By Kathryn L. Braun and Cynthia LaCounte
Prior to the arrival of Europeans, an estimated 5 million to 10 million individuals inhabited the land that now comprises the United States. They were organized in hundreds of communities, each with their own languages, cultures, economies, social institutions, and governance structures. Today, these groups are known as American Indians, Alaska Natives, and Native Hawaiians. In this article, we will refer to them collectively as Native Americans and, when talking about older Native Americans, as native elders.
Today, about 5.2 million U.S. residents are full or part American Indian or Alaska Natives (AIAN), and another 527,077 are full or part Native Hawaiian (U.S. Census Bureau, 2012, 2013). Taken together, Native Americans of the United States now make up about 2 percent of the nation’s population.
With population aging, the number and proportion of native elders have grown. Yet, native peoples experience continued disparities in health, disability, and longevity (Anderson, Bulatao, and Cohen, 2004). This article presents data on demographic and health indicators of Native Americans, discusses possible reasons for relatively poor health outcomes, and makes recommendations for research and practice.
Demographics and Health Indicators
Although there are limitations in existing data on native elder health, the available data suggest that they rank lower in socioeconomic and health indicators than their white counterparts.
There are several national sources of demographic and health data on Native Americans. Foremost are the decennial census and the American Community Survey (ACS), both administered by the U.S. Census Bureau. ACS data are collected annually, and small populations, such as AIANs and Native Hawaiians, are purposefully oversampled. Most often in data reported by the U.S. Census Bureau, Native Hawaiians are combined with other residents from the Pacific under the label of Native Hawaiians and other Pacific Islanders (NHOPI), and all AIAN tribes are combined under the AIAN label. For some indicators, the Census presents data for individuals that report AIAN or NHOPI as their only race, but for other indicators it presents data for individuals choosing AIAN or NHOPI alone, or in combination with other races.
Other national databases (e.g., the Behavioral Risk Factor Surveillance System and Medicare) have been used to examine AIAN and NHOPI, although native samples are usually small. The most comprehensive reports about Native Hawaiians are produced in Hawai‘i, but data often are limited to Native Hawaiians living in Hawai‘i. Small sample sizes and merging of tribes and ethnic groups into AIAN and NHOPI groupings limit our understanding of native elders.
AIANs are organized by tribe, and the United States recognizes 566 AIAN tribes. According to the 2010 U.S. Census, the largest American Indian tribes are the Cherokee, Navajo, Choctaw, Mexican American Indian, Chippewa, Sioux, Apache, Blackfeet, Creek, and Iroquois tribes. The largest Alaska Native groups are Yup‘ik, Inupiat, Tlingit-Haida, Alaskan Athabascan, Aleut, and Tsimshian. Native Hawaiians are not organized as a tribe. Rather, Hawai‘i was a sovereign nation recognized by many foreign powers when it was illegally overthrown in 1893 and annexed by the United States in 1898 (Apology Bill, 1993). Native Hawaiian groups continue to work to gain recognition for the Hawaiian nation.
More than half of the AIAN population lives in eleven states—California, Oklahoma, Arizona, Texas, New York, New Mexico, Washington, North Carolina, Florida, Michigan, and Alaska (U.S. Census Bureau, 2013). Only about 22 percent of AIAN in 2010 lived in the 681 designated American Indian areas (reservations) or Alaska Native Village Statistical Areas (U.S. Census Bureau, 2013). About 45 percent of AIAN elders (ages 65 and older) live in the Western United States, and another 33.5 percent live in the South; 80.3 percent of AIAN elders live in micro- and metropolitan areas (see Table 1, below).
Similar to AIAN, Native Hawaiians live in every state. Most Native Hawaiians are concentrated in Hawai‘i and California. Only 9 percent of Native Hawaiians live on Hawaiian Home Lands—lands held in trust for eligible Native Hawaiians by the state of Hawai‘i (U.S. Census Bureau, 2012). Almost 82 percent of NHOPI elders (ages 65 and older) live in the Western United States, and almost 99 percent live in micro or metropolitan areas (see Table 1).
Native Americans experience socioeconomic disparities. Only about half of AIAN householders nationwide and Native Hawaiian householders in Hawai‘i own their own homes, compared with about 64 percent of the overall population (U.S. Census Bureau, 2013). Nationally, only 17 percent of AIAN and 18 percent of Native Hawaiians ages 25 and older have a bachelor’s degree, in comparison to 33 percent of whites (Office of Hawaiian Affairs, 2013; Office of Minority Health, 2014). In 2012, the median household income was $37,353 for AIAN and $51,322 for Native Hawaiians, compared to $56,565 for whites. Also, about 26 percent of AIAN and 31 percent of NHOPI live below the poverty level, as compared to only 11 percent of whites (Office of Minority Health, 2014).
