Program Brief
American Indian/Alaska Native (AI/AN) people have long experienced lower life expectancy and disproportionate disease burden when compared with other Americans. This program brief provides a summary, by topic, of ongoing and recently completed AHRQ activities that specifically address the health of the AI/AN people.
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Contents
Introduction
Arthritis
Asthma
Cardiovascular Disease
Children's Health
Diabetes
Disparities
Managed Care for Medicaid
Mental Health
Perceptions of Care
Preventive Care
Quality of Care
Research Considerations
Research Infrastructure Development
Technology (Health Information Technology, Telehealth)
Tobacco Use
Traditional Medicine
Trauma
Women's Health
Key Acronyms
For More Information
Introduction
American Indian and Alaska Native (AI/AN) people continue to have disproportionately higher rates of illness
and higher mortality rates when compared with other Americans. AI/ANs die at higher rates than other Americans from tuberculosis (500 percent higher), alcoholism (550 percent higher), diabetes (200 percent higher), unintentional injuries (150 percent higher), homicide (100 percent higher), and suicide (70 percent higher). This group is also burdened with high infant mortality rates and high rates of obesity and diabetes among children.
The Agency for Healthcare Research and Quality (AHRQ) is committed to improving the quality, safety, effectiveness, and efficiency of health care for all Americans. AHRQ provides grants to enhance the health services research knowledge base; develops tools and talent that foster the health services research infrastructure; and builds relationships with tribal and other AI/AN organizations, the Indian Health Service (IHS), and other Federal agencies to advance excellence in health care for AI/ANs.
This program brief provides a summary, arranged by topic, of ongoing and recently completed AHRQ activities that specifically address the health of the AI/AN people.
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Arthritis
Rheumatoid arthritis (RA), a major cause of disability among the general U.S. population, has a higher prevalence among some AI/AN subgroups.
Study examines rheumatoid arthritis quality of care in Alaska Natives
This pilot study assessed the level of adherence to 27 quality indicators among an Alaska Native subpopulation living in the Anchorage Service Unit. The study team gathered data on patient and provider characteristics that influence quality of care and used IHS information to generate hypotheses for further investigation. Long-term goals include identifying deficiencies in arthritis care and developing quality initiatives for implementation statewide to improve care for Alaska Natives with rheumatoid arthritis. (Principal Investigator: Elizabeth Ferucci, Alaska Native Tribal Health Consortium; Grant HS15625, 9/30/05-9/29/07)
Quality of arthritis care for Alaska Natives varies significantly by quality measure
This study provides an initial evaluation of quality of care for RA in an Alaska Native population receiving care in an integrated health care system. The researchers assessed the providers' level of adherence to eight quality-of-care indicators among 106 Alaska Natives living in the Anchorage Service Unit. The highest performance scores were for folic acid prescription while on methotrexate (93.6 percent) and disease-modifying antirheumatic drug prescription (90.6 percent). The areas in need of greatest improvement were related to radiographs of both hands and feet and laboratory measures to monitor RA. Having at least one visit to a rheumatologist increased the likelihood of high performance on many, but not all, quality indicators. Ferucci ED, Donnithorne KJ, Koller KR, et al. Performance on rheumatoid arthritis quality indicators in an Alaska Native healthcare system. Qual Saf Health Care 2010 Jul 23 [Epub ahead of print]. (Grant HS15625).
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Asthma
Asthma is a chronic lung disease that affects 14 to 15 million people in the United States. People with asthma have almost half a million hospitalizations annually, and 5,000 die each year of the disease.When only race is considered, AI/ANs and blacks have a 25 percent higher prevalence than whites.
Asthma education conference held for tribal health officers
The main goal of this 2006 regional conference on asthma education was to inform Northern Plains tribal health agencies about the current state of knowledge, research, and treatment of asthma, its potential environmental health triggers, prevention strategies, and environmental improvement measures. Topics covered included exposures to everyday types of indoor and outdoor contaminants, such as environmental tobacco smoke, allergens, endotoxins, molds, insects, dust mites, pesticides, formaldehyde, exhaust from wood-burning stoves, motor vehicle exhaust, and other biological and chemical contaminants. Conference participants included tribal health representatives and directors, IHS staff, emergency medical workers, nurses, and pediatricians working with 18 tribes in a four-State region served by the Northern Plains Tribal Epidemiology Center. (Principal Investigator: David Osterberg, University of Iowa; Grant HS16435, 6/01/06-5/31/07)
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Cardiovascular Disease
Although mortality rates from cardiovascular disease (CVD) in the United States continue to decrease, CVD is the leading cause of death in American Indians beginning at age 45, compared with age 65 for the general U.S. population. AI/ANs are 1.2 times as likely as white adults to have heart disease, 1.6 times as likely to be obese, and 1.3 times as likely to have high blood pressure.
