Journal of Pediatric Psychology, Vol. 27, No. 8, 2002, pp. 717-725
© 2002 Society of Pediatric Psychology
Health Risks in American Indian Adolescents: A Descriptive Study of a Rural, Non-Reservation Sample
1 University of North Dakota, 2 Oklahoma State University
All correspondence should be sent to Jacqueline Gray, USDA/ARS Grand Forks Human Nutrition Research Center, Box 9034, Grand Forks, North Dakota 58202. E-mail: jgray{at}gfhnrc.ars.usda.gov.
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Abstract |
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Objective: To identify health risks among a rural, non-reservation group of American Indian adolescents.
Methods: A non-reservation sample of 243 American Indian students from a total sample of 1,815 students in a southwestern state completed health-risk screenings in the public schools. The students were between 14 and 18 years of age and in grades 9 through 12. Archival survey data were analyzed by age, gender, and race.
Results: Student reports of health-risk behaviors in the areas of physical health, substance use, emotional health, risk of injury, perceived grades, and academic expectations were examined. The majority of study participants reported average or below levels of health risks.
Conclusions: Non-reservation American Indian students have average or better health habits and expect to continue their educations beyond high school. There are some differences by gender and age.
Key words: health risk; American Indian; adolescents.
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Introduction |
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In the United States, there are wide disparities between the health status and practices of ethnic minority populations and the majority population. The predominant health problems among American Indians stem from risk behaviors related to injuries and chronic diseases (Rhoades, Hammond, Welty, Hanadler, & Amber, 1987
; Sugarman, Warren,
Oge, & Helgerson, 1992). Little research is available about
the health-promoting and health-damaging behaviors in ethnic minority groups
(Anderson, 1995). American
Indians have the highest injury death rate of any group in the United States
at all ages (Indian Health Service [IHS],
2000). A number of health risks have been identified among
American Indian people, the most common of which include alcohol abuse and
dependency (Austin, 1988;
Bagley, Angel, Dilworth-Anderson, Liu,
& Schinke, 1995; Beauvais
& LaBoeff, 1985, May, 1994;
Oetting & Beauvais, 1990),
unintentional injuries, and chronic diseases
(Bagley et al., 1995;
Rhoades et al., 1987;
Sugarman et al, 1992;
Yee et al., 1995). Cigarette
smoking, diet, obesity, and limited exercise are other health risk factors
associated with ethnic minority groups, including Native Americans
(Kagawa-Singer, Kumanyika, Lex, &
Markides, 1995).
Adolescent morbidity and mortality are closely associated with health-risk
behaviors such as substance use, unprotected sex, and violence (Centers for
Disease Control and Prevention [CDC], 1995). A national study by the CDC
(1998) found that 72% of
adolescent deaths were the result of motor vehicle accidents, unintentional
injuries (many occurring under the influence of alcohol or other drugs),
homicides, and suicides. Most of these deaths were preventable. In another
national study conducted by the CDC
(2000), findings for American
Indian/Alaskan students were combined with the larger sample because the
number of American Indian/Alaskan students was too low to analyze separately
(101/15,249 participants). Little research is available on the incidence of
health-risk behaviors among American Indian adolescents. In one study of
13,454 American Indian and Alaskan Native adolescents from reservations and
Alaskan villages in eight IHS areas, poor physical health was associated with
physical/sexual abuse, suicide attempts, substance abuse, poor school
performance, and nutritional inadequacy
(Blum, Harmon, Harris, Bergeisen, &
Resnick, 1992). Sex differences in health risk behaviors were also
noted in this study.
Health risk behaviors may also vary by reservation status. Morbidity and
mortality for health risk—related deaths for states with more urban and
non-reservation American Indians such as California and Oklahoma are lower
than those with predominantly reservation-based American Indian residents
(IHS, 2000). Of interest, no
research was available from non-reservation adolescents. More research is
needed in exploring the wellness and health-risks behaviors of American Indian
adolescents in order to develop more effective health promotion and behavioral
interventions.
The purpose of this research project was to explore the health risks of non-reservation American Indian adolescents. While this study is primarily descriptive and exploratory, we hypothesized that there would be differences in the health-risk behaviors of male and female adolescents. We also hypothesized that the health risks reported in the non-reservation sample would be more reflective of health risk behaviors for the majority culture than American Indian adolescents living on reservations, with the exception of family history of chronic disease.
