NCHS Data Brief ■ No. 372 ■ August 2020

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

National Center for Health Statistics

Health of American Indian and Alaska Native Adults, 

by Urbanization Level: United States, 2014–2018

Maria A. Villarroel, Ph.D., Tainya C. Clarke, Ph.D., M.P.H., and Tina Norris, Ph.D.

Key findings

Data from the National 

Health Interview Survey

● The age-adjusted percentage

of American Indian and Alaska

Native (AIAN) adults in fair

or poor health did not differ

by urbanization level and was

higher than all U.S. adults.

● The percentage of AIAN

adults with a disability

decreased from 18.9% in large

metropolitan statistical areas

(MSAs) to 12.9% in rural areas.

● The percentage of AIAN

adults with multiple chronic 

conditions increased from 

28.6% in large MSAs to 35.5% 

in rural areas. 

● The percentage of AIAN

adults with diagnosed 

hypertension was highest in 

medium and small MSAs 

(35.7%) and rural areas (35.0%). 

● The percentage of AIAN

adults with diagnosed

diabetes was highest in rural

areas (18.9%).

Historically, the American Indian and Alaska Native (AIAN) population in 

the United States has faced health disparities including greater prevalence of 

physical and mental health problems and high uninsured rates when compared 

with the non-AIAN population (1). Almost 80% of the AIAN population 

resides outside of reservations or land trusts and about 40% reside in rural 

areas (2). Rural Americans are more likely to die from preventable or selfmanageable conditions (3), and risk factors and health conditions may vary 

by urbanization level (4). This report examines differences in the percentage 

of selected health status and conditions by urbanization level between AIAN 

adults and all U.S. adults.

The age-adjusted percentage of adults in fair or poor health 

varied by urbanization level among all adults, but not 

AIAN adults.

NCHS reports can be downloaded from: https://www.cdc.gov/nchs/products/index.htm.

1Significantly different from total U.S. adults (p < 0.05). 2Significantly different from U.S. adults living in large MSAs (p < 0.05). 3Significantly different from U.S. adults living in medium and small MSAs (p < 0.05). 4Significantly different from U.S. adults living in rural counties (p < 0.05). 5Significant quadratic trend by urbanization level (p < 0.05).

NOTES: MSA is Metropolitan Statistical Area. Respondents were asked to assess their own health and that of family members 

living in the same household as excellent, very good, good, fair, or poor. When the sample adult is not the family respondent, this 

information is reported by a proxy. Classification of sample adults' county of residence was based on the 2013 NCHS Urban–Rural 

Classification Scheme for Counties. Estimates are age adjusted by the direct method to the 2000 projected U.S. population using

age groups 18–44, 45–64, 65–74, and 75 and over. Crude estimates of American Indian and Alaska Native adults in fair and poor 

health were 20.5% for total, 18.2% in large MSAs, 22.8% in medium and small MSAs, and 22.0% in rural counties. Access data 

table for Figure 1 at: https://www.cdc.gov/nchs/data/databriefs/db372-tables-508.pdf#1. 

SOURCE: National Center for Health Statistics, National Health Interview Survey, 2014–2018. 

 

 

 

 

 

 

 

Figure 1. Age-adjusted percentage of adults aged 18 and over in fair or poor health status, by 

selected race and urbanization level: United States, 2014–2018

 

 

 

 

 

 

 
NCHS Data Brief ■ No. 372 ■ August 2020

■  2  ■

Among AIAN adults, the age-adjusted percentage in fair or poor health did not differ by 

urbanization level, while the percentage of all U.S. adults who were in fair or poor health was 

higher for those in rural areas (15.6%) than those in large metropolitan statistical areas (MSAs) 

(11.1%) and in medium and small MSAs (12.4%) (Figure 1). AIAN adults (20.6%) were more 

likely to be in fair or poor health than all U.S. adults (12.1%) within each level of urbanization 

and among the total population. 

The age-adjusted percentage of adults with a disability differed by AIAN 

origin and urbanization level. 