Risk factors for developing cardiovascular disease increase as older American Indians age
As older American Indians age, more of them than the general population develop hypertension, diabetes, and low levels of high density lipoprotein cholesterol (HDL-C), all risk factors for developing CVD, according to this study. Researchers examined the development of major CVD risk factors among a rural group of 4,549 American Indians aged 45 to 74 during initial examination from 1989 to 1991 and 8 years later. This aging group had decreased prevalence of smoking and no consistent changes in adverse HDL-C and low-density lipoprotein-cholesterol profiles. However, the group had substantial increases in the prevalence of hypertension and diabetes, two of the most important CVD risk factors.
Source: Rhoades DA, Welty TK, Wang W, et al. Aging and the prevalence of CVD risk factors in older American Indians: The strong heart study. J Am Geriatric Society 2007 Jan;55:87-94. (Grant HS10854) Posttraumatic stress disorder linked to cardiovascular disease
Researchers interviewed 1,414 Northern Plains American Indians aged 18-57 years to examine the association with lifetime posttraumatic stress disorder (PTSD) and lifetime major depression on CVD among Northern Plains American Indians. Fifteen percent of respondents had PTSD, and 8 percent had major depression. CVD was more commonly reported by participants with PTSD than by those without PTSD (12 percent vs. 5 percent). More participants with major depression reported having CVD than their nondepressed counterparts (14 percent vs. 6 percent). The authors suggest rising CVD rates in this population may be better understood if PTSD is considered along with other traditional risk factors.
Source: Sawchuk CN, Roy-Byrne P, Goldberg J, et al. The relationship between posttraumatic stress disorder, depression, and CVD in an American Indian tribe. Psychol Med 2005 Dec;35(12):1785-94. (Grant HS10854) Cardiovascular disease death rates higher among AI/ANs than other U.S. groups
National vital events data published by the IHS prior to the early 1990s suggested that CVD mortality rates (for example, for heart attack and stroke) were lower for AI/ANs than the U.S. general population. Given that American Indians have for years had some of the Nation's highest rates of major CVD risk factors, such as smoking, diabetes, and obesity, the author adjusted for racial misclassification in the IHS data and concluded the opposite. She found that AI/ANs have higher CVD mortality rates than the rest of the U.S. population, and these rates may have been higher for more than a decade. Further, CVD mortality is increasing among AI/ANs but decreasing in the general population, widening a previously unrecognized disparity. After adjusting for age and racial misclassification, by 1996-1998 the number of CVD deaths per 100,000 among AI/ANs was 195.9 compared with 166.1 and 159.1 for all races and whites, respectively. The most striking and widening disparities were found for middle-aged AI/ANs; CVD mortality among elderly AI/ANs was lower than in the other groups.
Source: Rhoades, DA. Racial misclassification and disparities in CVD among American Indians and Alaska Natives. Circulation 2005 March 15;111:1250-6. (Grant HS10854)
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Children's Health
AI/AN children face serious health issues. AI/AN infants die at a rate of 8.3 per every 1,000 live births, compared with 6.7 per 1,000 for the entire U.S. population (2006 rate). The prevalence of overweight and obesity among AI/AN children has grown dramatically in the last 30 years, and type 2 diabetes is increasingly prevalent. On a positive note, as of 2008, the immunization rate for AI/AN children is similar to that for non-Hispanic whites.
