.9 39.3
7.0 4.4 4.2 7.3 9.4
37.0 6.1 27.0 2.9
25.2 3.2 32.4 5.7 15.3 20.3 32.4 39.0 32.2
5.4 4.2 5.6 7.4 8.3
33.5 6.2 25.1 3.1
29.9 3.7 34.5 6.7 20.5 24.3 34.5 39.5 46.0
6.6 5.6 6.1 9.4 11.0
36.9 7.6 29.4 3.5
8.6 3.0 15.4 8.4 9.7 9.2 11.1 13.4 5.5
8.4 4.8 6.2 7.8 7.2
14.0 9.4 9.3 3.0
who reported having ever smoked 100 cigarettes in their lifetime and who currently smoke. mass index 30.0 kg/m2. Calculated for women aged 20. cNo exercise, recreation, or physical activity (other than regular job duties) during the preceding month, 1998 and 2000 BRFSS only. dConsumption of 5 alcohol drinks on at least one occasion during the preceding month, 1999 BRFSS only. eCI, confidence interval. aIndividuals bBody
Compared with non-AI/AN women, more AI/ AN women reported current cigarette smoking and obesity. There were no differences in the proportions who report no leisure-time physical activity and binge drinking. Additionally, among AI/AN women, the prevalence of these four risk behaviors was significantly higher than HP2010 goals. The high rates of current smoking among AI/AN women correspond to those reported us-
ing earlier years of BRFSS data.5,7,9 However, there is inconsistency in the prevalence of smoking when examining rates among individual tribes or regions. Several studies show very high smoking rates among Plains Indians and Alaska Natives,5,15 whereas smoking rates among AI women in the Southwest are much lower.5,16 These data possibly reflect regional or tribal differences, or both, in smoking patterns that are masked when data are aggregated. Nevertheless, for
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DOSHI AND JILES TABLE 3.
HEALTHY PEOPLE 2010 OBJECTIVES AND GOALS FOR HEALTH RISK BEHAVIORS ASSESSED AI/AN WOMEN AND NON-AI/AN WOMEN FROM 1998–2000, BRFSS
AMONG
Healthy People 2010 objective
Year 2010 target
27.1a 19.2 22.1 26.11c
12.0% 15.0% 20.0% 6.0%
Current cigarette smoking Obesity (BMI 30) No leisure time physical activity Binge drinking, during the past month
Non-AI/AN womena % 95% CIb 20.8 19.3 30.3 7.5
0.2 0.3 0.4 0.3
AI/AN womena % 95% CI
Difference between target and AI/AN women
Difference between nonAI/AN and AI/AN women
15.8 11.8 12.0 3.6
7.0 7.5 1.7 2.1
27.8 26.8 32.0 9.6
2.6 2.8 3.3 2.8
aWeighted bCI,
and age-standardized to the 2000 U.S. women’s population (Census 2000). confidence interval.
AI/AN women as a group to reach the HP2010 goal for current smoking, a reduction of 15.8 percentage points will be necessary. The prevalence of cigarette smoking among AI/AN women has remained constant over the last 10 years.7,17 Targeted, affordable, accessible, culturally appropriate, and effective primary and secondary interventions are needed to reach the HP2010 goal and reduce the impact of cigarette smoking on AI/AN women’s morbidity and mortality. Obesity prevalence has reached epidemic proportions in the United States. This epidemic is reflected in all racial and ethnic groups but is par-
ticularly prevalent among minority populations, including AI/AN women. Studies among AI/ AN women have reported high obesity rates similar to those reported here.5,7,9,16,18 In a study of urban-living AI women aged 18–64, Harnack et al.19 reported that 66% were overweight, with a mean BMI of 30.1% (overweight defined as BMI 27.3 kg/m2). The Strong Heart Study reported that 73% of 45–74-year-old AI women from Arizona, Oklahoma, and the Dakotas were overweight.20 To reach HP2010 goals, obesity must be reduced by 11.8 percentage points among AI/AN women. Such a large reduction re-
FIG. 1. Comparison between selected risk behaviors among AI/AN women included in the 1998–2000 BRFSS and Healthy People 2010 goals. *p 0.01; **p 0.05.
