American Indian Health

SPH Partners with Communities on Research, Education, and Outreach

"Let us put our minds together and see what life we can make for our children."

Ask members of Bright Start to describe their program and chances are you will hear this quote from the famous Lakota leader Sitting Bull. Bright Start, or Ohiyu lyojanjan in Lakota, is a partnership of the School of Public Health and the Lakota people of the Sioux Nation of the Pine Ridge reservation in South Dakota. The two groups are working together on a school-based program to reduce obesity and diabetes in young children.

Bright Start builds on Pathways, the first large-scale, school-based obesity prevention program conducted in the United States. Pathways ran from 1993 to 2000 and included third to fifth graders from 41 schools and seven American Indian nations. True to its name, Pathways forged the strong ties between the Pine Ridge community and SPH that led to Bright Start, which focuses on 500 kindergarten and first-grade children in 14 Pine Ridge schools.

"Schools are the best place for change," says SPH professor Mary Story, lead investigator of Bright Start. "Breakfast and lunch are served at school, there's an opportunity for physical education, and you can connect to parents through teachers and administrators."

While diabetes has reached epidemic proportions in the general population, its rates are even higher among American Indians. Experts say American Indians are twice as likely to have diabetes as their white counterparts. They are also almost twice as likely to die from diabetes as non-Hispanic whites. Research has shown that 43 percent of American Indian five-year-olds in South Dakota are already overweight. That's why Bright Start aims to instill healthy habits at a young age.

Collaboration and sustainability are key components of the program.

"We are guests on the reservation," says Story. "We have the research expertise, but our staff who live on the reservation know what approaches work best. We rely on them for that insight."

Bright Start has worked to improve school meals by increasing fruit and vegetable offerings. It has increased physical activity to 60 minutes a day through short "actionbreaks" in the classroom, active recess on the playground, and a walking program. And it has involved parents through "family night" events centered on fun activities that promote healthy eating and physical activity.

The child-centered values of the Lakota tribe are the foundation for strong parental participation of the program. More than 72 percent of Bright Start families attended arecent family night event—and many of them had to drive close to an hour to get there.

"The parents and grandparents are truly concerned and always ask what they can do to help their children," says Bright Start project director Mary Smyth. "Their support is really impressive."

Smyth, too, has logged some serious mileage in the name of Bright Start. Since April 2006, she has made the drive from Minneapolis to South Dakota to spend close to 100 days in the Pine Ridge area, working with staff members, schools, and families. "We are all working on this together," she explains.

Bonnie Holy Rock echoes those sentiments. An Oglala Lakota member, she is Bright Start's field site coordinator and one of eight staff members from Pine Ridge who works on the project. Her connection to the SPH spans a dozen years and dates back to the Pathways project. Holy Rock credits the "positive collaborative efforts" of Pine Ridge and the University and points to the importance of "employing field staff from the area who know the schools, families,and communities."

Methodological Issues

Pamela Jo Johnson is a research associate in the school's State Health Access Data Assistance Center (SHADAC). She studies the methodological issues behind health disparities research—what data is used, whether it is accurate, and how it influences our assumptions of the health of certain populations. Johnson has compared national and state data on infant mortality and prenatal care rates among American Indians. She found that Minnesota faces significantly greater disparities of infant mortality between whites and American Indians than the national average.

And while national data suggests that disparities in prenatal care are narrowing, Johnson's work with state data shows otherwise. Here, Minnesota has some of the worst disparities in the entire nation.

"Clearly, Minnesota has the infrastructure to deliver effective health care, but it's not equally available to everyone," she says.

While local data is generally more relevant than national averages, Johnson's work highlights a challenge researchers face when studying minority populations locally: sometimes there isn't enough data to draw on for accurate findings. She found that even when combining three years of data, only 13 states and two counties (and not one U.S. city) had large enough American Indian populations to render accurate rates of infant mortality and prenatal care.

Researchers need to be aware of these shortcomings when citing national data, she says. Johnson hopes her work can highlight the disconnect between national and local rates and draw attention to health needs at the state and local level.

"The big picture isn't always our picture [in Minnesota]," she says. "The lesson is that we need to look in our own backyard to know what's really going on."

Environmental Justice

Environmental justice has been a growing area of interest for SPH professor Pat McGovern. Along with colleagues inthe Minnesota Department of Health (MDH), she has worked with members of the Leech Lake Band of Ojibwe from Cass Lake, Minn. Cass Lake has been on the EPA's list of Superfund sites since 1984, and recent tests still show several contamination "hot spots" of dioxin in residential areas. Exposure to harmful agents is compounded by the tribe's culture of subsistence fishing, hunting, and gardening.

McGovern and several students have worked with MDH's Division of Environmental Health, Site Assessment, and Consultation Unit and the Leech Lake Band on a variety of public health projects. Doctoral student Maggie Stedman-Smith provided educational materials about environmental exposures for the band at a Pow wow.

Wendy Kvale, a dual degree student in the SPH and School of Nursing, interned with the Leech Lake Band's health division and their public health nurses to provide continuing education and conduct a needs assessment to identify public health priorities. Kvale,who also works as an MDH public health nursing consultant for the Bemidji area, will continue her partnership with the band to assist them in working on identified priorities.

Marie Quasius, a dual degree student in the SPH and Law School, interned with MDH to research the interface between Superfund regulations and tribal law as it relates to clean-up of the Cass Lake Superfund site.

