1 table, 2 figures omitted
Injuries account for 75% of all deaths among American Indian and Alaska
Native (AI/AN) children and youth,1 and
AI/ANs have an overall injury-related death rate that is twice the U.S. rate
for all racial/ethnic populations.2 However,
rate disparities vary by area and by cause. To help focus prevention efforts,
CDC analyzed injury mortality data by Indian Health Service (IHS) administrative
area and by race/ethnicity. This report summarizes the results of these analyses,
which indicate that although death rates for some causes (e.g. drowning and
fire) have shown substantial improvement over time, rates for other causes
have increased or remained unchanged (e.g., homicide and suicide, respectively).
Prevention strategies should focus on the leading causes of injury-related
death in each AI/AN community, such as motor-vehicle crashes, suicides, and
Mortality data were obtained from CDC's National Center for Health Statistics
(NCHS) for 1989-1998 for black and white children and youth (i.e., those aged
£19 years) and from NCHS mortality data that IHS has categorized into
the 12 IHS administrative areas* in which AI/AN children and youth reside.
Rate calculations were based on deaths attributed to injuries that occurred
among children and youth. All rates were age-adjusted by using the 2000 U.S.
standard population. AI/AN rates were calculated by using the IHS service
population for 1989-1998 on the basis of modified 1990 census data and vital-event
data for 1989-1998. Black, white, and overall U.S. death rates were calculated
by using CDC's Web-Based Injury Statistics Query and Reporting System (WISQARS).3 The external cause of each injury death was derived
from the International Classification of Diseases, Ninth
Revision (ICD-9) E-codes. Causes of death included unintentional motor-vehicle
crashes, unintentional pedestrian events, firearm use, suicide, homicide,
unintentional drowning, and unintentional fire. The firearm category included
all firearm-related deaths, including those from suicide, homicide, and unintentional
or undetermined intent. Because of changes in code definitions and coding
rules between ICD-9 (1998 data and earlier) and ICD-10 (1999 and later), analyses
that combine data across coding schemes are problematic for some causes; for
this reason, the study period ended with 1998 mortality data.
During 1989-1998, injuries and violence were associated with 3,314 deaths
among AI/ANs aged £19 years residing in IHS areas. Motor-vehicle crashes
were the leading cause of injury-related death, followed by suicide, homicide,
drowning, and fires. Death rates for all causes were higher among AI/AN males
than females; however, the difference was smaller for fire-related deaths.
During 1989-1998, injury death rates declined for AI/ANs from all motor-vehicle
crashes (14%), drownings (34%), and fires (49%), and for pedestrians (56%);
rates increased for firearm-related death (13%) and homicide (20%) and remained
unchanged for suicide. When method was assessed, increases in the rate of
firearm-related homicide accounted for the overall increase in the overall
AI/AN motor-vehicle–related death rates by IHS area ranged from
11.4 per 100,000 population in the Alaska area to 41.2 in the Billings area.
The Aberdeen and Billings areas had rates more than three times higher than
national rates. Eight of the areas had motor-vehicle–related death rates
higher than the 95th percentile of all state rates. Rates in the California
and Oklahoma areas were similar to national rates.
AI/AN suicide rates were highest in the Tucson, Aberdeen, and Alaska
areas. These areas had rates that were five to seven times higher than overall
U.S. rates. Northern areas such as Aberdeen, Alaska, Bemidji, and Billings
all had suicide rates higher than the 95th percentile of all state rates.
The lowest suicide rates occurred in the California, Nashville, and Oklahoma
areas. Firearms (52%) and hanging (37%) were the leading methods of suicide
for AI/AN youth.
Despite decreases in injury rates for some causes, AI/AN rates for all
injuries combined were two times greater than overall U.S. rates (49.4 versus
24.0, respectively). Compared with blacks and whites, AI/AN children and youth
had the highest injury-death rates for motor-vehicle crashes, pedestrian events,
and suicide. Rates for these causes among AI/AN children and youth were two
to three times greater than rates for whites the same age. Black children
and youth had the highest rates for homicide and firearm deaths. AI/AN and
black children and youth had similar rates for fire-related deaths and drowning,
and both groups had higher rates than white children and youth.
LJD Wallace, MSEH, R Patel, MPH, A Dellinger PhD, Div of Unintentional
Injury Prevention, National Center for Injury Prevention and Control, CDC.