The U.S. Census estimated that 37.1 percent of AIAN and 26.7 percent of NHOPI elders were living alone in 2010, compared to 43.0 percent of white elders. Urban-dwelling AIAN elders are more likely to live alone than their reservation counterparts, but less likely to live in poverty, and about 6.2 percent of AIAN grandparents live with grandchildren (Office of Minority Health, 2014). In Hawai‘i, 48 percent of all grandparent householders living with grandchildren under age 18 are Native Hawaiian, whereas only 22 percent of the general population is Native Hawaiian (Office of Hawaiian Affairs, 2013).
Although the number of native elders is growing, life expectancy of AIAN and Native Hawaiians continues to lag three to four years behind that of the general U.S. population (Indian Health Service, 2014; Ka‘opua et al., 2011). Thus, while adults ages 65 and older represent 14.4 percent of the white population in the United States, they only comprise 7.1 percent of the AIAN population and 5.2 percent of NHOPI population (U.S. Census Bureau, 2014; see Table 2, page 62). In Hawai‘i, about 7.3 percent of Native Hawaiians are ages 65 and older (Office of Hawaiian Affairs, 2013).
Mortality and chronic conditions
AIAN have higher mortality rates than other Americans for a number of conditions, including chronic liver disease and cirrhosis (368 percent higher), diabetes mellitus (177 percent higher), unintentional injuries (138 percent higher), assault and homicide (82 percent higher), intentional self-harm and suicide (65 percent higher), and chronic lower respiratory diseases (59 percent higher) (Indian Health Service, 2014). In Hawai‘i, Native Hawaiians are more than five times as likely to experience diabetes between the ages of 19 and 35 (11 percent versus 2 percent) as non-Hawaiians. Native Hawaiians also have the highest cancer mortality rates of the five largest ethnic groups in the state (Office of Hawaiian Affairs, 2011).
On a national level, Ng and colleagues (2014) examined racial differences in physical and mental health, health symptoms, sensory and functional limitations, and risk factors among 236,289 older Medicare Managed Care members. They found significant racial differences, with all non-white racial groups (except Asians) doing worse than whites on most health indicators. For example, about 22 percent of AIAN and NHOPI elders reported depressed mood much of the time in the last year, compared to 11.7 percent of white elders. Even after controlling for key socio-demographic factors (like education), Ng and colleagues still found that AIAN and NHOPI elders were significantly more likely than white elders to report chest pain, shortness of breath, or foot symptoms in the last four weeks, depressed mood much of the time in the last year, and vision and hearing problems. AIAN elders also were more likely than white elders to be obese and report more than one activities of daily living (ADL) impairment (see Table 2).
AIANs report lower levels of cancer screening than whites, especially for colorectal cancer. Based on 2010 data, only 49.5 percent of AIAN ages 50 and older were in compliance with colorectal cancer screening recommendations in 2010, compared to 59.8 percent of whites (Centers for Disease Control and Prevention, 2012). Only 55.8 percent of Native Hawaiians ages 50 and older were in compliance with colorectal cancer screening recommendations, compared to 64.2 percent of whites (Hawai‘i Health Matters, 2014).
All federally recognized AIANs are entitled to healthcare. This is provided by the Indian Health Service (IHS) through IHS-run facilities, which serve any registered AIAN, or by tribal contractors, which give priority to tribal members. However, only 40 percent of AIAN access IHS facilities and contractors (Morton et al., 2008). When asked about insurance coverage in 2012, about 48 percent of AIAN reported they had private insurance, about 38 percent reported using Medicaid, and about 23 percent said they lacked health insurance coverage (Office of Minority Health, 2014).
There is nothing equivalent to the IHS for Native Hawaiians. However, the Native Hawaiian Health Improvement Act of 1998 established five Native Hawaiian Health Care Systems, which help Native Hawaiians in Hawai‘i access health insurance and healthcare, while providing health education and some primary care services. About 6 percent of Native Hawaiians reported lacking health insurance coverage in 2010 (Office of Hawaiian Affairs, 2011).
Reasons for Disparities
Numerous reasons have been proposed to explain the disparities experienced by Native Americans and native elders. In this section, we will discuss three reasons—historical trauma, social determinants of health, and access to care.
