# Presentation: 441581

## Childhood Interrupted: Injuries Among American Indian and Alaska Native Children 

- <date/time>

**Childhood Interrupted: Injuries Among American Indian and Alaska Native Children **

- David Wallace, MSEH
- National Center for Injury Prevention
- and Control

## Epidemic in Indian Country:

- Takes the life of one Native American child or teen daily
- Kills more Native American children than all other causes combined
- Receives relatively little attention compared to the magnitude of the problem

- Injury

**Notes:**
Epidemic Definition: Occurrence of health-related event clearly in excess of normal expectancy

## Injuries Are Not “Accidents”

- They have known risk factors
- They occur at higher rates among vulnerable populations
- They are predictable and preventable

**Notes:**
Injuries are considered to be either unintentional or else  intentional in nature. The differences between these are large and varied, since:
Unintentional injuries (like the falls, car crashes, drowning and burns shown here) usually occur because of factors related to individual behavior or knowledge, the physical environment, or laws and enforcement, without the intent of anyone involved; and
Intentional injuries (including the varied types of violence listed here) occur because of a person’s deliberate intent to harm another person
Our ability to prevent these very different injuries is based on carefully analyzing the contributing factors of these injuries, and carefully selecting those methods for preventing these injuries. We’ll see more about unintentional and intentional injuries throughout the course. 

## Injury Risk Factors for American Indians and Alaska Natives

- Median age of 24 vs. 33 for all US Races.
- About 32% are below poverty level.
- Risky Environments: Driving long distances on rural, isolated roadways.
- Alcohol involvement is higher than other racial groups.

## Public Health Impact of Injuries Among Native Americans

- Highest Unintentional Injury Rates
- MV: 3rd Leading Cause of Death vs. 8th—US
- Highest Suicide Rates
- 2nd Highest Homicide Rates
- Rates 1.5 to 8 Times Greater than National Rates Depending on Region, Cause, and age

## Leading Causes of DeathNative Americans, Aged 1-19 Years 1997-1998

## Leading Causes of Injury DeathNative Americans, Age 0-19 Years

- Motor Vehicle 36%

- Suicide 12%

- Firearms 13%

- All Other 13%

- Fire 5%

- Drowning 6%

- Homicide 11%

- Suffocation 4%

## Motor Vehicle Crashes

- 2-3 Native American children or teens have been killed every week for the last 10 years

## Motor Vehicle-Related Death Rates Ages 0-19, 1981-1998

- Native American

- White

- Black

- Data Source:  IHS mortality data for Native Americans; Black/White: NCHS mortality, CDC WISQARS

- 35% decrease

## Motor Vehicle CrashesNative Americans, Ages 0-19 

- Ranks 1 or 2-- Leading Cause of Death at Each Year of Life from 1-19
- 56%--Occupants
- 22% --Pedestrians
- 4% Bike/Motorcycle

## Native American Pedestrian Deaths, Ages 0-19	

- Majority killed on Public Roads
- Half of 1-4 year olds Killed in Non-Traffic settings such as driveways
- Non-Traffic settings—Leading cause of injury death for one-year olds.
- Among Children 1-9 Years--Number Pedestrian Deaths > Occupant Deaths

## Motor Vehicle-Related Deaths per 100,000Ages 0-19, IHS Areas, 1989-1998

**WA**

**Portland**
** ****22.3**

**Billings**
**        ****43.9**

**Aberdeen**
**        ****39.5**

**Bemidji**
**   ****29.7**

**OR**

**ID**

**MT**

**WY**

**ND**

**SD**

**NE**

**MN**

**IA**

**WI**

**MI**

**IN**

**ME**

**NY**

**PA**

**California**
**      ****17.0**

**CA**

**NV**

**UT**

**AZ**

**AK**

**CO**

**NM**

**KS**

**OK**

**TX**

**United States Rate-- 11.48**
**All IHS Rate—26.4**

**LA**

**MS**

**AL**

**FL**

**SC**

**NC**

**TN**

**Percentile**

**95 - 100**

**75 - 94**

**50- 74**

**0 - 49**

**Tucson**
**    ****24.5**

**Navajo**
**   ****37.3**

**Albuquerque**
**       ****33.7**

**Oklahoma City**
**     ****16.7**

**Nashville**
**     ****20.5**

**Phoenix**
**        ****32.6**

**Alaska**
**     ****12.1**

## Motor Vehicle-Related Injuries Among Native American Children  

- Child Safety Seat/Seat Belt Use is Still Low In Many Native American Communities, even in the presence of mandatory use laws