The age-adjusted percentage of AIAN adults with a disability was almost twice as high (16.3%) 

as all U.S. adults (8.9%) (Figure 2). The percentage of AIAN adults with a disability decreased 

with decreasing urbanization level, from 18.9% among those living in large MSAs to 12.9% 

among those living in rural areas. The percentage of all U.S. adults with a disability increased 

with decreasing urbanization level, from 7.9% in large MSAs to 11.5% in rural areas. The 

percentage of AIAN adults with a disability was higher than all U.S. adults among those living in 

large MSAs (18.9% compared with 7.9%) and medium and small MSAs (16.0% compared with 

9.5%) but there was no difference in rural areas. 
NCHS Data Brief ■ No. 372 ■ August 2020

■  3  ■

The age-adjusted percentage of adults with multiple chronic conditions 

differed by urbanization level for AIAN and all U.S. adults. 

About one-third of AIAN adults (31.9%) had multiple chronic conditions, compared with about 

one-fourth of all U.S. adults (24.2%) (Figure 3). The age-adjusted percentage of adults with 

multiple chronic conditions increased with decreasing urbanization level for both AIAN and all 

U.S. adults. The percentage with multiple chronic conditions was higher for AIAN adults than all 

U.S. adults among those living in large MSAs (28.6% compared with 22.6%), medium and small 

MSAs (33.2% compared with 25.4%), and rural areas (35.5% compared with 28.9%). 
NCHS Data Brief ■ No. 372 ■ August 2020

■  4  ■

The age-adjusted percentage of adults diagnosed with hypertension 

differed by AIAN origin and urbanization level. 

The age-adjusted percentage of AIAN adults with diagnosed hypertension was 33.7%, which 

was higher than the percentage among all U.S. adults (28.7%) (Figure 4). Among AIAN adults, 

the percentage with diagnosed hypertension was highest for those living in medium and small 

MSAs and rural areas, whereas among all U.S. adults, the percentage of adults with diagnosed 

hypertension increased with decreasing urbanization level. The percentage of AIAN adults with 

diagnosed hypertension was higher than all U.S. adults among those living in large MSAs (31.6% 

compared with 27.5%) and among those in medium and small MSAs (35.7% compared with 

29.5%), but similar for those in rural areas. 
NCHS Data Brief ■ No. 372 ■ August 2020

■  5  ■

The age-adjusted percentage of adults diagnosed with diabetes differed by 

urbanization level for AIAN and U.S. adults. 

The age-adjusted percentage of AIAN adults with diagnosed diabetes was almost twice (15.0%) 

as high as all U.S. adults (8.6%) (Figure 5). The percentage of adults with diagnosed diabetes 

was highest among those living rural areas for both AIAN and all U.S. adults. The percentage of 

AIAN adults with diagnosed diabetes was higher than all U.S. adults among those living in large 

MSAs (13.7% compared with 8.3%), medium and small MSAs (13.5% compared with 8.6%), 

and rural areas (18.9% compared with 10.4%). 

Summary 

In general, AIAN adults were more likely to be in fair or poor health, have a disability, have 

multiple chronic conditions, and to have been diagnosed with hypertension and diabetes 

compared with all U.S. adults. This finding was consistent across most urbanization levels.

Health trends by urbanization level varied among AIAN adults and among all U.S. adults. While 

the percentage of all U.S. adults with disabilities and diagnosed hypertension increased steadily 

with decreasing urbanization level, and the percentage in fair or poor health was highest in rural 

areas, these trends did not parallel those among AIAN adults. In contrast to all U.S. adults, the 

percentage of AIAN adults with disabilities decreased steadily with urbanization level, diagnosed 
NCHS Data Brief ■ No. 372 ■ August 2020

■  6  ■

hypertension was similarly highest for those in medium and small MSAs and in rural areas, and 

the percentage in fair or poor health status did not differ by urbanization level. 

Among AIAN adults and among all U.S. adults, the percentage with diagnosed diabetes was 

highest in rural areas, and the percentage with multiple chronic conditions increased steadily with 

decreasing urbanization level. Previous research shows that rural residents have an increased risk 

of chronic health conditions and may experience greater barriers to health care access that may 

exacerbate these conditions compared with residents in more urbanized areas (4–6). 

Understanding the factors driving differences in health status and disability may be informative to 

efforts to curtail health disparities among AIAN adults, particularly those living in smaller-sized 

MSAs and rural areas. 