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Method |
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Participants
Two hundred forty-three non-reservation American Indian students in several school districts in a south-western state were among the 1,815 (1,572 non-Indian) public high school students administered the Senior High School Health Risk Inventory (SHRI; Dewey, 1991
) as part of the schools' routine wellness screenings
completed by the state department of health. These data were archival and
housed in the state department of health. No information was available as to
these students' tribal affiliations, except that they self-identified as
American Indian or Alaskan on the wellness survey. The surveys were
administered in a geographic area where tribes of eastern woodland origins
reside. Most of these American Indian students came from homes where both biological parents resided (n=98; 40.3%); 58 students (23.9%) came from homes with one parent and one stepparent; 54 students (22.2%) were currently living in a single parent home; 33 students (13.6%) identified their living situation in other categories.
Procedure
The Commissioner of Health approved the analysis of the archival health
risk database. Participants' identities (including individual students and
schools) were not included in the database provided to the researchers.
One hundred thirty-one American Indian boys and 112 girls completed the SHRI. A summary of the participants by age, grade, and living situation is provided in Table I. The majority were 15 (n = 68; 28.0%) or 16 (n = 68; 28.0%) years old, with a range in age from 14 to 18 years old. Students identified themselves as being in either the 9th grade (n = 54; 22.2%), 10th grade (n = 99; 40.7%), 11th grade (n = 38; 15.6%), or 12th grade (n = 52; 21.4%).
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Instrument
The SHRI is a 40-item screening instrument that measures the degree to
which high school students engage in health-related behaviors such as eating
habits, dental care, physical fitness, tobacco use, alcohol use, drug use,
personal safety, aggression, suicidal ideation and intention, stress,
depression, grief, sexual activity and sexually transmitted diseases, and
level of support. Students reviewed each item and rated the extent to which
they engaged in wellness or health-risk behaviors. Student responses were
scored by computer program and archived into the database.
While this instrument has been widely used by schools for wellness
screenings, there have been no published findings on the psychometric
properties of the SHRI until now. Internal consistency reliability for the
SHRI was computed for the total sample (Cronbach 
= .83). Cronbach
alphas for non-Indian and Indian participants were .83 and .81, respectively.
Although caution and careful interpretations are necessary considerations when
using instruments developed based on majority culture with ethnic minority
students, we believed that this survey instrument assesses important
information about general health behaviors among Indian and non-Indian
students. The relevant variables are listed in Tables
II and
III. The SHRI also provides
information on student demographic variables (i.e., gender, race, living
situation, age, and grade level) and perceptions of grades and academic goals.
Total scores on the SHRI can range from 0 to 100, with lower scores
representing significant health risks and higher scores representing healthier
attitudes and behaviors.
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Results |
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The mean total score on the SHRI for this sample of American Indian high school students was 71.47 with a standard deviation of 17.51 (female: M = 76.27, SD = 13.93; male: M = 67.27, SD = 19.14). Mean total score for the non-Indian participants was 76.22 with a standard deviation of 16.65 (female: M = 78.67, SD = 15.07; Male: M = 74.24, SD = 17.59). The following categories were developed (Dewey, 1991
) to
identify each participant's overall wellness or level of health risk based on
SHRI total scores: excellent or very low risk (scores of 90 and above), good
or low risk (scores of 80 to 89), fair or average risk (scores of 70 to 79),
risky or high risk (scores of 50 to 69), and hazardous or very high risk
(scores of 49 and below). Overall, the American Indian/Alaskan students in
this sample reported an average risk of health-related problems. The frequency
distributions of Indian boys' and girls' SHRI total health risk scores are
listed by category in Table II.
This table also includes their ratings of perceived grades and academic
expectations. Girls in the study tended to have better overall health habits than boys, with 48.2% of girls (n = 54) and 32.8% of boys (n = 43) having "Good" or "Excellent" health habit scores. Boys in the study (46.6%; n = 61) scored more frequently in the "Risky" to "Hazardous" health habit categories compared to girls (26.8%; n = 30).
More Indian girls with higher perceived grades and health risk scores (i.e., increased wellness) expected to go farther in school, while grades and health risk scores did not appear to affect the academic expectations of Indian boys. Almost 80% (77.8%, n = 189; non-Indian: 81.7%, n = 1,285) of Indian students planned to continue their education beyond high school. Indian students who reported above average grades were more likely to have total health habit scores in the "good" to "excellent" range (50%; n = 41; non-Indian: 31.8%, n = 501) compared to Indian students who reported below average grades (20.8%, n = 5; non-Indian: 0.8%, n = 13). In addition, Indian students who planned to continue their education beyond high school were more likely to have "good" to "excellent" (34.5%, n = 84; non-Indian: 46.5%, n = 831) total health habit scores compared to those who planned to stop with a high school education (23.7%, n = 14; non-Indian: 50.8%, n = 91).