Over the past year, McGovern, Stedman-Smith, and SPH faculty members Bruce Alexander and Tim Church have worked with the Mdewakanton Dakota Sioux Indians of Prairie Island, Minn. Prairie Island is the site of a nuclear power plant, nuclear waste storage facility, and a network of high voltage power lines. Tribal council members approached University faculty to request a study investigating the health effects of living near these facilities.

The SPH team analyzed previous studies of communities who live near nuclear plants and power lines. The researchers also conducted focus groups with tribal elders, adults, and youth to hear about their health and safety concerns. Said one woman in a focus group: "[What] worries me . . .is that I want my child to grow up here knowing the culture,the heritage, being around the people . . .[but] am I putting my children's health in jeopardy so they can know their ways, their traditions, their culture?"

While some tribal members expressed concerns over cancer and other diseases associated with nuclear power, more spoke about worries over potential terrorist attack of the plant and a lack of disaster preparedness.

"The nuclearpower plant is number one on the [nation's] terrorist attack list and [the Department of] Homeland Security refuses to do anything about it," said a tribal elder in a focus group."We could lose this place in the blink of an eye."

As a possible next step, the SPH team has offered the services of the school's disaster preparedness training experts. McGovern says discovering this critical area of concern highlights the importance of asking the community to determine how they want the research partnership to evolve.

"This is the benefit of community participatory research," says McGovern. "In this case, we learned that tribal members wanted the focus to be more on disaster preparedness."

Health Care Access SPH associate professors Kathleen Thiede Call and Donna McAlpine are working to understand the factors that contribute to health disparities in Minnesota. Call directed a study funded by the Minnesota Department of Human Services to illustrate the barriers to care faced by adults and children in public health care programs. From that study, Call and colleagues created a special report of the barriers to care faced by American Indians enrolled in Minnesota Health Care Programs (MHCP) such as Medicaid and MinnesotaCare. The report was funded by the Medica Foundation, the grant-making sister organization to Medica Health Plans, a Minnesota-based nonprofit HMO.

The researchers surveyed 560 American Indian enrollees on the problems they experience when trying to get health care. They looked at discrimination, financial barriers, clinic hours, transportation, family and work responsibilities, trust in providers, and language and cultural issues. The researchers found that American Indians were more likely than other MHCP enrollees to cite work and family responsibilities as a problem when trying to access heath care.

Trustworthiness of doctors in general appeared to be a greater barrier for American Indian children than other MHCP children. And American Indian parents were three times more likely to lack trust in their child's doctor than MHCP parents overall.

In what she refers to as an effort to "move beyond the data to make change" Call, McAlpine, and their community partners have convened a series of forums. The forums include members of the Latino, American Indian, Hmong, Somali, and African American coummunities, as well as members of more than a dozen health institutions. Funded by the Media Foundation and UCare of Minnesota, the forums offer a place for community members and health care professionals to work together on recommendations for reducing barriers to care.

The "Working Together to Achieve Results" forums take place at the Powderhorn Phillips Cultural Wellness Center in Minneapolis. American Indian community members who have participated in the forums have proposed that health organizations work with the Bureau of Indian Affairs to improve access to services among those living away from a reservation and in the city who currently cannot afford care. They have called for improvements in communication about insurance coverage—which providers accept insurance and what is covered.

Community members have said that the burden of time and energy needed to get this information is especially difficult for elders, who are more likely to give up and go without services. They have also asked providers for support to increase access to elders who can teach on the traditional ways of health care, including good nutrition and cooking with herbs.

Tobacco Control

It's well known that American Indians in some parts of the country use tobacco more than other ethnic and racial groups. This is especially true in Minnesota, where about 60 percent of American Indians smoke, a rate far higher than American Indians nationally. But little is known about why the rates are so high or what can be done to address them. Most tobacco prevention research of the past has failed to build on the strengths of American Indian culture or to truly partner with community members. Previous interventions have also failed to acknowledge the sacred use of tobacco in Indian culture, and instead have deemed all tobacco use as "bad."

The American Indian Community Tobacco Project (AICTP) was founded in 2001 to create a reality-based research model that involves the Twin Cities American Indian community. The AICTP is co-led by SPH professor Jean Forster and John Poupart, president of the St. Paul-based American Indian Policy Center.

AICTPis funded by ClearWay Minnesota, a nonprofit group that funds tobacco research around the state. The AICTP steering council is made up of American Indian community members who have final authority on all aspects of the research.The steering council is charged with developing intervention strategies that take advantage of the traditional strengths of American Indian culture. Their strategies address the spiritual use of tobacco, the importance of children in the community, the widespread acknowledgement of the tobacco problem, and a strong belief in the community's role toserve its people.

"This is reality-based research that's culturally appropriate. It involves [American Indians] from the first stages to the outcomes," says Poupart, a member of the Anishinabe tribe. "We have ownership in the process and product."

Poupart has seen his fair share of the kind of research that led to mistrust of outsiders among the American Indian community.

"The old saying is that we've been researched to death," he says. "I'd like to add to that [saying] that we want to be researched back to life."

"This [research] model is helpful in eliminating that mistrust," says Isaiah Brokenleg, one of three current SPH students to work on AICTP. Securing funding so that SPH students can work on AICTP has been a key development for Forster and SPH program coordinator Kris Rhodes, an Anishinabe member who earned an M.P.H. from the school in 2000.

"It's been beneficial to see my work benefiting the community," says Brokenleg. "But [working on AICTP] has also been my saving grace in some ways. It's kept me connected to the Indian community while in school."