International meeting held on indigenous child health
This collaborative conference, held in Montreal on April 20-22, 2007, focused on innovative clinical care models and community-based public health approaches for children and youth in First Nations, Inuit, Metis, American Indian, and Alaska Native communities. The conference was planned and jointly sponsored by a number of U.S. and Canadian organizations and agencies. While the health care systems in the U.S. and Canada differ, there are many similarities in terms of providing culturally effective care to indigenous children and youth. This conference brought exposure to successful models of care and unique research implemented at the community level, and offered opportunities for providers to gain valuable skills in areas of health disparities among indigenous children. Additional information is available at www.aap.org/nach/2InternationalMeeting.htm.  (Principal Investigator: Sunnah Kim, American Academy of Pediatrics; Grant HS16753, 12/01/06-11/30/07)
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Diabetes
AI/ANs have the highest rates of type 2 diabetes in the United States. Diabetes is traditionally a disease of older people, but diabetes is being diagnosed at young ages in American Indian communities. American Indian youths (15-19 years old) have the highest prevalence (4.5 per 1,000) of type 2 diabetes among all ethnic groups. Of AI/ANs aged 18 years and older, about 17.2 percent have diabetes. Diabetes is least common among Alaska Natives (8.1 percent) and most common among American Indians in the southern U.S. and southern Arizona (26.7 percent and 27.6 percent respectively). The Pima Indians of Arizona have one of the highest diabetes rates in the world.
More comprehensive diabetes education programs are linked to better diabetes care
Researchers found that few diabetes education programs for AI/ANs met national standards in 2001. They also found that more comprehensive programs were associated with better quality diabetes care. All 88 IHS-funded diabetes care programs in 2001 completed a checklist of criteria from the IHS Integrated Diabetes Education Recognition Program (IDERP) on how well programs implemented each of the 10 national standards for diabetes self-management education. Programs were then categorized as Level 1 (developmental), Level 2 (educational), or Level 3 (integrated). Patients receiving care from Level 2 and Level 3 programs had higher completion rates of all 15 diabetes quality-of-care indicators compared with those in programs at or below Level 1. Yet, only 9 of the 86 programs had fulfilled enough criteria to qualify for at least Level 2 IDERP recognition. The remaining 77 programs qualified at Level 1 or less. Programs were often understaffed and unable to complete the extensive documentation process required by the IDERP, according to the authors. Since the study, with additional IHS funding toward staff and training, the number of IDERP-recognized programs grew to 37 in 2009.
Source: Roubideaux Y, Noonan C, Goldberg JH, et al. Relation between the level of American Indian and Alaska Native diabetes education program services and quality-of-care indicators. Am J of Pub Health 2008 Nov; 98(11):2079-84. (Grant HS10854). Robeson County Primary Care Research Network studies prevalence of diabetes in local American Indians
This project brings together 54 providers, 21 of which are American Indian, with the goal of creating a research network of primary care providers who largely serve American Indian patients in Robeson County, North Carolina, a rural county that is home to most of the State's more than 50,000 members of the Lumbee Tribe. In addition to creating the network of primary care practices where disease- and tribe-specific data can be collected, researchers will estimate diabetes prevalence in adults and children as well as collect pilot data on the care processes for diabetes. The creation of the network, measurement of diabetes prevalence, and results of the pilot study will be used to direct further work for improving the identification and care for diabetes in the community. (Principal Investigator: Bonnie Yankaskas, University of North Carolina at Chapel Hill; Grant HS15989, 8/01/06-7/31/08)
AI/AN patients in urban areas more likely than rural patients to receive diabetes education
The authors of this study reviewed medical record data as part of the IHS Diabetes Care and Outcomes Audit in 2002. They compared Indian health facilities' adherence to diabetes care guidelines when treating all 710 AI/AN patients with diabetes at 17 urban Indian health clinics and a random sample of 1,420 AI/AN patients from 225 rural Indian health facilities. Urban patients were more likely than rural patients to have received formal diabetes education in the past 12 months (76 vs. 62 percent). After adjusting for other factors affecting outcomes, blood glucose levels, blood pressure, and cholesterol levels were similar for urban and rural patients. Overall, rates of adherence to nationally recommended care guidelines for AI/AN health programs were comparable to or surpassed rates described for the general population.
Source: Moore K, Roubideaux Y, Noonan C, et al. Measuring the quality of diabetes care in urban and rural Indian health programs. Ethnicity & Disease 2006 Autumn;16:772-7. (Grant HS10854) Structural change is needed to stem diabetes crisis
Native American communities in the United States have experienced an upswing of community participation in health programming, especially for diabetes. The author suggests that because knowledge of the disease, its risk factors, and the behavioral elements that assist in its spread and prevalence are known, a structural change is needed in tribal health care. A holistic approach is required that recognizes how genetic, cultural, environmental, and political-economic factors work simultaneously to produce the current crisis in diabetes.