**Notes:**
This slide is a review of the problem of MV injury among Native American children:

MV crashes are the leading cause of death overall for Indian children.

The use of child safety seats is still quite low on many reservations

## Slide 14

## Navajo Nation Occupant Restraint Law  

- 1988 Navajo Nation passed primary enforcement law for seat belt and child restraint use:
- Recent study found a 50% reduction in motor vehicle injury hospitalization rates for Navajo Nation children and youth comparing before the law to after.

- Phelan KJ, et al. Pediatric motor vehicle related injuries in the Navajo Nation. Injury Prevention 2002;8:216-220.

**Notes:**
Notes:  In 1997, the Bureau of Indian Affairs (BIA), Office of Indian Education, partnered with the Centers for Disease Control and Prevention (CDC) and conducted a Youth Risk Behavior Survey of all high school students---grades 9-12—attending BIA schools.  5605 students completed the voluntary survey, for a response rate of 72%.  The results are considered statistically reliable and representative of all BIA students in grades 9-12.  Source: 1997 Youth Risk Behavior Survey of High School Students Attending Bureau Funded Schools. Bureau of Indian Affairs, Office of Indian Education Programs, and  Centers for Disease Control, Division of Adolescent School Health.

Almost half—48%--had ridden with drivers who had been drinking in the past month.
21% of the students reported driving after drinking alcohol during the past month.
37% rarely or never used seat belts
And 15% had attempted suicide during the last year.

## Recommendations For ReducingMotor Vehicle-Related Injuries

- Tribes should strive to focus on four key areas:
- Increasing seat belt use
- Improving child passenger safety practices
- Decreasing drunk driving
- Eliminating key road hazards
- Solutions Must include:
- Community education
- Laws promoting safe behaviors
- Law enforcement to maximize compliance
- Partnering with local experts, such as IHS

- Source: Dr. David Grossman, Harborview Injury Prevention Center

## Alcohol and Injury   

- What Percent of American Indian and Alaska Native Deaths Are Alcohol-Related?

-  Sources: May P, *The Epidemiology of Alcohol Abuse Among American Indians: the Mythical and Real Properties*.
-  The  Primary Care Provider, Volume 20, March 1995, Indian Health Service; . *Ethnicity and Alcohol-Related Fatalities,*
* **1990-1994, by *Voas RB and Tipetts AS, National Highway Traffic Safety Administration, 1999.

- Homicide

- Suicide

- Motor Vehicle

- Pedestrian

- —85%

- —75%

- —73-65%

- —84%

**Notes:**
Read slide as a question to the class.  Tell students to turn to the person next to them to discuss answers for a few minutes.  Ask for answers from the class.  Each mouse click reveals another answer.  Tell students not to look at the answers in the slide handouts.

Notes: The reference for the homicide and suicide percentages is from Philip May, The Epidemiology of Alcohol Abuse Among American Indians: the Mythical and Real Properties.  The  Primary Care Provider, Volume 20, March 1995, Indian Health Service.  Dr. May has done alcohol research in Indian country for over 20 years, and is one of the most knowledgeable in the field of American Indian alcohol abuse and injuries.  Mention that this article is in their notebooks.

