MICHIGAN TRIBAL HEALTH DATA REPORT

MICHIGAN TRIBAL HEALTH DATA REPORT

OBJECTIVES Participants will recognize unique aspects of tribal government and health systems Participants will identify health disparities specific to breast and colon cancer for Michigan s Native American population Participants will identify key components of successful tribal public health programs Participants will Identify opportunities for collaboration

OUTLINE - SETTING THE STAGE: Overview of Indian Health Services The Tribal Clinic and Public Health Perspective Funding and Staffing Challenges Inter-Tribal Council of Michigan Structure and Role Data Collection Challenges, Data Sources Health Disparities what the data tells us Cancer and associated risk factors Current Programs and use of evidence based and promising practices and collaboration

TONY ABRAMSON Clinic Manager Sault Tribal Health Center Bachelor of Science in Nursing Program LSSU Master of Science in Nursing Program MSU Blessed with a loving spouse and family of 3 children and 12 grandchildren.

DR. DONALD WARNE Donald K. Warne, MD, MPH Director, Master of Public Health Program (Title change to Chair upcoming) Associate Professor and Mary J. Berg Distinguished Professorship in Women's Health Master of Public Health, 2002 Health Policy and Management Harvard School of Public Health Doctor of Medicine, 1995 Stanford University School of Medicine Bachelor of Science, Kinesiology, 1989 Arizona State University As an enrolled member of the Oglala Lakota Tribe from Pine Ridge, South Dakota, he grew up with the wise counsel and inspiration of numerous relatives who are Lakota medicine men and spiritual leaders, and a mother who is a professor of nursing

LEGAL BASIS OF FEDERAL PROGRAMS FOR AI/AN 1849 responsibility for Native American Health transferred from War Department to Bureau of Indian Affairs (BIA) Oversaw appropriations for the establishment of health programs for Native Americans. 1955 Indian Health Service was established to take over this responsibility

LEGAL BASIS OF FEDERAL PROGRAMS FOR AI/AN Principal legislation authorizing FUNDING is the Snyder Act of 1921 Indian Self-Determination and Education Assistance Act of 1975 created a process for transferring health programs to tribal governments.

LEGAL BASIS OF FEDERAL PROGRAMS FOR AI/AN 1976 Indian Health Care Improvement Act sought to : Assure access to high quality health care for native Americans Assist tribes in developing capacity to staff and manage their own health centers Advocate for Native Americans with respect to health care IHCIA made permanent in 2010 as part of the Affordable Care Act

CANCER DEATH RATES (PER 100,000 POPULATION)

THE TRIBAL HEALTH SYSTEM Tribal Government Elected Leaders - Chairperson & Council Members Tribal Government with roles similar to Federal Executive, Judicial & Legislative functions Executive responsible for all Tribal programs and services, e.g, health, housing, food distribution, assistance services, conservation, etc Enterprises Tribal businesses and Casino s Scarce resources to support govt & services.

THE TRIBAL HEALTH SYSTEM Health Program Tribes manage health programs to best fit the needs of their Tribal communities (PFSA s). Portion of operation funds provided thru IHS. Current IHS funding in the BPO is approximately 60% level of need. Facilities are generally built and maintained by the Tribes when possible.

THE TRIBAL HEALTH SYSTEM Challenges Large service area to cover access issues. Gaps in services exist due to funding and service limitations. Uncertain funding sequestration, politics Tribal governmental needs and limitations in resources Priority determinations due to funding limitations PRC, level of health services Inconsistent funding for prevention Limitations of grant funding for new health initiatives.

REVIEW The United States has a legal obligation to provide health care to American Indians? True False

TREATY OBLIGATION Governmental duty to provide health services to Indian Tribes. Negotiated treaties exchanging Native American land and resources for federal promises of health care and other services. Relationship established in 1787 based on Article I, section 8 of the US Constitution: a government to government relationship between the federal government and tribal government.

INTER-TRIBAL COUNCIL OF MICHIGAN

INTER-TRIBAL COUNCIL OF MICHIGAN To act as a forum for member tribes To advocate for member tribes in the development of programs and policies which will improve the economy, education, and quality of life for Michigan s Native Americans; and To provide technical assistance to member tribes, assisting in the development of tribal regulations, ordinances, and policies applicable to health and human services.

CHALLENGES TO DATA COLLECTION Small population size Cultural sensitivity - low participation rates in standardized surveys, history of mistrust Racial misclassification Data ownership and protection Funding

SOLUTIONS AND THE DATA SOURCES AI/ATS Tribal BRFSS Tribal RFS Cancer Registry Linkages and analysis Partners: CDC MPHI State Cancer Registry Michigan Cancer Consortium University of Michigan Tribal Leaders

SNAPSHOT OF THE REPORT 41.9% of respondents were obese, compared to 28.7 % of the MI general population; 31% were overweight. (ITCM BRFS 2005) 29.5 % of respondents reported no leisure time activity, compared to 22.8% of the general population. (ITCM BRFS 2005) Data from the 2012 ITCM AI/ATS show smoking rates over 43%, and as high as 72% in one tribal community, compared to the National rate of 18.1% and State rate of 23.3%. The 2010 ITCM RRFS showed significant rates of MI American Indian adult respondents with more than one chronic condition: 28% of respondents had high blood pressure and high cholesterol; 36% had diabetes and heart disease (2010 ITCM RRFS); 12% of obese adults were diabetic, and had heart disease (2010 ITCM RRFS)

REVIEW Does your county or service area show data for American Indians or Alaska Natives? Yes No Don t know

2012 STATE CANCER REGISTRY ANALYSIS Mean age of diagnosis of all cancers was younger for the AI population at 56.98 years compared to all races ages of 62.23 years. Younger age diagnosis is also documented in specific cancers for the AI population compared to the general population.