Source: Smith-Morris, CM. Community participation in tribal diabetes programs. Am Indian Culture and Research J 2006;30(2):85-110. (Grant HS10802) -
Pregnancy may be best time to curb diabetes in the Pima
The author delves into the spectrum of causes, perspectives, and conditions that underlie the occurrence of diabetes in the Pima community. Using narratives of pregnant Pima women and nearly 10 years of research in this community, the volume provides the Pimas' perspective of type 2 and gestational diabetes and their experience, including their core values of motherhood, foodways, ethnic identity, exercise, attitude toward health care, and willingness to seek care. The author asserts that the prenatal period may offer the most hope for curbing the epidemic.
Source: Smith-Morris, CM. Diabetes among the Pima: Stories of survival. Tucson: University of Arizona Press. 2006. (Grant HS10802)
Pima women place high value on own and others' experiences with gestational diabetes
Because it is mostly symptomless, gestational diabetes can be a mysterious disease. Medical information that contradicts family and friends' information on diabetes can contribute to Pima women's not undergoing testing during pregnancy. Though Pima women do listen to health professionals, they also rely on their family and friends as sources of medical information.
Source: Smith-Morris C. Prenatal mysteries of symptomless diabetes in the Gila River Indian community. In: Ferreira ML, Lang GC, Eds. Indigenous peoples and diabetes. Durham: Carolina Academic Press, 2006:187-202. (Grant HS10802) Providers and patients have similar concerns about preventing diabetes
When pregnant women develop gestational diabetes, they and their children are at risk for developing type 2 diabetes. Pima women have been targeted for diabetes prevention because of the disease's prevalence in the community. Both health care professionals and the Pima raise the same set of questions about diabetes prevention and surveillance during pregnancy.
Source: Smith-Morris C. Diagnostic controversy: Gestational diabetes and the meaning of risk for Pima Indian women. Med Anthropol 2005 Apr-Jun;24(2):145-77. (Grant HS10802)
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Disparities
Improvements in preventive services, care for chronic conditions, and access to care have led to a reduction and in some cases elimination of disparities in access to and receipt of care for AI/AN populations; however, disparities in care continue to be a problem for some conditions.
AHRQ is supporting efforts to identify and address disparities in health and health care among AI/ANs:
Higher education among American Indian elders increases their likelihood of engaging in physical activity
AI/ANs report lower levels of leisure-time physical activity than majority populations. This lack of exercise puts them at risk for obesity, hypertension, type 2 diabetes, and cardiovascular disease, which are becoming more prevalent in many AI/AN communities. However, as with many other groups, more educated AI/AN elders have higher levels of physical activity than their less educated counterparts, finds a new study. Researchers correlated education with physical activity level among 125 sedentary AI/AN elders (age 50 to 74 years) enrolled in a 6-week trial comparing 2 approaches to physical activity monitoring. After controlling for relevant demographic and health factors, they found that groups at different educational levels (less than high school, completed high school, General Education Degree or some vocational education, and college education) did differ significantly in caloric expenditure due to moderate to vigorous exercise, with the differences increasing significantly with higher levels of educational attainment.
Source: Sawchuk C, Bogart A, Charles S, et al. Education is associated with physical activity among American Indian elders. American Indian Alaska Native Mental Health Research 2008: 15(1); 1-17. (Grant HS10854). Distance to cancer care facilities hinders access for American Indians
For specialized services such as cancer care that are not widely distributed geographically, access may be fundamentally limited by distance, which can be measured in travel time. Using census data, researchers estimated travel times to National Cancer Institute (NCI)-designated Cancer Centers, academic medical centers, and oncologists by various demographic characteristics, including race/ethnicity and region. AI/ANs, nonurban dwellers, and residents in the South had the longest travel times to a NCI Cancer Center. Travel burdens also persisted for AI/ANs and nonurban populations for cancer treatment by academic medical centers and oncologists. These disparities in access merit further examination if corrective policies are to be designed and implemented.