Colonizers of lands that now comprise the United States often used guns and steel to secure that land, killing native peoples if they resisted. Westerners also brought infectious diseases, to which native peoples had no immunity, including measles, chicken pox, scarlet fever, influenza, cholera, and malaria. Many Native Americans died from these diseases, especially adults and elders, decreasing access of the tribe to reliable sources of information about its history and traditions (Osorio, 2002; Young, 1994). Laws like the Indian Removal Act were enacted to support the White Man’s claims on the land. For example, Congress passed the Act in 1830 to relocate Indian tribes from the Eastern United States to west of the Mississippi River (Hendrix, 2001), and Congress supported the illegal overthrow of the sovereign nation of Hawaii in 1893 (Apology Bill, 1993).
Beginning in 1819, the U.S. Congress appropriated funds to pay missionaries or people of “good moral character” to “civilize” American Indians and suppress native traditional practices (Hendrix, 2001). In 1895, the Alaska territory was partitioned into regions, with each region targeted by a religious group to spread Christianity and establish trade schools for Alaska Natives (La Bell et al., 2005). In Hawai‘i, missionaries from the United Church of Christ first arrived in 1820. Members of missionary families married Native Hawaiians, and their progeny gained control of the land and economy within two to three generations (Osorio, 2002).
Churches and government worked together to establish schools designed to integrate native peoples into Western society. For AIAN, orphanages and day schools gave way to large boarding schools run by the Bureau of Indian Affairs, starting in 1878 for Native Americans and in the 1930s for Alaska Natives. Children were relocated a great distance from home, and resistant parents were threatened with incarceration. Because the purpose of these schools was to assimilate native children, their native clothes were burned, their hair was cut short, and they were routinely punished for speaking their own language (Hendrix, 2001; La Bell et al., 2005). Although boarding schools were rarer in Hawai‘i, school children also were punished for speaking their native language after an 1896 law requiring schools to teach only in English (Lucas, 2000). Today, only about 22 percent of AIAN and less than 5 percent of Native Hawaiians speak their native tongues.
Sotero (2006) describes how historical trauma links to present-day health disparities. The colonized generations directly suffer from the introduction of new diseases, weapons, and rules. Younger generations watch as older generations grieve, prematurely die, and lose land and power. Progeny of the colonized generations may assimilate feelings of inferiority and shame about their heritage, and have decreasing access to elders who can transmit native language and culture. At the same time, the dominant culture establishes laws and social structures that reflect their own worldview and are advantageous to their progeny. As colonizers take over the land and the economy, native peoples have decreasing access to their indigenous livelihoods, while being disallowed, ill-prepared, or uninterested in participating in livelihoods that enrich the colonizers.
Social determinants of health
There is a growing body of research that links lower life expectancy and disproportionate disease burden to social factors, such as having low educational attainment, growing up in poverty, and living in resource-poor or dangerous neighborhoods. These circumstances are shaped by the (mis)distribution of money, power, and resources (World Health Organization, 2012). On an individual level, this means the “place people occupy on the social hierarchy affects their level of exposure to health-damaging factors, their vulnerability to ill health, and the consequences of ill health” (Marmot, 2007).
Because of historical relocation from traditional lands and livelihoods and, in some cases, continued marginalization from mainstream society, native people may experience a cumulative disadvantage. This means that fewer opportunities for education lead to fewer opportunities for living-wage jobs, which lead to lower family incomes, and so on across generations. As noted earlier, Native Americans have a lower socioeconomic position compared to whites in the United States.
One’s neighborhood, as well as one’s position in the social hierarchy, can affect access to care. Towne and colleagues (2014) examined countylevel data to understand cancer-screening disparities among Medicare beneficiaries in areas with high concentrations of AIAN populations. Using data from 3,225 counties, the authors examined the presence of healthcare facilities in the county, the average distance in miles to the closest provider of mammography and colonoscopy screenings, and the percentage of adults ages 65 and older screened. After controlling for socioeconomic factors, rurality, and age distribution, the authors found that areas with higher levels of AIAN individuals had lower utilization of mammography and colonoscopy, but also were more distant from services. Research in Hawai‘i has yielded similar findings, as Native Hawaiians who must drive long distances or fly to another island for care are less likely than those in Honolulu to receive timely cancer screening and treatment (Braun et al., 2002).
Native peoples also may have limited access to care because they feel that facilities and practitioners are unfriendly or discriminatory. Facility waiting and exam rooms may be unwelcoming, and providers can have negative attitudes toward patients from different ethnic or racial groups (Shavers et al., 2012). Native peoples also may be reluctant to access services because of historic mistrust in government-supported providers and researchers (James et al., 2013).
