MCH in Indian Country - Partnerships to Identify and Address Health Disparities

1. MCH in Indian Country - Partnerships to Identify and Address Health Disparities 14th Annual MCH Epidemiology Conference December 10, 2008 Judith Thierry, DO, MPH Indian Health Service Stacy Bohlen National Indian Health Board Title: MCH in Indian Country ~ Partnerships to Identify and Address Health Disparities Sponsors: Sam Posner, Judith Thierry, Lorie Chesnut Proposed Moderator: Judith Thierry, D.O., M.P.H., MCH Coordinator, Indian Health Service (IHS) Session Description: This plenary will consist of three parts. The first will be a brief epidemiologic review of health disparities experienced by American Indians and Alaskan Natives (AIAN) throughout the country (10 minutes). Judith Thierry and Stacy Bohlen, Executive Director, National Indian Health Board The second, a description of partnerships and resources within the national system of care for AIAN including the National and Indian Health Board (including the newly developed Tribal Epidemiology Centers) and the Urban Indian Health Program (20 minutes). Stacy Bohlen, Executive Director, National Indian Health Board The third portion will highlight state partnerships with aforementioned agencies to identify and address health disparities experienced by AIAN. Three states of varying size, resources and proportion of AIAN population will discuss epidemiologic approaches used to identify health disparities and describe how they worked collaboratively to address identified issues for this vulnerable population[1]. For five minutes, state representatives will describe AIAN populations within their jurisdiction, then devoting ten minutes to discussion specific to analytic issues. Suggested states include Alaska, New Mexico and Minnesota (15 minutes per state or 45 minutes for the section). The session will conclude with a wrap-up by the moderator and an opportunity for questions of the panel (15 minutes). between the State of Minnesota and the Great Lakes Tribal Epidemiology Center addresses disparities in infant and maternal mortality through an infant death review project. Justification: While significant improvements have been seen in the area of AIAN maternal and child health in past decades, disparities continue to exist. According to the IHS Regional Differences in Indian Health (2000-2001) report, high birthweight (4,000 grams or more), alcohol and tobacco use during pregnancy, births to diabetic mothers, and infant mortality rates are higher for the AIAN population than for the U.S. population as a whole[2]. Leading causes of infant death also vary between populations, with Sudden Infant Death Syndrome responsible for 18% of AIAN infant deaths as compared with 10.7% of the U.S. population in 1997. Pneumonia and Influenza, a cause of death which signals a lack of access to basic health services, was responsible for 4.2% of AIAN infant deaths while not listed as a leading cause of death for the U.S. population in that same year2. Disproportionate death rates continue into adulthood. Age-adjusted suicide death rates are twice that of the U.S. population with rates in Alaska more than four times the U.S. rate (1997). Age-adjusted rates of death due to unintentional injuries are three times the national average (94.7/100,000) for the AIAN population as compared to a U.S. rate of 30.1/100,000 in 19972. Many of these same disparities have been identified through state Title V annual reporting, which provide progress for MCH Performance Measures. Yet a cursory review of the 2005 Needs Assessments from six western states revealed little evidence of partnerships between state Title V administrations, tribal governments and IHS clinic sites. One major factor identified by state personnel is a lack of understanding about the current system of care and resources to assist problem identification, data analysis and (culturally appropriate) program development for the AIAN population. Our purpose, therefore, is to provide resources for states to increase collaborative efforts for the benefit of pregnant woman, infants and children. Three states have been selected which are diverse in size and with unique health issues. These states will provide examples of innovative epidemiologic partnerships, providing information on challenges when identifying and addressing the health needs of vulnerable populations, successes achieved through collaborative efforts and lessons-learned. Attendees with be provided with the tools necessary to replicate such novel practices in their home states, with their own disparate populations. Moderator: Judith Thierry, D.O., M.P.H., MCH Coordinator, Indian Health Service. Captain Thierry, a board certified Pediatrician, provides technical assistance and MCH leadership to the Office of the Director and the Office of Public Health for the 1.9 million American Indians and Alaskan Natives under the care of the IHS. Working closely with MCH Coordinators across the county and in Urban areas, Dr. Thierry targets infant mortality (including SIDS, birth defects and preventable injuries), tobacco exposure, immunizations and breastfeeding as primary areas for improvement before the end of the current decade. AIAN Disparities and Indian Health System: Stacy A. Bohlen, Executive Director of the National Indian Health Board, (Sault Ste. Marie Chippewa). The National Indian Health Board (NIHB), a national non-profit organization, represents