Definitions

American Indian and Alaska Natives (AIAN): Based on any mention of American Indian or 

Alaska Native to the question, “What race or races [do you/does person] consider [yourself/

himself/herself] to be?” 

Diagnosed diabetes: Based on a positive response to the survey question, “Have you ever been 

told by a doctor or health professional that you have diabetes or sugar diabetes?” Women were 

asked to exclude diagnoses received only during pregnancy.

Diagnosed hypertension: Based on a positive response to the survey question, “Have you ever 

been told by a doctor or health professional that you had hypertension?”

Disability: Based on the reported level of difficulty (no difficulty, some difficulty, a lot of 

difficulty, or cannot do at all/unable to do) in six domains of functioning: seeing (even if 

wearing glasses), hearing (even if wearing hearing aids), mobility (walking or climbing stairs), 

communication (understanding or being understood by others), cognition (remembering or 

concentrating), and self-care (such as washing all over or dressing). Adults who respond “a lot 

of difficulty” or “cannot do at all/unable to do” to at least one domain are classified as having a 

disability. 

Health status: Based on a fair or poor response when asked if the sample adult’s health is 

excellent, very good, good, fair, or poor. When the sample adult is not the family respondent, this 

information is reported by a proxy.

Multiple chronic conditions: Based on a doctor or other health care professional’s diagnosis of 

at least 2 of 10 selected chronic conditions. These selected conditions were based on previous 

research (7,8) and included ever having a diagnosis of hypertension, cancer, stroke, coronary 

heart disease, diabetes (excluding gestational diabetes), arthritis (including rheumatoid arthritis, 

gout, lupus, and fibromyalgia), hepatitis, a current diagnosis of asthma, a diagnosis of weak or 

failing kidneys in the past 12 months, and a diagnosis of chronic obstructive pulmonary disease 

(COPD), emphysema, or chronic bronchitis in the past 12 months. 

Urbanization level: For this report, urbanization level was categorized by collapsing the 2013 

NCHS Urban–Rural classification scheme for counties (9) into 1) large MSAs (central and fringe 

counties in MSAs of 1 million or more persons); 2) medium and small MSAs (counties in MSAs 
NCHS Data Brief ■ No. 372 ■ August 2020

■  7  ■

with 250,000 to 999,999 persons and counties in MSAs of less than 250,000 persons; and 3) rural 

(counties in micropolitan statistical areas and noncore counties).

Data source and methods

This analysis used pooled 2014–2018 National Health Interview Survey (NHIS) data. NHIS 

is a nationally representative multipurpose health survey of the civilian noninstitutionalized 

U.S. population. It is conducted continuously throughout the year by the National Center for 

Health Statistics (NCHS). Interviews are conducted in the respondent’s home, but follow-ups to 

complete interviews may be conducted by telephone when necessary. For more information about 

NHIS, visit: https://www.cdc.gov/nchs/nhis.htm.

Point estimates and the corresponding variances were calculated using SAS-callable SUDAAN 

version 11.0 (10) to account for the complex sample design of NHIS. Sample adult sampling 

weights were adjusted for pooled data and included the Adult Functioning and Disability 

sampling weights to account for the split-ballot design of the disability questions during 

2014–2017. All estimates in this report meet NCHS standards of reliability as specified in 

the “National Center for Health Statistics Data Presentation Standards for Proportions” (11). 

Estimates were age-adjusted using the direct method and adjusted to the 2000 U.S. standard 

population, using four age groups: 18–44, 45–64, 65–74, and 75 and over. Linear and quadratic 

trends by urbanicity were evaluated using Proc Descript, Poly option. Differences between 

percentages were evaluated using two-sided significance tests at the 0.05 level. The estimated 

standard error of the difference between AIAN adults and U.S. estimates accounted for 

nonindependence of AIAN and U.S. estimates by incorporating their covariance.

About the authors

Maria A. Villarroel, Tainya C. Clarke, and Tina Norris are with the National Center for Health 

Statistics, Division of Health Interview Statistics.

References

1. Jones DS. The persistence of American Indian health disparities. Am J Public Health 

96(12):2122–34. 2006.