We offer the following three recommendations to improve the health and well-being of native elders: expand our knowledge of Native American groups; increase access to care (and increase its cultural competence); and, support social policy that reduces health disparities. Expanding our knowledge Much of our information about AIAN and NHOPI elders is derived from national datasets, like the Census and the ACS, which may include limited numbers of Native Americans and native elders. Also, in the past, Pacific Islander groups were combined with Asians, which masked significant differences between Asians and NHOPI, as well as differences across Asian groups and differences across NHOPI populations (Braun et al., in press). Because small samples limit the inferences that can be drawn from data, future research should support the oversampling of AIAN and NHOPI populations (Empowering Pacific Islander Communities, 2014).
Another approach is to focus studies on native populations, and U.S. federal funding has supported some such data collection in AIAN populations. Examples include the Education and Research Towards Health (EARTH) study (focused on the Sioux, Pima, and Maricopa tribes, and Alaska Natives); the Native Elder Care Study (focused on the Eastern Band of Cherokee), and the Strong Heart Study (Goins et al., 2011; Lanier, Redwood, and Kelly, 2012; Rhoades et al., 2007; Slattery et al., 2007). Much also is being learned from studies conducted by the three National Resource Centers on Native American, Alaska Native, and Native Hawaiian Elders, funded by the Administration on Aging (see article in this issue by Browne and colleagues, page 70).
Along with focused data collection, researchers interested in learning more about AIAN and NHOPI elders should consider using communityengaged methods to adopt research instruments to indigenous populations (Braun et al., 2014). An example is the Native Elder Life Scale (NELS), a culturally tailored version of the Hwalek-Sengstock Elder Abuse Screening Tool, developed to assess elder mistreatment in AIAN populations (Jervis et al., 2014).
Researchers also need to gather and disseminate more information on indigenous points of view. Qualitative methods have proven useful in examining traditional roles of native elders, and their perceptions of aging, dementia, caregiving, and cancer screening (Griffin-Pierce et al., 2008; Hennessey and John, 1995; Hopkins et al., 2007; James et al., 2013; Jervis, Boland, and Fickenscher, 2010; Red Horse, 1980).
Increasing access to care
In addition to expanding services to underserved areas, enhancing the cultural competence of providers can increase access to care. Hendrix (2001) provides a comprehensive guide for geriatric care providers working with AIAN elders in a monograph prepared for Stanford’s Geriatric Education Center. She recommends learning if AIAN elders grew up on a reservation, their experience with boarding school, their exposure to traditional Indian beliefs and practices, and the status of their healthcare benefits (IHS, tribal contract/compact, Medicare, Medicaid, etc.).
It is wise to establish rapport and build trust before asking direct questions about health, and to seek permission to perform a physical examination. Avoid references to health concerns as “problems,” as this implies a power differential between the provider (usually a member of the dominant society) and the patient, and may be seen as patronizing. Patients showing symptoms related to depression may refer to depression as a “heavy heart,” “an esteem problem,” “lack of balance or harmony,” or a “part of life.” Asking questions, rather than making assumptions, is recommended. Examples of possible questions include: What do you think caused this? Why do you think it started when it did? What do you think your sickness does to your body? What kinds of things usually are done in this circumstance? Mau (2010) makes similar observations and recommendations for NHOPI elders in another monograph from the Standard Geriatric Education Center.
If native populations are engaged in developing interventions and accompanying health education materials, health interventions will be more relevant and attractive. A related approach is to train individuals from the native community as community health outreach workers and navigators, empowering them to help other community members learn about health and access needed services. For example, interventions employing lay navigators have been very successful in increasing AIAN and Native Hawaiian participation in cancer screening (Braun et al., 2012).
Supporting social policy
Reducing health disparities requires creating and enforcing policies that help reduce disparities in socioeconomic status and access to care (Adler and Newman, 2002). The Affordable Care Act of 2010 is an example of a social policy that aims to equalize citizen access to quality healthcare in the United States (U.S. Congress, 2010). Policies and programs that expand access for Native Americans to higher education and careers in the health professions also are recommended.
This article has outlined some disparities experienced by Native Americans and discussed reasons behind them. Reducing disparities will require more knowledge about native histories, cultures, and values—knowledge that can help us increase the cultural competence of providers and services, and tailor relevant programs. Such knowledge also can support social policy that expands services and facilitates economic parity for native populations.
Kathryn L. Braun, Dr.PH., is professor of public health, co-principal investigator of ‘Imi Hale Native Hawaiian Cancer Network, and co-principal investigator of H¯a K¯upuna National Resource Center for Native Hawaiian Elders at the University of Hawai‘i, Honolulu, Hawaii. She can be contacted at email@example.com. Cynthia LaCounte directs the Administration on Aging’s Office for American Indian, Alaskan Native, and Native Hawaiian Programs, in the Administration for Community Living, U.S. Department of Health and Human Services, Washington, D.C. She can be contacted at firstname.lastname@example.org.
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