Source: Onega T, Duell EJ, Shi X, et al. Geographic access to cancer care in the U.S. Cancer 2008; 112:909-918. (Grant T32HS00070). AHRQ cosponsors conference on racial/ethnic disparities
AHRQ was a participating cosponsor of the Department of Health and Human Services' Office of Minority Health National Leadership Summit on Eliminating Racial and Ethnic Disparities in Health held in January 2006. A list of presentations relevant to minority communities, including AI/AN subpopulations, can be found on the summit Web site at http://minorityhealth.hhs.gov/npa/templates/browse.aspx?lvl=2&lvlID=28. Researcher examines native elder health disparities
At one of AHRQ's Excellence Centers to Eliminate Ethnic/Racial Disparities, a team headed by an American Indian researcher examined the health care of elderly AI/ANs for diabetes, heart disease, cancer, and respiratory diseases, such as influenza, tuberculosis and pneumonia—chronic conditions for which the AI/AN population is at an increased risk. Individual projects included improving the quality of diabetes care; increasing participation in clinical preventive services, such as immunization and cancer detection/management; smoking cessation; as well as identifying both the barriers and facilitators to improved health status and functioning of older Al/ANs. (Principal Investigator: Spero Manson, University of Colorado; Grant HS10854, 9/30/00-9/29/06) Survey measures disparities between American Indians and U.S. population
The authors looked at the usefulness of a 36-item health survey for comparing the health of American Indians to an age- and gender-matched sample of the U.S. general population. The survey's scales include physical functioning, pain, general health, vitality, social functioning, mental health, and physical and emotional roles. They found that the 36-Item Short Form Health Survey is an important tool for studying cultural equivalence and health disparities increases.
Source: Beals J, Welty TK, Mitchell CM, et al. Different factor loadings for SF36: The Strong Heart Study and the National Survey of Functional Health Status. J Clin Epidemiol 2006 Feb;59(2):208-15. (Grant HS10854) -
Several projects address health disparities in Montana and Wyoming
The authors report on the progress of studies undertaken as part of a collaborative consortium formed to address health disparities (for example, lower life expectancy) affecting Montana and Wyoming tribal nations. Funded until 2011, six studies address topics such as seatbelt use, eye disease, suicide prevention, emergency medical services, and physical and mental health care access improvement.
Source: (Andersen SR, Belcourt GM, Langwell KM. Building healthy tribal nations in Montana and Wyoming through collaborative research and development. Am J Public Health 2005 May;95(5):784-9. (Grant HS14034)
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Managed Care for Medicaid
Managed care has brought many changes to health care delivery and financing in the United States. While this has created many benefits, it has also complicated the health care industry. When New Mexico introduced Medicaid managed care for physical and mental health services in 1997, it spawned many unintended consequences.
Managed care for Medicaid may not be beneficial in rural areas
New Mexico's Medicaid managed care program led to administrative burdens, payment problems, and high turnover among providers. The restrictions the program instituted on inpatient and residential treatment aggravated access issues for Medicaid recipients and caused the Federal Government to terminate the State's program, though it later reversed that decision. The authors suggest that the advantages of managed care for cost control, access, and quality assurance may be diminished in rural, medically underserved states.
Source: Willging C, Waitzkin H, Wagner W. Medicaid managed care for mental health services in a rural state. J Health Care Poor Underserved 2005 Aug;16(3):497-514. (Grant HS09703)
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Mental Health
For AI/ANs, alcoholism rates are more than seven times the national average, suicide rates are almost double, and homicide rates are one-and-a-half times the national average for all races. Although some AI/ANs have access to care through IHS, barriers such as access to care and questionable quality and comprehensiveness of care may impede those who need help.
Childhood experiences influence war-related PTSD
The authors looked at the relationship between childhood conduct disorders, levels of war zone stress, and war-related PTSD symptoms in 591 male participants from the American Indian Vietnam Veterans Project. Childhood conduct disorder, which involves risk taking, was associated with war-related PTSD symptoms, independent of how much stress was encountered in the war zone. Symptoms of conduct disorder may be important for care providers to consider when they treat American Indian Vietnam veterans with PTSD and may be important for the military in assessing American Indians for combat readiness.
Source: Dillard D, Jacobsen C, Ramsey S, and Manson S. Conduct disorder, war zone stress, and war-related posttraumatic stress disorder symptoms in American Indian Vietnam veterans. J Traumatic Stress 2007 Feb;20(1):53-62. (Grant HS10854) -
Posttraumatic stress disorder linked to pain in Plains Indians study
The authors examined the relationship between PTSD and pain in 3,084 American Indians from the Northern and Southwestern Plains areas. Nineteen percent of women and 10 percent of men experienced lifetime PTSD, and women in both areas were nearly twice as likely as men to have lifetime PTSD. The authors found a strong association of PTSD and physical pain and suggest that more research is needed among American Indians and other minorities to examine if and how the pain experience varies by tribe or culture.