Description of Findings for Health-Risk Categories
American Indian students' endorsement of health risks was further analyzed
by gender over four general categories based upon factor loadings of the items
and previous research (Blum et al.,
1992; CDC, 2000):
(1) physical health habits, (2) emotional health habits, (3) substance use,
and (4) risk of injurious behaviors. All responses are listed in
Table III.
Physical Health. The items examined under the physical health
habits category contained elements related to family health history, dental
care, diet, and exercise. While a family history of heart attack, high blood
pressure, stroke, and diabetes and higher-risk dietary habits was common, good
dental hygiene and use of exercise was evident. At least 63% of all Indian
students in this sample had a family history of serious health problems, and
20.1% of students did not know if there was a history of these diseases in
their families. Both Indian boys and girls had significantly higher incidences
of family history of chronic diseases than their non-Indian counterparts (male
2[2] = 7.5, p = .024; female 2[2] =
6.15, p = .046). Indian girls, however, were more aware of this
family history than Indian boys (2[2] = 12.92, p =
.002) In terms of dental care, 96.3% of students (n = 234) brushed
their teeth daily or almost daily and 75.3% (n = 183) had seen the
dentist within the past year.
Indian girls (37%) were more likely to be on a diet to lose weight compared
to Indian boys (10.7%; 2[1] = 24.48, p = .000). Over
half of the Indian students ate breakfast less than three times per week. This
was significantly more common in Indian boys than non-Indian boys
(2[2] = 16.89, p = .001). Over three-fourths of
Indian students ate junk food and red meat and over half ate fried foods at
least three times per week. Indian boys ate red meat significantly more often
than Indian girls (2[3] = 11.67, p = .009). However,
significantly fewer Indian boys ate junk food than the non-Indian boys
(2[3] = 8.25, p = .041). Older Indian students (age
16 or older for girls and age 17 and older for boys) ate junk food, fried
foods, and red meat less often than younger Indian students in this sample.
Most of the students reported being physically active, with 58.4% of Indian
students getting 30 minutes of aerobic exercise and 68.3% participating in
recreational activities at least three times per week. Indian boys, however,
reported significantly more aerobic exercise than girls (2[3]
= 9.0, p = .029). Significantly more Indian girls participated in
recreational activities more often than non-Indian girls (2[3]
= 7.98, p = .046).
Emotional Health. Emotional health habits included stress-related
issues, depression, feeling that life was not worth living, serious personal
losses, and suicidal thoughts or attempts. Only 12.3% of the Indian students
in this sample felt a lot of stress from school pressures. Indian girls
(47.3%) reported more home stress than Indian boys (26.7%;
2[3] = 19.99, p = .000). For girls, the stresses at
home increased between the ages of 15 and 16 and then decreased. For boys, the
peak stresses at home were between the ages of 16 and 17. Less than one in ten
Indian students indicated a lot of stress in dating relationships (8.8%,
n = 22), with the girls being significantly more stressed than the
boys (2[3] = 8.12, p = .044). More Indian girls (25%)
than boys (11.4%) indicated they had been depressed in the past six months
(2[3] = 8.90, p = .031). At the same time, Indian
girls (8.4%) had significantly fewer close personal friends than non-Indian
girls (13.3%; 2[3] = 10.86, p = .013). Girls (Indian:
83.9%; non-Indian 86.2%), in general, reported seeking support from friends or
family more frequently than boys (Indian: 62.6%; 2[3] = 18.83,
p = .000; non-Indian: 64.3%; 2[3] = 147.87,
p = .000). In addition, Indian boys reported feeling depressed in the
past 6 months more so than non-Indian boys (2[3] = 8.93,
p = .030). While Indian girls (68.7%) and boys (64.3%) did not
significantly differ in their feelings that life was not worth living,
significantly more Indian males than non-Indian males (83.6%) felt this way
(2[3] = 17.32, p = .001). Reports of depression
peaked at age 16 for boys and 15 for girls, with less depression in boys and
girls at age 17. Forty-three percent of all Indian students had suffered at
least one serious personal loss, such as the break-up of a relationship,
parental divorce, or the death of someone close to them, within the past 6
months. More Indian girls than boys had experienced the suicide of a friend or
classmate (2[1] = 4.43, p = .035). Serious thoughts
or attempts of suicide peaked at age 15 for girls, but numbers of Indian boys
having thoughts or attempts of suicide remained constant across ages.
Fifteen-year-old girls indicated more serious losses including the suicide of
a friend or classmate, while boys experienced increases in their personal
losses between the ages of 16 and 18. However, 37.4% of boys rarely or never
sought support from friends or family compared to 16.1% of girls
(2[3] = 18.83, p = .000).
