标题：A Nationwide Population-Based Study Identifying Health Disparities Between American Indians/Alaska Natives and the General Populations Living in Select Urban Counties
摘要：Objectives. Despite their increasing numbers, little is known about the health of American Indians/Alaska Natives living in urban areas. We examined the health status of American Indian/Alaska Native populations served by 34 federally funded urban Indian health organizations. Methods. We analyzed US census data and vital statistics data for the period 1990 to 2000. Results. Disparities were revealed in socioeconomic, maternal and child health, and mortality indicators between American Indians/Alaska Natives and the general populations in urban Indian health organization service areas and nationwide. American Indians/Alaska Natives were approximately twice as likely as these general populations to be poor, to be unemployed, and to not have a college degree. Similar differences were observed in births among mothers who received late or no prenatal care or consumed alcohol and in mortality attributed to sudden infant death syndrome, chronic liver disease, and alcohol consumption. Conclusions. We found health disparities between American Indians/Alaska Natives and the general populations living in selected urban areas and nationwide. Such disparities can be addressed through improvements in health care access, high-quality data collection, and policy initiatives designed to provide sufficient resources and a more unified vision of the health of urban American Indians/Alaska Natives. Over the past 3 decades, American Indians and Alaska Natives have increasingly relocated from rural and reservation communities to the urban centers of the United States. Census data show that 61% of American Indians/Alaska Natives resided in these areas in 2000, up from 38% in 1970. 1 Such demographic shifts are related to the federal relocation and termination policies of the 1950s, as well as the educational, employment, and housing opportunities that exist in urban settings. 2 Although urban living offers more of certain opportunities, the departure of American Indians/Alaska Natives from reservations has typically resulted in a loss of access to health care, historically provided by the Indian Health Service (IHS). 3 To provide health care for the increasingly urban American Indian/Alaska Native (AIAN) population, the IHS awards contracts and grants to 34 nonprofit agencies located in major metropolitan areas across the United States. These agencies, referred to as urban Indian health organizations (UIHOs), exist largely in cities designated in the past as AIAN relocation sites by the federal government. Despite the increasing numbers of urban American Indians/Alaska Natives, little is known about their health. It is difficult to identify and target this group because of the geographic dispersal and small numbers of urban American Indians/Alaska Natives relative to the general population of the United States. Also, unlike reservation populations, the urban AIAN population comprises multiple tribal groups with diverse ethnic, cultural, and social characteristics. Political diversity exists between tribes that may or may not be recognized by the federal government or state governments. Moreover, degrees of urban acculturation vary, and movement around urban centers may be high as a result of feelings of social and cultural isolation associated with nonreservation living. Finally, in some regions of the country, American Indians/Alaska Natives are misclassified on vital statistics records. 4 , 5 Such errors result in consistent underestimation of AIAN rates of infant mortality, injuries, cancer, and overall mortality; some rates are as much as 47% higher after correction for miscoding. 6 – 9 Studies also indicate a greater likelihood of racial misclassification when American Indians/Alaska Natives die in urban settings. 7 , 10 A few studies have addressed the health status of urban American Indians/Alaska Natives but only on a local or regional basis. One population-based investigation compared urban American Indians/Alaska Natives with other urban racial groups residing in a metropolitan area of Washington State. Disparities were found between urban American Indians/Alaska Natives and urban Whites in rates of low birthweight, risk factors for poor birth outcomes, communicable diseases, mortality among nonelderly individuals, injuries, and alcohol-related deaths. 11 The results of other studies have confirmed the disparities found between these 2 urban groups. 12 , 13 There is also little information available on the urban AIAN population targeted by the 34 federally funded UIHOs. Such information is necessary for these organizations to allocate their resources effectively, customize health care services, implement program evaluations, and launch policy initiatives. As a group, UIHOs have minimal technological infrastructure with no shared standardized data system that can be used to provide a collective description of their target populations. Our primary goal was to assess the health status of the urban AIAN population served by UIHOs. As mentioned, this information is critical if these organizations are to demonstrate the effectiveness and impact of their services. Because of the lack of data on the UIHO patient population, data on American Indians/Alaska Natives living in UIHO service areas were used as a proxy for data on American Indians/Alaska Natives served by the UIHOs. In addition, their health status was used to approximate that of the larger urban AIAN population. By assessing standard socioeconomic, maternal and child health, and mortality indicators, our study also addressed the Healthy People 2010 initiative to eliminate racial health disparities. 14 Specifically addressing the health of the urban AIAN population is an important step in including this group in efforts to improve the health status of the entire AIAN population; however, this inclusion of urban American Indians/Alaska Natives in such efforts should not minimize the importance of nonurban AIAN populations facing similar health disparities. To our knowledge, this is the first nationwide population-based study examining the health status of urban American Indians/Alaska Natives.