BREAST CANCER INCIDENCE

BREAST CANCER INCIDENCE

DIGITAL STORY

COLON CANCER INCIDENCE Similar to breast cancer for females, the mean age of diagnosis for those with early or late stage colon cancer was 59.6 years for AI males compared to 68.49 years for white males.

COLON CANCER INCIDENCE BY AGE GROUP

COLON CANCER INCIDENCE Among AI males with early or late stage colon cancer, 77% were diagnosed in the screening appropriate age group compared to 92.35 % of white males

CANCER SCREENING RATES 2008 SCRBS 59% of Michigan women ages 40+ reported mammo and CBE within past year 75% of Michigan women ages 40+ reported mammo and CBE within past two years 99.2% of general population women age 40+ reported having a pap test within the past year; 79% within past three years

COLON CANCER SCREENING 2008 SCRBS 60% of Michigan s general population age 50+ report having an age appropriate colon cancer screening test Both of these are well below the State s target rate of 75%

COLON CANCER GPRA RATES

REVIEW A greater portion of AI s are diagnosed outside (younger) of the recommended screening guidelines than those of the general population for several cancers. Should we consider race as a risk factor? Should we consider race specific screening guidelines?

DIGITAL STORY

SELECTED RISK FACTORS - Obesity Physical activity Nutrition Commercial tobacco use Other, i.e. Environmental risk factors Reach risk factor survey and the AI/ATS data sources

COMMERCIAL TOBACCO USE Tobacco plays a significant role in the American Indian Culture. Sacred tobacco is a gift from the creator and is used in traditional ceremonies and prayer. Traditional tobacco is free of added chemicals and poisons, as opposed to commercial tobacco products.

LUNG CANCER Our 2012 analysis looked at all cancer cases from 1985 to 2009 Of all female cancers, Lung made up 10.8% compared to all AI female cancers, of which Lung made up 14.32% of all cancers Of all male cancers, Lung made up 16.08 % of the cancers; of all AI cancers among males, Lung made up 19.68%

SMOKING STATUS CURRENT SMOKERS 2012 MI BRFS 23% Steps BRFS 38% REACH RFS 49% AI ATS Tribe 1 46% AI ATS Tribe 2 72% AI ATS Tribe 3 48% AI ATS Tribe 4 34% AI ATS Tribe 5 36% 0% 20% 40% 60% 80% 100%

TOBACCO KNOWLEDGE ATTITUDES AND BELIEFS Roughly 95% believe that secondhand smoke is harmful Between 60% and 90% believe there are health benefits to quitting Between 54% and 76% believe that smoking should not be allowed in indoor work areas. AI/ATS data five tribes from 2000 to 2015

CESSATION STORY

RISK FACTORS OBESITY 0% 20% 40% 60% 80% 100% 2012 MI BRFS 31% Steps BRFS 41% Reach RFS 46% AIATS Tribe 1 46% AIATS Tribe 2 44% AIATS Tribe 3 33% AIATS Tribe 4 54% AIATS Tribe 5 50%

RISK FACTORS PHYSICAL ACTIVITY Only 32% are meeting the recommendations for moderate physical activity ( 150 minutes every week) AI/ATS Only 30% are meeting the recommendations for vigorous activity ( 60 minutes every week) AI/ATS

RISK FACTORS - NUTRITION 39% of participants reported consuming more than one but less than three servings of fruits and vegetables per week. (RFS) Only 24% had more than five servings of fruits and vegetables per week. (RFS)

RISK FACTORS- NUTRITION

WHAT ARE WE DOING? Competitive Funding via Federal, State and Private Foundations provide for collaboration to implement culturally relevant HPDP Programs. Funding limits rarely allow us to work with all 12 tribes. Examples of successful collaborations:

COLON CANCER Did touring the colon increase your knowledge? Not At All Somewhat Very Much Do you intend to make lifestyle changes? 100 80 60 40 20 0 Do you intend to get screened? Not At All Somewhat Very Much Not At All Somewhat Very Much

REACH US SERVED THREE OF THE 12 TRIBES FROM 2008-2012 In one tribal clinic, the proportion of clinic patients screened for tobacco use and assessment increased from 35% to 69% In one tribal community the proportion of tobacco users with a documented smoking cessation intervention increased from 15% to 34% Participation in physical activity grew in one tribal community, with a tenfold increase in the number of visits to the community fitness center each quarter; While less than one-quarter of diabetic patients are currently receiving comprehensive care, this figure tripled from 7% to 21%

TRIBAL U.P. BREAST HEALTH LEARNING COLLABORATIVE Serves 4 tribes in the U.P. Implementing QI projects aimed to: 1) increase breast health screening rates among the women in the targeted population ages 40 to 49 by 20%; 2) decrease the time span between breast cancer screening, diagnosis, and treatment for women within the target population. Collaboration with State and Local BCCCP, Hospitals and Cancer Treatment Facilities

MCC YOUTH TOBACCO SCREENING PROJECT Works with Two Tribal Clinics Uses Results of AI/ATS and Registry Linkages Provides Education with CME s Implements Youth Tobacco Screening Policies and Protocols (Clinic and Dental) Referral Resources and Training; Quit Line Includes education on e-cigarettes

SUMMARY THE OVERALL PICTURE Tribes and sovereign nations have unique government and health systems Data collection is challenging for the AI/ AN population Tribes desperately lack adequate funding and resources to address health disparities Tribal Organizations assist and support tribes to implement effective HPDP programs. Through collaboration, we can impact health disparities for the American Indian Population Megwetch ( Thank you)