Reference for the motor vehicle and pedestrian percentages is from Ethnicity and Alcohol-Related Fatalities, 1990-1994, by Voas RB and Tipetts AS, National Highway Traffic Safety Administration, 1999.  The data for this study were from NHTSA FARS data from police reported traffic deaths which were matched to NCHS death certificate data to be able to assign race/ethnicity.  The 73% would be considered an estimate, but is similar in the findings of other smaller studies.  It appears that this percentage has decreased, for using the NHTSA FARS query system the percent of AI/AN motor vehicle traffic deaths that were alcohol-related in 2000 was 65%.  This is also considered an estimate, but is based upon BAC tests.

- Source: NHTSA FARS Query system 2002:
-  _[http://www-fars.nhtsa.dot.gov/](http://www-fars.nhtsa.dot.gov/)__; and _*Ethnicity and Alcohol-Related Fatalities, 1990-1994, by *Voas RB and Tipetts AS, National Highway Traffic Safety Administration, 1999.

- Are We Making a Difference?
- Percent of Alcohol-Related Motor Vehicle Deaths, Native Americans and All US Races

## American Indian Youth Risk Behavior Survey, 1997   

- 1997 BIA/CDC Youth Risk Behavior Survey, students in grades 9-12:
- 48% Rode with Drinking Drivers
- 21% Drove after Drinking
- 37% Rarely/Never used Seat Belts
- 15% Attempted Suicide

**Notes:**
Notes:  In 1997, the Bureau of Indian Affairs (BIA), Office of Indian Education, partnered with the Centers for Disease Control and Prevention (CDC) and conducted a Youth Risk Behavior Survey of all high school students---grades 9-12—attending BIA schools.  5605 students completed the voluntary survey, for a response rate of 72%.  The results are considered statistically reliable and representative of all BIA students in grades 9-12.  Source: 1997 Youth Risk Behavior Survey of High School Students Attending Bureau Funded Schools. Bureau of Indian Affairs, Office of Indian Education Programs, and  Centers for Disease Control, Division of Adolescent School Health.

Almost half—48%--had ridden with drivers who had been drinking in the past month.
21% of the students reported driving after drinking alcohol during the past month.
37% rarely or never used seat belts
And 15% had attempted suicide during the last year.

## Leading Causes of Native American Infant Injury Deaths 

- Unintentional suffocation, choking, and strangulation:  leading cause of injury death birth-7 months old.
- Homicide ranked second
- Motor Vehicle ranked third
- Greatest number of injury deaths occurred in first month of life

**Notes:**
Unintentional Hanging/Strangulation--not in bed:  18%

176 kids died from Suffocation/Choking/Strang.

## Native American Unintentional Suffocation Deaths

- Young children—infants mostly--die from airway Obstruction/Strangulation/Suffocation
- 2.4 times as many infants die from these causes than motor vehicle crashes
- 25%--Bed or Crib (40% for infants)
- 24%--Inhalation/Ingestion Objects
- 20%--Unintentional hanging
- 13% --Food Related

**Notes:**
Unintentional Hanging/Strangulation--not in bed:  14%

176 kids died from Suffocation/Choking/Strang.

## Native American Fire and Burn Deaths, Ages 0-19

- Ranked 1st or 2nd Leading Cause of Injury Death for children Aged 2-5
- Almost all were House Fires
- Highest Rates: Bemidji, Aberdeen, Alaska
- These 3 Area Rates were about 6 Times Greater--US National Rate

## Fire-Related Deaths per 100,000Ages 0-19, IHS Areas, 1989-1998

**WA**

**OR**

**ID**

**Portland**
**    ****2.04**

**MT**

**WY**

**Billings**
**   ****1.68**

**ND**

**SD**

**NE**

**Aberdeen**
**     ****7.72**

**MN**

**IA**

**WI**

**MI**

**IN**

**PA**

**NY**

**MA**
**CT**

**ME**

**Percentile**

**Bemidji**
**          ****7.58**

**Phoenix**
**     ****1.26**

**CA**

**California ****0.79**

**Tucson**
**    ****3.21**

**Navajo**
**     ****1.91**

**Albuquerque**
** ****1.47**

**TX**

**OK**

**KS**

**Alaska**
**           ****6.94**

**Nashville**
**      ****1.67**

**LA**

**MS**

**AL**

**95-100**

**75 -94**

**50 - 74**

**0 - 49**

**FL**

**TN**

**NC**

**SC**

**NV**

**UT**

**AZ**

**CO**

**NM**

**United States Rate – 1.33**

**Oklahoma City**
**          ****1.49**

## Fire-Related Death RatesAges 0-19, 1981-1998

- Native American

- White

- Black

- Data Source:  IHS mortality data for AI/AN; Black/White: NCHS mortality, CDC WISQARS