Substance Use. Those areas addressed under the substance use
behaviors domain included tobacco, alcohol, marijuana, cocaine, crack, and
other drug use. Substance use in general was more common and more frequent
among Indian boys than girls. The majority of Indian students did not smoke.
However, smoking was significantly higher in Indian students than non-Indian
students (male 2[4] = 20.52, p = .000; female
2[4] = 10.14, p = .038), and smoking was
significantly higher in Indian boys than girls (2[4] = 9.76,
p = .045). The frequency of smoking was lowest among the 14-year-old
students. The number of smokers and the amount of cigarettes smoked increased
with each age group until age 17 for boys and age 16 for girls, when the
number of smokers and amount used began to decline. No Indian girls in this
study reported using smokeless tobacco, while 16.1% of Indian boys did so
daily (2[4] = 42.98, p = .000).
Drinking alcohol at least once a week was reported by more Indian boys than
girls (2[4] = 18.05, p = .001). In addition, more
Indian boys drank at least three alcoholic beverages in a week (28.3%)
compared to Indian girls (9%; 2[4] = 18.05, p =
.001). Drinking of alcohol increased until 16 for both Indian boys and girls.
Indian girls began to drop in their alcohol consumption and frequency at 16,
while Indian boys tended to remain constant through 18. Weekly marijuana use
was reported by 17.5% of the Indian boys and only 7.2% of the Indian girls
(2[4] = 8.6, p = .07). In addition, Indian boys used
marijuana more frequently than non-Indian boys (2[4] = 13.92,
p = .008). Crack and cocaine use was very rare in Indian boys (1.5%);
however, they used cocaine significantly more than Indian girls (0%;
2[3] = 8.01, p = .046).
Injury Risk. The behaviors identified as putting students at risk
of injury included driving or riding with someone under the influence of drugs
or alcohol; not using seatbelts; riding motorcycles, especially without a
helmet; having access to a gun or knife; and being involved in physical
fights. As with substance use, these injury risk behaviors were seen more
commonly in Indian boys than girls. Indian boys (40.5%) were more likely to
drive or ride with someone under the influence of drugs or alcohol in the past
6 months compared to non-Indian boys (29.6%; 2[3] = 13.97,
p = .003). In addition, Indian boys (27.6%) were less likely to wear
seatbelts than Indian girls (10.7%; 2[3] = 14.39, p =
.002). Although Indian boys (44.3%) rode motorcycles more often than Indian
girls (17%), they also were less likely to wear a helmet, with 27.5% of boys
and 6.3% of girls never wearing a helmet when riding (2[3] =
22.07, p = .000).
Although the majority of these Indian students (males: 90.1%; females:
45.5%) have easy access to a gun or a knife because of the rural area and high
incidence of hunting and fishing among residents of the area, this was not
viewed as unusual. Boys, in general, had greater access to a weapon than girls
(Indian: 2[1] = 56.6, p = .000; non-Indian:
2[4] = 232.74, p = .000). In addition, 62.2% of
Indian boys and 41% of Indian girls reported being in a physical fight in the
past year (2[2] = 12.03, p = .002). Fighting was more
common for the younger girls (14 to 15) than the older ones (16 and older).
The same was true for boys. Fighting for boys increased until 16 and began
declining in numbers of fights at age 17. Many of these students included
fights with siblings that resulted in hitting, kicking, or slapping.
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Discussion |
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Responses to the wellness screening survey by this group of rural, non-reservation American Indian high school students from a southwestern state revealed that over half of Indian boys, compared to 70% of non-Indian boys, and three-fourths of Indian girls, compared to four-fifths of non-Indian girls, practiced average or above health habits as defined by Dewey (1991
). Indian adolescents in
this study engaged in some significant health-risk behaviors and appear to be
experiencing some significant stressors in their lives. In general, Indian
boys and girls did not differ too much on physical health risks. However, they
were more likely to report family histories of significant health problems
compared to non-Indian students. Indian girls reported more emotional health
risks (e.g., depressed moods, home and relationship stress, and knowing
someone who committed suicide) than Indian boys. Indian boys were more likely
to report injury risk behaviors (e.g., riding without fastening their
seatbelts, riding motorcycles without helmets, getting into physical fights,
having access to a gun or knife) and substance use behaviors (e.g., smoking
cigarettes, using smokeless tobacco, drinking alcohol, using marijuana and
cocaine) compared to Indian girls. When comparing Indian students to non-Indian students, a few differences in health risk behaviors were noted. Indian students were more likely to report family histories of significant health problems and were more likely to smoke cigarettes compared to non-Indian students. Indian boys were more likely to feel that life was not worth living and to drive or ride with someone under the influence compared to non-Indian boys. Indian girls were more likely to participate in recreational activities, but also reported having few close friends compared to non-Indian girls.
