ASk A Researcher

November 2013

Fargo-Moorhead American Indian Community-Sponsored Health Needs Assessment

photoDonna Grandbois is an assistant professor of nursing at NDSU. She is an enrolled member of the Turtle Mountain Chippewa Nation, Belcourt, ND and is one of the three core faculty in the Master of Public Health American Indian Specialization. She addresses questions relating to the Fargo-Moorhead American Indian Community-Sponsored Health Needs Assessment.

Q:  What are the unique health needs of American Indians in urban settings?
It should come as no surprise that the indigenous people of the United States are consistently confronted by the most challenging socioeconomic conditions of any population group, whether they live in an urban or a reservation setting. The American Dream that has been so available to immigrants coming to this country has been placed beyond the reach of most Native Americans by a variety of social and structural barriers. Significant to this discussion, of the more than 5.2 million individuals who identified themselves as either partly or solely American Indian or Alaska Native (AIAN) in the 2010 U.S. Census, 78% no longer live on reservations or Native lands (Kaufman Report, 2011); of that 72.3% reside in Metropolitan Statistical Areas (MSAs) across the United States. While there is no standard definition of an urban American Indian or Alaska Native, individuals may self-identify as an urban American Indian or Alaska Native based on ancestry, tribal enrollment, shared culture, appearance, or participation in events organized by a local American Indian or Alaska Native community.

Background Information
The Indian Health Service (IHS) was designed to address the health care needs of American Indians. It evolved out of various government programs, based on treaty agreements and federal laws that exchanged land and mineral rights for services. The first treaty that included medical services was signed between the United States and the Winnebago Indians in 1832. In 1849 Congress transferred the Bureau of Indian Affairs (BIA) from the War Department to the Department of the Interior, including all health care responsibilities for American Indians. The Snyder Act of 1921 included congressional authorization for the BIA to provide Indian health care "for the benefit, care, and assistance of the Indians throughout the United States." In 1955 Congress transferred total responsibility for Indian health from the Department of the Interior to the Public Health Service (PHS). This legislation stated that "all facilities transferred shall be available to meet the health needs of the Indians and that such health needs shall be given priority over that of the non-Indian population." The PHS, a division of the Department of Health, Education, and Welfare (HEW) formed the Division of Indian Health, which was renamed the Indian Health Service in 1958.

However, the Indian Health Service has chronically suffered from inadequate funding, and is unable to adequately serve the population it is trying to serve. A 2010 report by former Senate Committee on Indian Affairs Chairman Byron Dorgan, D-N.D., found that the Aberdeen Area of the Indian Health Service (IHS) is in a "chronic state of crisis." "Serious mismanagement of problems and a lack of oversight of this region have adversely affected the access and quality of health care provided to Native Americans in the Aberdeen Area, which serves 18 tribes in the states of North Dakota, South Dakota, Nebraska and Iowa," according to the report. In 2013 the Indian Health Service was hit hard by sequestration funding cuts of $800,000 which particularly impacted the already-underfunded service. Consequently, although urban Natives constitute about two-thirds of Indian people in the United States, they receive fewer federal dollars to meet urgent health, employment, educational and other needs than do reservation communities. According to the Kaufman Report (2011), of which the Fargo-Moorhead Metro area was a part, Urban AIAN people, when compared to all races, are younger (41.3% of urban AIANs are below 25 years of age compared to 34.7% of the all-races population) and less educated (19.9% of urban AIAN individual’s 25 years of age or older attain a bachelor’s degree compared to 32.7% of the all- races population).  Urban AIANs have lower incomes, with 41.2% of the urban AIAN population examined living under 200% of the Federal Poverty Level (FPL), compared to 28.5% of all races from the same Metropolitan Statistical Areas (MSA).  Across the 57 MSAs examined, 11.6% of urban AIANs are unemployed, compared to 7.1% of all races.

North Dakota’s Urban Indians
Urban Indians living in the metropolitan areas of North Dakota are especially hard hit because there are virtually no health care provisions in place for them, either through the IHS or Urban Indian Health Centers or Clinics, though they mirror the same disparities described previously. Further impacting this dire situation is the fact that Title V funding is not available for North Dakota’s urban Native people. Essentially, they have greater need, but much less or no access to services.