- 64% decrease

**Notes:**
For 97-98 the Indian rate is still about 2 times greater than White rate.

## Drowning Death RatesAges 0-19, 1981-1998

- Native American

- White

- Black

- Data Source:  IHS mortality data for AI/AN; Black/White: NCHS mortality, CDC WISQARS

- 62% decrease

**Notes:**
For 97-98 the Indian rate is still about 2 times greater than White rate.

## Violence in Indian Country

- “We use to see my mom and dad beat each other up and we thought that’s the way it was supposed to be”
- American Indian victims of violence

**Notes:**
Trigger Exercise: 

These quotes are from interviews of Indian victims and perpetrators of intimate partner violence, one form of violence, from a study at San Carlos Apache Reservation, AZ.  Take time to let students read over these statements to help to put a personal face on the topic of violence.  Most of the presentation will be about risk factors, and data, but violence affects real people.  

Source:  Hamby SL, Skupien MB. Domestic violence on the San Carlos Apache Reservation: rates, associated psychological symptoms, and current beliefs. I.H.S. Primary Care Provider 1998; August: 103-106.

## Homicide Rates Ages 0-191981-1998

- Native American

- White

- Black

- Data Source:  IHS mortality data for AI/AN; Black/White: NCHS mortality, CDC WISQARS

- 18% decrease

**Notes:**
While AI/AN homicide rates are still twice the White rate, the Black homicide rate is 2.5 times greater than the AI/AN rate for 97-98

## Homicides per 100,000, Ages 0-19 IHS Areas, 1989-1998

**WA**

**OR**

**ID**

**Portland**
**     ****5.83**

**MT**

**WY**

**Billings**
**  ****12.74**

**ND**

**SD**

**NE**

**Aberdeen**
**    ****10.45**

**MN**

**IA**

**WI**

**MI**

**IN**

**PA**

**NY**

**ME**

**Percentile**

**Bemidji**
**           ****6.42**

**Phoenix**
**    ****12.12**

**CA**

**California ****3.03**

**Tucson**
**   ****15.81**

**Navajo **
**      ****8.69**

**Albuquerque**
**          ****7.29**** **

**TX**

**OK**

**KS**

**Alaska**
**            ****5.81**

**Nashville**
**     ****2.40**

**LA**

**MS**

**AL**

**95-100**

**75 -94**

**50 - 74**

**0 - 49**

**FL**

**TN**

**NC**

**SC**

**NV**

**UT**

**AZ**

**CO**

**NM**

**United States Rate – 5.87**

**Oklahoma City**
**          ****3.85**

## Evidenced-Based Strategies to Prevent Child Abuse and Neglect 

- Nurse Home Visitation:
- Nurses conducting home visits to young at risk low income mothers during pregnancy (average of 9 visits) and from birth through child’s second birthday (average of 25 visits).

- Source: Olds DL, Henderson CR, et al. Prenatal and Infancy Home Visitation by Nurses: Recent Findings. In The Future of Children, Home Visiting: Recent Program Evaluations, Spring/Summer 1999.  www.futureofchildren.org

**Notes:**
Notes on Nurse home visitation:

The data on effectiveness on nurse home visits comes from a long term study done in Elmira, NY, and replicated with mostly low income African American teen mothers in Memphis, TN.  The program is recommended by the American Academy of Pediatrics, and is a proven strategy to prevent child abuse and neglect.  The program is most effective for those mothers who are most at risk:  unwed, teenage, poor, and with poor support network.  Nurse visitation works best with trained Nurses as opposed to paraprofessionals as they seem more credible and have more skills at dealing with clients.  See the excellent chapter on Nurse visitation by David Olds and others in: Prenatal and Infancy Home Visitation by Nurses: Recent Findings. In The Future of Children, Home Visiting: Recent Program Evaluations, Spring/Summer 1999.  www.futureofchildren.org