In terms of perceived performance in school, over 5 in 6 Indian boys (9 of 10 non-Indian) and 19 in 20 Indian girls (24 of 25 non-Indian) believed their grades were average or above when compared to their peers. In addition, five out of six American Indian adolescents (four of five non-Indian) indicated a plan to continue their education beyond high school. This is an interesting finding since American Indians have one of the highest high school dropout rates in the country and this sample was almost identical to their non-Indian counterparts. It is important to follow this study with longitudinal studies that track the health behaviors and actions of students to see if they are able to follow through with these plans.
In previous studies, the top three causes of death among adolescents in the
United States are accidents, homicide, and suicide, with 20% of all
mortalities resulting from drunk driving
(Julien, 1998). American
Indian adolescent boys have the highest suicide rate of any ethnic group
(CDC, 2000). The incidence of
suicidal ideation and attempts in this non-reservation American Indian sample
was lower than that reported in a national survey
(Blum et al., 1992). The
possibilities of more hope of success and resources for education and
employment for this non-reservation sample when compared to many reservation
situations could be one explanation for the difference. Further exploration of
these issues would be necessary to provide effective interventions.
In this sample, 15-year-old female American Indian students were more
likely to drive (ride with someone) under the influence; that may be due to
not having a driver's license and dating older partners who were drinking. For
some of these rural youths, there may be no alternative form of transportation
available to them after drinking. In this study, 15-year-old girls and
16-18-year-old boys were more likely to be depressed and to use substances
compared to students other age groups in this study, which compared to the
results reported by Blum et al.
(1992). The lack of privacy and
mental health resources in rural communities makes it more difficult for these
students to seek help.
There are a number of practical implications for health care professionals (e.g., medical doctors, psychologists, healers) and school officials based on the findings of this study. Health promotion and education activities regarding injury prevention (i.e., using seatbelts, promoting the use of motorcycle helmets, gun safety, etc.) would be important with adolescents in general and specifically with American Indian students who are at higher risk of injury.
In addition, nutrition education and the link between healthy behaviors and preventing the diseases that are chronic in the majority of Indian families would be important considerations. The majority of these Indian students have good habits regarding exercise at this time in their lives. They need to be encouraged to continue to maintain an active lifestyle and examine how activities can be continued throughout their lifespans. Although adolescents, because of their active lifestyle, can eat more junk food, red meat, and fried foods than adults without effects on cholesterol, heart disease, and diabetes, it would be important to emphasize healthy eating habits to be maintained into adulthood rather than dieting, which is more common among adolescent girls than adolescent boys, who are more interested in increasing body mass.
It is also important to screen for depression, stress, and isolation (e.g., may have fewer friends), especially among Indian girls. The majority of Indian girls in this study reported having good social support and sought it out regularly. While the majority of Indian students in this study seek support from friends and family, it is important to develop family communication and support networks that would be an integral part of maintaining the cultural family support and relieving some of the stresses of walking in two worlds.
Indian boys in this study appear to be more at risk for health problems than girls. They reported more injury risks and more substance problems than girls. Boys were also less likely to seek support from family and friends. Indian boys were also more likely to feel depressed and to feel that life was not worth living compared to non-Indian boys. Based on all of this information, Indian boys may need special attention from psychologists, other health care professionals, and cultural and spiritual leaders to reduce these risks and, most important, to reach out and provide support. It is important to support their efforts to seek help when it is needed.
The limitations of this study include the use of archival data with no additional source to validate the students' self-reports. The findings of this study should be interpreted with caution when applying these results to other ethnic minority student groups. In addition, since differences occur among various tribes and nations, the findings of this study should also be interpreted with caution, particularly for American Indian students who come from non-rural and reservation settings. There are some obvious limitations with any self-report measure such as wellness screening instruments: (1) participants may or may not accurately report their current behaviors and experiences, and (2) the measures are limited in the number of questions available to assess for each domain of interest. Although different wellness studies have used different measures of health risk and wellness, this is the first study that has explored the use of the SHRI. Despite the increased use of the SHRI in schools' wellness screenings across the nation, more research is needed to confirm the reliability and validity of this instrument.
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Acknowledgments |
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We thank the Oklahoma Department of Health for permission to use its archival data for the purposes of this study. We also appreciate the assistance of Timothy Daheim, Charla Hall, and John Romans with regard to this research project.
Received March 16, 2001; revision received July 12, 2001; accepted January 21, 2002
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