Currently 42,996 American Indians call North Dakota home (US Census, 2010), with 3,917 living within the Fargo-Moorhead Metro area (Kaufman Report, 2011). The largest cities in the Red River Valley include Fargo, West Fargo, and Moorhead, Minnesota. The area is predominately white but has substantial populations of Native Americans and immigrants (new Americans) from primarily Somalia and Spanish-speaking countries. Additionally, because there are approximately 100,000 Native persons with in a 3 ½ hour radius of these central hub cities and nine Indian reservations in close proximity, the area has always been one where Native people relocate to attain temporary housing and services. In spite of their high hopes for a more prosperous and healthy environment, approximately 49.7% of North Dakota’s Native people live below 200% of the federal poverty level.  These situations present unique and complicated barriers for the Native population. Further impacting an already difficult situation, most providers of medical services in the Red River Valley are not culturally competent in providing health care to the Native population. This report (2011) also found that HRSA-funded community health centers like the one located in Fargo typically have few, if any, AIAN patients, unless the clinic offers culturally appropriate care. There is no indication that the Family HealthCare Center has made a systemic effort to attract Native clients. Additionally, many American Indians experience outright racism and discrimination, and some believe they receive substandard services because of their race or because of their insurance status. It goes without saying that these barriers to care experienced by AIAN people need to be addressed in a timely manner.

Q:  What is the Fargo-Moorhead American Indian Community-Sponsored Health Needs Assessment?
In response to the lack of sufficient data to determine the unmet needs of urban Indian families in the Fargo-Moorhead Metro area, I, as Principal Investigator, and Jaclynn Wallette, as Co-investigator, in collaboration with the Native community, approached the Fargo Native American City Commission to request funding to conduct the needs assessment survey. The Commission granted the funds to conduct the survey, which was a part of the larger survey conducted by the Greater Fargo-Moorhead Community Health Needs Assessment Collaborative. In an effort to build community capacity, six members of the Native community are now IRB certified by NDSU, enabling the community to replicate a needs assessment survey at their discretion.  

Q:  How was the assessment conducted?
The Greater Fargo-Moorhead Community Health Needs Assessment Collaborative (CHNAC) was established in May 2011 in response to the needs of both Public Health and local hospitals to complete Community Health Assessments. The 2010 Health Care Reform enactment requires that each hospital must conduct a community health needs assessment at least every three years, and take into account input from persons who represent the broad interests of the community served by the hospital facility including those with expertise in public health. Specifically, the CHNAC was responding to Internal Revenue Code 501 (R) Requirements to conduct the Community Health Needs Assessment. The Code allowed for collaboration with other organizations but separate documentation by each facility was required. The Collaborative, of which I am a charter member, made plans to develop an implementation strategy that would address each and every need identified by the CHNAC. The CHNAC worked to create transparency and to make the results widely available to the public. The two major hospitals in Fargo, Essentia and Sanford Health, worked together, along with other members to develop a common methodology to conduct primary research among identified key stakeholders as well as a representative, generalizable survey sample of the greater community. The survey provided the foundation for Community Asset Mapping, as well as County Health Profiles; County Diversity Profiles and County Aging Profiles. After reviewing the final results it was determined that the community-wide survey had few, if any, Native Americans. This is why Jaclynn Wallette and I, in collaboration with the Native community, conducted our own survey, using the same survey tool as the larger survey. The Group Decision Center’s (GDC) data gathering software and facility resources were utilized to conduct the survey. The GDC made computer generated data reports available to the researchers, as well as the Native community. Plans are underway to compile these data for inclusion on the ND Compass social indicators website.

Q:  Why do we need a health needs assessment for American Indians?
The Fargo-Moorhead Metro area, as a result of emigration from the reservations, has a large population of American Indians who reside within its city limits. Due to this fluidity in migration, many Native American statistics have not been accurately reflected in basic demographics or in census data. Importantly, Native Americans who live in the Fargo-Moorhead community and surrounding area face unique geographic and economic obstacles in getting the help and services they need. The nearest Indian Health Service clinics are the IHS-operated health centers on the White Earth Reservation at Ogema, MN, and on the Lake Traverse Indian Reservation at Sisseton, SD. The distance to either facility creates a transportation barrier (weather permitting), preventing many of Fargo’s AIANs from accessing services, which comes at a great cost to their health and well-being as well the negative impact to the health care systems in this metro area. This type of situation proliferates a Band-Aid approach to health care; effectively limiting any preventive care or early interventions. Additionally, financial resources/gas, time off from work, inadequate modes of transportation, child care, and inability to schedule appointments all create many more barriers that become insurmountable for people living in this kind of poverty. The Greater Fargo-Moorhead community can align with the Native community through inclusion in asset mapping to proactively address these issues to bring about much needed changes.