2. Office of Minority Health, Profile: American Indian/Alaska Native profile. U.S. Department 

of Health and Human Services. Available from: http://minorityhealth.hhs.gov/omh/browse.

aspx?lvl=3&lvlid=62.

3. Callaghan TH, Ferdinand AO, Akinlotan M, Primm K, Lee JS, Macareno B, Bolin J. Healthy 

People 2020 progress for leading causes of death in rural and urban America: A chartbook. Policy 

brief. Southwest Rural Health Research Center. 2019. Available from: https://srhrc.tamhsc.edu/

docs/chartbook-march-2020.pdf.

4. Meit M, Knudson A, Gilbert T, Yu ATC, Tanenbaum E, Ormson E, et al. The 2014 update of 

the rural-urban chartbook. Rural Health Reform Policy Research Center. 2014. Available from: 

https://ruralhealth.und.edu/projects/health-reform-policy-research-center/pdf/2014-rural-urbanchartbook-update.pdf.
NCHS Data Brief ■ No. 372 ■ August 2020

5. Rural Health Information Hub. Rural Health Disparities. 2019. Available 

from: https://www.ruralhealthinfo.org/topics/rural-health-disparities.

6. National Council on Disability. Understanding disabilities in American 

Indian & Alaska Native Communities: Toolkit guide. Available from: 

https://ncd.gov/publications/2003/Aug12003.

7. Goodman RA, Posner SF, Huang ES, Parekh AK, Koh HK. Defining and 

measuring chronic conditions: Imperatives for research, policy, program, and 

practice. Prev Chronic Dis 10:120239. 2013.

8. U.S. Department of Health and Human Services. Multiple chronic 

conditions—A strategic framework. Optimum health and quality of life 

for individuals with multiple chronic conditions. Washington, DC: U.S. 

Department of Health and Human Services. 2010. Available from: 

https://www.hhs.gov/sites/default/files/ash/initiatives/mcc/mcc_framework.pdf.

9. Ingram DD, Franco SJ. 2013 NCHS urban–rural classification scheme 

for counties. National Center for Health Statistics. Vital Health Stat 2(166). 

2014.

10. RTI International. SUDAAN (Release 11.0.3) [computer software]. 2018.

11. Parker JD, Talih M, Malec DJ, Beresovsky V, Carroll M, Gonzalez JF 

Jr, et al. National Center for Health Statistics data presentation standards for 

proportions. National Center for Health Statistics. Vital Health Stat 2(175). 

2017. 

Keywords: disability • chronic conditions • urban rural • National Health 

Interview Survey. 

Suggested citation

Villarroel MA, Clarke TC, Norris T. Health 

of American Indian and Alaska Native 

adults, by urbanization level: United States, 

2014–2018. NCHS Data Brief, no 372. 

Hyattsville, MD: National Center for Health 

Statistics. 2020.

Copyright information

All material appearing in this report is in 

the public domain and may be reproduced 

or copied without permission; citation as to 

source, however, is appreciated. 

National Center for Health 

Statistics

Brian C. Moyer, Ph.D., Director

Amy M. Branum, Ph.D., Acting Associate 

Director for Science

Division of Health Interview Statistics

Stephen J. Blumberg, Ph.D., Director

Anjel Vahratian, Ph.D., M.P.H., Associate 

Director for Science

For e-mail updates on NCHS publication 

releases, subscribe online at: 

https://www.cdc.gov/nchs/email-updates.htm.

For questions or general information

about NCHS:

Tel: 1–800–CDC–INFO (1–800–232–4636)

TTY: 1–888–232–6348

Internet: https://www.cdc.gov/nchs

Online request form: https://www.cdc.gov/info

ISSN 1941–4927 Print ed.

ISSN 1941–4935 Online ed.

CS318046 

U.S. DEPARTMENT OF

HEALTH & HUMAN SERVICES

Centers for Disease Control and Prevention

National Center for Health Statistics

3311 Toledo Road, Room 4551, MS P08

Hyattsville, MD 20782–2064

OFFICIAL BUSINESS 

PENALTY FOR PRIVATE USE, $300

For more NCHS Data Briefs, visit:

https://www.cdc.gov/nchs/products/databriefs.htm.

FIRST CLASS MAIL 

POSTAGE & FEES PAID 

CDC/NCHS

PERMIT NO. G-284