AI/AN children and youth are at greater risk for preventable injury-related
death than other children in the United States. Although AI/AN death rates
from motor-vehicle crashes, pedestrian events, drowning, and fire decreased
during 1989-1999, the overall injury disparity compared with rates for whites
persists. AI/AN children and youth have not benefitted to the same degree
as white children and youth from interventions in areas such as traffic safety
(e.g., increased child-restraint use, safety-belt use, and reductions in alcohol-impaired
driving).4 Primary enforcement of occupant-restraint
laws (i.e., stopping a driver solely for a restraint violation) combined with
active enforcement and public awareness are the most effective strategies
for increasing occupant-restraint use.5 The
majority of AI/AN tribes are considered sovereign nations and pass and enforce
their own traffic-safety laws. Several tribes have passed occupant-protection
laws, but enforcement of these laws often is challenging for the mostly rural
tribal police departments.4 AI/ANs have
the highest alcohol-related motor-vehicle–death rates of all racial/ethnic
groups,6 which places children at risk when
riding with impaired drivers and puts youth at risk as drivers and passengers.
In states with reservations, an estimated 75% of suicides, 80% of homicides,
and 65% of motor-vehicle–related deaths among AI/ANs involve alcohol.7 Young drivers are at risk particularly for dying
in a car crash as a result of driver inexperience, nighttime driving, and
alcohol use. Several tribes have the authority to restrict driving privileges
on the reservations, enforce a lower blood-alcohol concentration (BAC) limit
(e.g., 0.02 g/dL BAC for underage drinking), and set curfew ordinances to
help reduce deaths from motor-vehicle crashes.4
During 1989-1999, homicide accounted for the largest increase in injury-death
rates among AI/ANs. Despite advances in knowledge about how to prevent youth
violence,8 more needs to be learned about
how to apply these advances to the prevention of youth violence in AI/AN communities.
Suicide rates for AI/AN youth did not decline during the study period and
were especially high in the Alaska, Aberdeen, and Tucson areas. The AI/AN
Community Suicide-Prevention Center and Network in New Mexico has reduced
suicides among AI/AN youth with a community-based approach involving school-based
youth helpers, mental health referral and assistance, and outreach to families.9 Additional research is needed to determine the
risk factors and reasons for the substantially higher suicide rates in the
Alaska and Aberdeen areas and for the protective factors in other IHS areas
with lower rates.
The findings in this report are subject to at least one limitation.
Injury-mortality rates probably underestimate the true rates for AI/ANs because
of the misclassification of race/ethnicity on state death certificates.10 Misclassification of AI/AN race/ethnicity is estimated
to range from 30% (California) to 1% (Navajo Nation) depending on IHS area.10
AI/AN tribes and IHS recognize the importance of preventing injuries
and are working to reduce this burden. In 2000, IHS funded 25 tribes for 5
years to build tribal capacity in injury prevention by establishing injury-prevention
programs in tribal health departments. The majority of these programs address
occupant protection for reducing motor-vehicle–related injuries and
other high-priority injuries depending on local need. In Alaska, strategies
include float-coat and personal flotation–device promotion and distribution
programs to prevent drowning, safe firearm storage with gun-safe programs,
and suicide prevention programs. Substantial improvements also have been made
in reducing fire-related deaths among AI/ANs. One promising intervention program
is Sleep Safe, a smoke alarm–distribution and education program targeting
children and families in AI/AN Headstart Schools. Sleep Safe, which is supported
by IHS and the U.S. Fire Administration, has funded programs in 55 Headstart
schools and has distributed approximately 11,000 smoke alarms to AI/AN families
(H. Cully, Oklahoma Area IHS, personal communication, 2003).
Interventions should be tailored to specific local settings and problems.
For interventions to be successful, local practices and cultures need to be
considered. Such efforts are needed to reduce and eliminate the injury-disparity
gap between AI/AN and other U.S. children.
*Aberdeen, Alaska, Albuquerque, Bemidji, Billings, California, Nashville,
Navajo, Oklahoma, Phoenix, Portland, and Tucson.
Injury Mortality Among American Indian and Alaska Native Children and
Youth—United States, 1989-1998. JAMA. 2003;290(12):1570-1571. doi:10.1001/jama.290.12.1570