## Evidenced-Based Strategies to Prevent Child Abuse and Neglect 

- Nurse Home Visitation:  Results
- 80% fewer cases of child abuse and neglect among intervention children
- 56% reduction in injury-related ED visits
- At 15 year follow-up, intervention children reported fewer instances of running away, fewer arrests and convictions, and less alcohol consumption.

**Notes:**
Program Results:

There were 80% fewer cases of police reported child abuse and neglect among children whose mothers received the nurse home visit intervention compared to the control group.  There was also a 56% reduction in injury-related emergency department (ED) visits among intervention children.

A follow-up of the children was done at 15 years, and researchers found that among intervention children, there were fewer self reported instances of running away, fewer arrests and convictions, and less frequent drinking episodes compared to control group teenagers. 

It appears that in addition to reducing the risk for child abuse and neglect, nurse home visitation can also reduce non-fatal injury rates and reduce negative behaviors among teens that often lead to violence. 

## Native American Youth Suicide

- 15-19 Year Old Males--Greatest Risk
- Rates Over 4 Times Female Rates
- 1st, 2nd or 3rd Leading Cause of Injury Death--Ages 12-19
- Alaska and Aberdeen Area rates 8 and 6 times greater than U.S. rates

**Notes:**
While the vast majority of Suicides occurred among older teens in the 15-19 year agegroup, Suicides did occur among 10-14 year olds.

Suicide is the leading cause of injury death among youth and teens in Alaska.

## Suicides per 100,000, Ages 0-19IHS Areas, 1989-1998

**WA**

**OR**

**ID**

**Portland**
-       8.5

**MT**

**WY**

**Billings**
-   8.6

**ND**

**SD**

**NE**

** ****Aberdeen**
-     19.6

**MN**

**IA**

**WI**

**MI**

**IN**

**PA**

**NY**

**MA**
**CT**

**ME**

**Percentile**

**Bemidji**
-            10.7

**Phoenix**
-     8.1

**CA**

**California **
- 5.0

**Tucson**
-    18.8

**Navajo**
-       7.4

**Albuquerque**
** **7.7

**TX**

**OK**

**KS**

**Alaska**
-             25.1

**Nashville**
-        2.9

**LA**

**MS**

**AL**

**95-100**

**75 -94**

**50 - 74**

**0 - 49**

**FL**

**TN**

**NC**

**SC**

**NV**

**UT**

**AZ**

**CO**

**NM**

**All IHS Areas Rate – 9.2**
**United States Rate – 3.0**

**Oklahoma City**
-              4.3

## Suicide Rates Ages 0-19,1981-1998

- Native American

- White

- Black

- Data Source:  IHS mortality data for AI/AN; Black/White: NCHS mortality, CDC WISQARS

- 23% increase

**Notes:**
In the IHS service areas for 1997-1998, the AI/AN rate was 2.8 times greater than White rate

## Youth Suicide Risk Factors

- Easy access to lethal means
- Firearm in home = 5 times greater risk
- Local clusters of suicide
- Impulsivity
- Alcohol
- Being Male

*Kellerman AL, Rivara FP, Somes G, et al. Suicide in the home in relation to gun ownership. New England J of Medicine. 1992;327:467-72.  *Photo source: Ryan Hill, IHS, Alaska.

**Notes:**
Drs. Kellerman and Rivara and others found that having a firearm in the home was associated with about a 5- fold increase in the risk of suicide among household residents.
Kellerman AL, Rivara FP, Somes G, et al. Suicide in the home in relation to gun ownership. New England J of Medicine. 1992;327:467-72.

## Percent of Suicides by Method and Sex, Ages 5-19, AI/AN, 1989-1998

- _Data Source_: CDC, WISQARS, 2002.