Prevalence of Selected Risk Factors for Chronic Disease and Injury Among American Indians and Alaska Natives -- United States, 1995-1998

Since the 1950s, morbidity and mortality attributable to infectious diseases among American Indians and Alaska Natives (AIs/ANs) have declined and chronic diseases, especially diabetes, and injury have remained important determinants of poor health (1). Knowledge of the prevalence of behavioral risk factors for chronic disease and injury can be used to form policies and programs to improve the health of AIs/ANs. Based on data obtained from the Behavioral Risk Factor Surveillance System (BRFSS) from 1993 through 1996, CDC published regional estimates of the prevalence of 10 behavioral risk factors for AIs/ANs (2). This report updates data from the earlier report and focuses on three of the 10 risk factors for chronic disease and injury among AIs/ANs.

BRFSS is a state-based, random-digit-dialed telephone survey of the civilian, noninstitutionalized U.S. population aged greater than or equal to 18 years. For this analysis, data from 5964 AI/AN respondents to BRFSS from 1995 through 1998 in 36 states, corresponding to the area covered by the Indian Health Service (IHS) administrative areas, were aggregated into five geographic regions.* Identification as AI/AN was based on response to the question, "What is your race?" Data were weighted to both the respondent's probability of selection and the 1990 sex-specific AI/AN census estimates for each state. To account for the complex survey design, SUDAAN was used to calculate confidence intervals (3). Risk measures used for this analysis included current cigarette smoking, awareness of having diabetes, and safety belt non-use. Current cigarette smoking was defined as currently smoking cigarettes and having smoked at least 100 cigarettes. Awareness of having diabetes was defined as having answered "yes" to the question, "Have you ever been told by a doctor that you have diabetes?" Women who were told they had diabetes only during pregnancy were not classified as being aware of having diabetes. At-risk safety belt use was defined as not reporting "always" in response to the question "How often do you use seatbelts when you drive or ride in a car?" The questions on cigarette smoking and diabetes were asked during all 4 years of data collection; the safety belt use question was asked only in 1995 and 1997.

The prevalence of current cigarette smoking among both AI/AN men and women was highest in the northern plains (47.0% for men and 42.1% for women) and lowest in the southwest (25.4% for men and 17.8% for women) (Table 1). The percentage of women who reported current cigarette smoking in Alaska was high (41.8%) compared with the percentage of women smokers in other regions. For all regions combined, men reported current cigarette smoking more frequently than did women (34.7% versus 27.9%).

The prevalence of awareness of having diabetes was slightly higher among AI/AN women (8.4%) than men (6.4%). AI/AN men and women in Alaska had the lowest reported awareness of having diabetes (2.8% and 3.3%, respectively).

Not always wearing a safety belt when riding or driving in a motor vehicle was reported most frequently by men (60.5%) and women (47.1%) in the northern plains and least frequently by men (21.6%) and women (17.2%) in the Pacific coast region. For all regions combined, men reported not always wearing a safety belt when driving or riding in a motor vehicle more frequently than did women (39.7% versus 30.5%).

Reported by the following BRFSS coordinators: J Cook, MBA, Alabama; P Owen, Alaska; B Bender, MBA, Arizona; T Clark, Arkansas; B Davis, PhD, California; M Leff, MSPH, Colorado; M Adams, MPH, Connecticut; F Breukelman, Delaware; I Bullo, District of Columbia; S Hoecherl, Florida; L Martin, MS, Georgia; A Onaka, PhD, Hawaii; J Aydelotte, MA, Idaho; B Steiner, MS, Illinois; K Horvath, Indiana; K MacIntyre, Iowa; J Tasheff, Kansas; T Sparks, Kentucky; B Bates, MSPH, Louisiana; D Maines, Maine; A Weinstein, MA, Maryland; D Brooks, MPH, Massachusetts; H McGee, MPH, Michigan; N Salem, PhD, Minnesota; D Johnson, MS, Mississippi; T Murayi, PhD, Missouri; P Feigley, PhD, Montana; L Andelt, PhD, Nebraska; E DeJan, MPH, Nevada; L Powers, MA, New Hampshire; G Boeselager, MS, New Jersey; W Honey, MPH, New Mexico; C Baker, New York; P Buescher, PhD, North Carolina; L Shireley, MPH, North Dakota; P Pullen, Ohio; N Hann, MPH, Oklahoma; J Grant-Worley, MS, Oregon; L Mann, Pennsylvania; J Hesser, PhD, Rhode Island; M Wu, MD, South Carolina; M Gildemaster, South Dakota; D Ridings, Tennessee; K Condon, Texas; K Marti, Utah; C Roe, MS, Vermont; K Carswell, MPH, Virginia; K Wynkoop-Simmons, PhD, Washington; F King, West Virginia; P Imm, MS, Wisconsin; M Futa, MA, Wyoming. Behavioral Surveillance Br, Div of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note:

The findings in this report document regional and sex differences in the prevalence of selected risk factors for chronic disease and injury among AIs/ANs. Significant regional variations were found in the prevalence of cigarette smoking and at-risk safety belt use for both men and women, and in awareness of having diabetes, particularly among women. These rates and the differences observed are similar to those found among AIs/ANs during 1993-1996 (2). Although the earlier study examined 10 risk behaviors or health conditions, this report only examined three because they demonstrate the most substantial geographic variation and because AIs/ANs are at higher risk for these behaviors or conditions than the general U.S. population (2).