Source: Buchwald D, Goldberg J, Noonan C, et al. Relationship between post-traumatic stress disorder and pain in two American Indian tribes. Pain Med 2005 Jan-Feb;6(1):72-9. (Grant HS10854)
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Perceptions of Care
To gauge AI/ANs satisfaction with the quality of their health care, researchers use surveys, focus groups, and other assessment tools.
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Collaboration between Choctaw Nation, AHRQ, and IHS yields the American Indian Survey, an adaptation of CAHPS®
The Consumer Assessment of Healthcare Providers and Systems (CAHPS®) surveys measure patients' experiences with ambulatory and facility-level care. Since these surveys are not adapted for ethnic and linguistic minority populations, the Choctaw Nation Health Service (CNHS) Program and AHRQ agreed to explore developing a survey to collect patient experience-of-care data to evaluate care received by patients at different CNHS clinics. AHRQ and the CAHPS® consortium, together with the IHS, worked with CNHS to develop a CAHPS® American Indian Survey. They conducted a mail survey of the Choctaw population that yielded 696 surveys (a 58 percent response rate). This collaboration and community-based participatory research helped to produce a useful survey tool that can be used by other American Indian tribes and by the IHS.
Source: Weidmer-Ocampo B, Johansson P, Dalpoas, D, et al. Adapting CAHPS® for an American Indian population. J Health Care for the Poor Underserved 2009; 20:695-712.
Older American Indians often have a poorer view of their health than their doctors
Investigators surveyed 115 patients 50 years and older who sought care at a Cherokee Nation clinic and their seven health care providers. In 40 percent of medical visits, providers and patients rated the patient's health differently. In 68 percent of the cases, providers rated patients healthier than the patients rated themselves. Differing perceptions between providers and patients about the patient's health are associated with inadequate and unnecessary treatment, poor adherence to treatment advice, dissatisfaction with care, diminished symptom resolution, and mismatching of care services to needs. Misaligned perceptions of health status pose special concerns for chronically ill patients, who must carefully follow providers' advice to maintain their health, and for older patients, who are often unassertive with providers and unlikely to challenge their perceptions.
Source: Garroutte EM, Sarkisian N, Arguelles L, et al. Cultural identities and perceptions of health among health care providers and older American Indians. J General Internal Med 2006 Feb;21:111-6. (Grant HS10854) AI/ANs most likely to report discrimination in health care
This study found that the AI/AN racial group were most likely to report discrimination in health care. AI/ANs who identified as both AI/AN and white were twice as likely to perceive discrimination as whites. A telephone survey of adults in the 2001 California Health Interview Survey found that 7.1 percent of the AI/AN group, 8.8 percent of the AI/AN plus white group, 5.6 percent of blacks, 4.3 percent of whites, and 2.6 percent of Asian Americans felt discriminated against at some point during the past year of care. More than 20 percent of AI/AN, black, and Asian American respondents reporting discrimination cited race as the sole reason compared with less than 10 percent of AI/AN plus white and white respondents.
Source: Johansson P, Jacobsen C, and Buchwald D. Perceived discrimination in health care among American Indians/Alaska Natives. Ethnicity & Disease 2006 Autumn;16:766-71. (Grant HS10854) Survey of patients' experiences completed
Researchers completed standardized surveys of patients' experiences with the Billings Area Office of the IHS in 2003 to develop new performance initiatives and learn why eligible patients with other insurance coverage choose non-IHS providers. Gaining this information is particularly important because the IHS can receive reimbursement from public and private insurers when services are provided to covered patients. The research team used AHRQ's CAHPS® program, a multiyear initiative of AHRQ that assesses the patient-centeredness of care, compares and reports on performance, and improves the quality of care. Researchers, through a cooperative agreement, used survey results to develop a performance improvement plan in spring 2007 that identified cost-effective, feasible strategies for improving care. Follow-on work will include deploying interventions at one hospital and three ambulatory clinics to give researchers an opportunity to refine tools and interventions for use in culturally diverse populations served by underfunded health care providers. Principal Investigator: Gordon Belcourt, Montana/Wyoming Tribal Leaders Council. (Grant HS14034 9/30/03-9/29/11)
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