HEALTH BEHAVIORS AMONG AMERICAN INDIAN/ALASKA NATIVES
quires innovative approaches for implementing multifaceted intervention programs. The prevalence of no leisure time physical activity found in this report is similar to estimates reported by Hahn et al.7 among AI/AN women. When looking at specific tribal data on leisure time physical activity, the Navajo Health and Nutrition Survey reported that 28.9% of Navajo women interviewed were sedentary.21 Findings from the U.S. Women’s Determinants Study estimated that 48.7% of AI/AN women over age 40 engaged in no leisure time physical activity.22 Women who participated in the U.S. Women’s Determinants Study were slightly older than those who participated in the BRFSS and the Navajo Health and Nutrition Survey. This age difference may account for the higher prevalence of sedentary lifestyle reported by Brownson et al.22 Although AI/AN women do not meet HP2010 goals for engaging in leisure time physical activity, they are not different from non-AI/AN women in this regard. These results indicate that physical inactivity is a problem for all U.S. women, including AI/AN women. Numerous reports indicate that alcohol abuse is a major health problem among the AI/AN population.1,23,24 In fact, AI/AN have higher alcoholrelated mortality rates than the general population.4,25 There are few reports of excess alcohol consumption among AI/AN women . The binge drinking prevalence reported in this study is consistent with that reported by Denny and Holtzman9 using BRFSS data from 1993 through 1996. Within the BRFSS methodology, it appears that binge drinking prevalence among AI/AN women has increased slightly over the past 10 years from an estimated 8.6% (combined 1990–1993) to 10.4% for 1999. Data from the current study indicate that binge drinking prevalence among AI/AN women is only slightly higher than that for non-AI/AN women. To reach HP2010 goals for binge drinking, the rate must decrease by 4.4 percentage points among AI/AN women and by 3.5 percentage points for non-AI/AN women over the next 5 years. More effective interventions must be developed and made accessible to all women, including AI/AN women. Health risk behaviors among AI/AN women have not been widely studied. This study shows that the prevalence of all behaviors studied was significantly higher for AI/AN women than the goals set by HP2010. A review of recent literature indicates that these high rates have been constant
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over the past 6–10 years.5,7,9,16–22 Thus, these findings suggest that intervention programs that target these behaviors are not reaching AI/AN women or they are not effective for AI/AN women. There are many avenues along which effective prevention programs can be implemented. This study highlights where large gaps exist between risk behaviors and HP2010 objectives, suggesting where resources from existing and new programs should be targeted. The Indian Health Service (IHS) is the most obvious avenue for channeling prevention programs and services to AI/AN populations, especially those who live on or near reservations. Many AI/AN now live in urban areas where IHS services and programs are not readily available.26–29 Recognizing that approximately 70% of those who identify themselves as AI/AN live in urban areas,29 IHS supports urban Indian health programs through grants and contracts to the National Council of Urban Indian Health (NCUIH).30 At present, NCUIH supports programs at 41 sites located in cities across the United States. The services offered range from referral and prevention education to comprehensive healthcare.30 These urban Indian programs are a key provider of care to the large population of uninsured urban Indians.30 These are also potential sites for the development, implementation, and evaluation of intervention programs that target the health disparities identified in the current study. In addition to IHS’s efforts, several federal initiatives have been funded to address racial and ethnic disparities in health. These initiatives include Racial and Ethnic Approaches to Community Health (REACH 2010),31 Steps to a HealthierUS,32 and programs through the Department of Justice.33 The findings in this study are subject to some limitations. First, these data are based on self-report and are subject to recall bias and a tendency toward socially acceptable responses. Second, the BRFSS is a telephone survey and, therefore, only reaches households with telephones. In 2000, approximately 11.9% of AI/AN households did not have working telephones, in contrast to only 2.4% of households nationwide.34 Additionally, telephone service on AI/AN reservations varies considerably; more than 60% of Navajo reservationbased households do not have telephone service, and 21% of Zuni tribal homes lack telephones.34 Differences in telephone coverage is very impor-
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tant because those who do not have telephones in their homes are more likely to be of a lower socioeconomic status and at higher risk for engaging in these adverse behaviors.35–37 Third, this study is unable to report estimates by tribal affiliation or by reservation residency status because the BRFSS does not collect this information. The BRFSS sample of AI/AN women is not large enough to generate stable estimates for AI/AN women on an annual basis. Data are aggregated over several years to produce stable estimates for AI/AN women. As a result of the sample size and lack of data on tribal affiliation and reservation residency status, diversity in health risk behaviors between tribes is unaccounted for and may be masked by aggregating data across tribes and regions.2,38 The solutions to these problems are to collect data about reservation residency status and tribal affiliation and to increase the sample size of the AI/AN population in the BRFSS. ZIP code information, collected in 2001, was used to determine metropolitan statistical area (MSA) and primary metropolitan statistical area (PMSA) for each respondent. Using the MSA and PMSA information, we estimated that approximately 77% of the BRFSS study population reside in urban areas (data not reported). This corresponds to the documented trend for AI/AN to move to urban areas28 and supports our belief that BRFSS data are representative of urban AI/AN populations. To improve the health of all AI/AN and to eliminate health disparities between AI/AN women and women of other racial groups, access to prevention and interventions services is essential. This project identified the need for interventions that address key risk behaviors and the importance of increasing resources and services for AI/AN women and especially for urban AI/AN nationwide. Elimination of disparities and improving the health of AI/AN women are dependent on development and implementation of effective and efficient culturally appropriate interventions at the community level, based on appropriate and timely data.
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