Comparison of these findings with the 1994 and 1995 BRFSS for the general U.S. population demonstrate disparities between AIs/ANs and the general population (4). Except for the southwest region, compared with the general population, the prevalence of smoking among AIs/ANs was greater. In addition, in 1995, the prevalence of awareness of having diabetes was greater for AIs/ANs than for the general population, with the exception of AIs/ANs in Alaska. These comparisons can be used to target efforts to eliminate these disparities.

The findings in this report are subject to at least three limitations. First, BRFSS reaches only persons with telephones. Approximately 23% of AI/AN households do not have a telephone--a higher percentage than for any other racial/ethnic group in the United States (5). As a result, these findings probably underestimate the health risks for AIs/ANs because those without telephones are more likely to be of lower socioeconomic status and at higher risk for disease than those with telephones (6,7). Second, BRFSS does not collect information on tribal affiliation or reservation residency. Aggregating AIs/ANs into geographic regions alone does not account for the diversity of health behaviors among different tribes (1,8). Finally, because the estimates were based on self-reported data, they may be subject to recall and social desirability biases. Despite these limitations, BRFSS is the only source of continuously collected population-based information on AI/AN health behaviors. These findings are especially important because little population-based research has been conducted on the health behaviors of this population group (9,10).

Monitoring the health behaviors of AIs/ANs enables public health officials to assess levels of risk and regional and sex differences for these risks to better direct prevention efforts. In this way, disparities in risk behaviors that previously have been shown to exist between AIs/ANs and the general U.S. population can be identified (2). This is particularly important with the increase in chronic disease among adults in the United States.

References

1. Young TK. Recent health trends in the Native American population. In: Sandefur GD, Rindfuss RR, Cohen B, eds. Changing numbers, changing needs: American Indian demography and public health. Washington, DC: National Academy Press, 1996:53-75.
2. Denny CH, Holtzman D. Health behaviors of American Indians and Alaska Natives: findings from the Behavioral Risk Factor Surveillance System, 1993-1996. Atlanta, Georgia: US Department of Health and Human Services, CDC, 1999.
3. Shah BV, Barnwell BG, Bieler GS. SUDAAN: software for the statistical analysis of correlated data; user's manual, release 7.0. Research Triangle Park, North Carolina: Research Triangle Institute, 1996.
4. CDC. State and sex-specific prevalence of selected characteristics, Behavioral Risk Factor Surveillance System, 1994 and 1995. MMWR 1997;46(no. SS-3).
5. US Department of Commerce, Economics and Statistics Administration. Statistical brief: phoneless in America. Washington, DC: US Department of Commerce, 1994; publication SB/94-16.
6. Pearson D, Cheadle A, Wagner E, Tonsberg R, Psaty BM. Differences in sociodemographic, health status, and lifestyle characteristics among American Indians by telephone coverage. Prev Med 1994;23:461-4.
7. Peterson DE, Remington PL, Kuykendall MA, Kanarek MS, Diedrich JM, Anderson HA. Behavioral risk factors of Chippewa Indians living on Wisconsin reservations. Public Health Rep 1994;109:820-3.
8. Ericksen EP. Problems in sampling the Native American and Alaska Native populations. In: Sandefur GD, Rindfuss RR, Cohen B, eds. Population changing numbers, changing needs: American Indian demography and public health. Washington, DC: National Academy Press, 1996:113-29.
9. Sugarman JR, Warren CW, Oge L, Helgerson SD. Using the Behavioral Risk Factor Surveillance System to monitor year 2000 objectives among American Indians. Public Health Rep 1992;107:449-56.
10. Lefkowitz D, Underwood C. Personal health practices: findings from the survey of American Indians and Alaska Natives. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, 1991; AHCPR publication no. (PHS)91-0034.

* Alaska=Alaska; East=Alabama, Connecticut, Florida, Kansas, Louisiana, Maine, Massachusetts, Mississippi, New York, North Carolina, Oklahoma, Pennsylvania, Rhode Island, South Carolina, Tennessee, and Texas; Northern Plains=Indiana, Iowa, Michigan, Minnesota, Montana, Nebraska, North Dakota, South Dakota, Wisconsin, and Wyoming; Pacific Coast=California, Idaho, Oregon, Washington; Southwest=Arizona, Colorado, Nevada, New Mexico, and Utah.

TABLE 1. Prevalence of selected risk factors for American Indians and Alaska Natives, by sex and region* -- Behavioral Risk Factor Surveillance System, United States, 1995-1998^†

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