Q:  How can the data from this study be used?
The overarching goal conducting this survey was to provide important health and community data and input to inform the development of a comprehensive service system, to enhance the quality of services available, and to support community partnered applications for external funding to provide culturally responsive health care. The lack of data on urban Indians greatly impedes their ability to raise funds for services, to provide culturally congruent, comprehensive services, and to make the case to local policy-makers and legislators that Indian health is an important issue in urgent need of attention and investment. There is mounting scientific evidence that mental health and well-being are critical factors that greatly influence an extensive range of outcomes for individuals and for the communities in which they live (WHO, 2009). Mental health and the fundamental element of resilience, when coupled with equal access to resources, can empower people to cope with adversity in healthy ways so they are able to reach their full potential as contributing members of society (WHO, 2009). Several studies have demonstrated that resilience is built by developing assets in individuals, families, and communities through evidence-based health promotion and prevention strategies Therefore, it is essential to focus not only on the strengths, risk factors, and barriers found in our communities, but on resilience as well. It is our hope that this survey will enable the Fargo-Moorhead urban Indian community to determine how to best meet their own health and wellness needs.

Q:  How do the assessment results differ from those of the general community?
I believe that the Native American component of the Greater Fargo-Moorhead community survey has successfully brought data from this underserved and vulnerable segment of our community to the table. Dr. Donald Warne presented the finding from the Native American Needs Assessment Survey at the community Key Stakeholders Meeting held on June 27, 2013. I believe he will elaborate more on these differences in his column.

Q:  Will additional communities be studied?
Yes, plans are underway as a result of the Centers for Disease Control and Prevention (CDC) Public Prevention Health Fund: Community Transformation Grants (CTG) that was awarded to North Dakota. North Dakota submitted a statewide grant application and was awarded a $370,000 grant each year over  a five-year term as one of the CDC’s Capacity Building Communities. The overarching purpose of this grant was to develop an effective program to prevent heart attacks, strokes, cancer, and other leading causes of death or disability through evidence and practice-based policy, environmental, programmatic, and infrastructure changes in states, large counties, tribes, and territories. I submitted one of the over 20 proposals that were submitted to the state for inclusion in the grant. My proposal was successfully included in the grant application, bringing NDSU to the table at the state level. Dr. Donald Warne and I are Co-PI’s on the CTG sub-contract award and are on the CTG State Leadership Team, along with Dr. Linda Frizzell. Dr. Terry Dwelle, State Health Director and Kelly Nagel, Public Health Liaison are the project’s principal investigators. The Center for Rural Health at UND also has a sub-contract. The CTG State Leadership Team is currently developing plans to begin implementation in the near future.  

Q:  What is the most pressing issue for the health of American Indians in North Dakota?
Short and simple, the most pressing issue is basic access to health care. Additionally, many research studies have demonstrated that healthcare for Native people is much more successful when it is culturally respectful and appropriate. Other pressing issues include a wide-ranging spectrum of problems and barriers that create deplorable conditions for the Native people of this state.  Addressing these broader, more structural issues requires the development of a statewide, multi-faceted strategy by the leadership of this state.  North and South Dakota have the lowest high school graduation rates in the country for American Indian students, an issue that ensures that these problems will proliferate and continue their chronic trajectory. The unprecedented poverty experienced by Native people in a state with such vast resources must be scrutinized to find workable solutions. To do otherwise is unacceptable.     

Q:  You were recently selected to be a Hampton Faculty Fellow based at the Mayo Clinic.  Can you tell us about the program?  What do you hope to bring back to American Indian communities in North Dakota from this program?

It is my hope to be instrumental in helping to address the grave cancer disparities that confront Native people by finding ways to improve cancer prevention and control in American Indian and Alaska Native populations. American Indian and Alaska Native (AIAN) populations have very high incidence rates for specific cancer sites and poor survival rates or most cancers. I will begin my affiliation with the Hampton Faculty Fellowship at a conference this week. I am very excited about this important opportunity. I will be meeting leading cancer researchers, be involved in assigned coursework on topics relevant to cancer control, and will begin to develop at least one major grant application (e.g., Diversity supplement, K07, K22, R03, or R21). Click here for information about the Hampton Faculty Fellowship.

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