Tribal Governments in the area of health care delivery, whether tribes receive their care directly from the Indian Health Service or through contracting and compacting. The NIHB also works with federal and state governments as well as private foundations. The organization is responsible for policy analysis, research, program assessment, technical assistance and project management. Representing the tribal perspective, the National Indian Health Board works with Area Health Boards that work directly with the 558 tribal governments across the country. Ms. Bohlen will discuss disparities in health outcomes for the MCH population and describe the current Indian health system including the Indian Health Service, National and Area Tribal Health Boards and the Urban Indian Health Program. New Mexico: Alexis Avery, MPH, PhD, Epidemiology/ PRAMS  New Mexico is a culturally diverse state with 9.8% (2006) of its population identified as AIAN and 22 federally recognized tribes residing within its boundaries[3]. A relatively small state with regard to births (28,835 in 2005)[4], New Mexico has developed a rich collection of data query systems and reports specifically on the AIAN population, which are available through the Department for Public Health website. These include the Racial and Ethnic Disparities Report Card - August 1, 2007, and the New Mexico American Indian Health Status Report 2005. Further, because federally recognized tribal affiliations are included on the New Mexico Birth Certificate, data can be analyzed beyond the broad category of AIAN. This allows the development of the New Mexico Tribal Report, which provides data by tribe for MCH measures including low/no-prenatal care, low birth weight, births to diabetic mothers, adolescent births and infant deaths. Minnesota: Sharon T. Smith, Tribal Health Liaison, Office of Minority & Multicultural Health sharon.t.smith@health.state.mn.us While residents of Minnesota generally have a higher level of health than residents of many other states, disparities continue to exist with the AIAN population, particularly within maternal and child health outcomes. Approximately 1% of the state’s population identifies as AIAN3 while in 2005, 2% of all births occurring the state were from this population[5]. This reflects the higher fertility rate and distinct shape of the AIAN population pyramid (as compared to that of the U.S. in general) which is shifted toward a younger population. In particular, postneonatal infant mortality occurs in 5.7/1000 in AIAN infants as compared to 4.2/1000 African American and 1.7/1000 White Minnesotans. Maternal mortality is also elevated within the AIAN population, with a pregnancy-associated death rate (1990-1999) nearly three times higher than that of the White race5. To combat this trend, Minnesota Title V staff work closely with the Great Lakes Tribal Epidemiology Center through an Infant Mortality Review process. Approximately twenty infant deaths have been reviewed in the past year, accompanied by maternal interviews. Through the review process, partners will work together to identify issues and create recommendations to reduce the number of maternal and infant deaths. Alaska: Thalia Wood, MPH, CLS, Children’s Health Unit Manager, Women's Children's and Family Health, Division of Public Health, Department of Health and Social Services thalia.wood@alaska.gov The state of Alaska, with frontier areas covering the majority of its 571,915 square miles and a population density of 1.1 persons per square mile, proves to be a challenging region with regard to health care access. With 13.1% of its population identifying as AIAN3, the familiar term “outreach” has a very different meaning in Alaska, where the Community Health Aides Program identifies and trains indigenous persons to provide care (under the supervision of physicians and mid-level health practitioners) to villages which may be hundreds of miles from the nearest IHS clinic facility. Prop-planes and basket sleds transport health personnel and patients alike over vast distances. It is in such a setting that the Indian Health Service sets the standard for innovation through the creative use of telemedicine, outreach programs and close collaborations with the Alaska State Department for Public Health. Alaska’s Pregnancy Risk Assessment Monitoring Survey (PRAMS) staff works closely indigenous people to assure that survey materials are culturally appropriate and because of this, the survey enjoys a high response rate (83.3% in 2001)[6]. This allows planners to identify major health disparities such as rates of maternal smoking which, during the last three months of pregnancy, exceed 50% as identified by PRAMS data in 2005[7].Title: MCH in Indian Country ~ Partnerships to Identify and Address Health Disparities Sponsors: Sam Posner, Judith Thierry, Lorie Chesnut Proposed Moderator: Judith Thierry, D.O., M.P.H., MCH Coordinator, Indian Health Service (IHS) Session Description: This plenary will consist of three parts. The first will be a brief epidemiologic review of health disparities experienced by American Indians and Alaskan Natives (AIAN) throughout the country (10 minutes). Judith Thierry and Stacy Bohlen, Executive Director, National Indian Health Board The second, a description of partnerships and resources within the national system of care for AIAN including the National and Indian Health Board (including the newly developed Tribal Epidemiology Centers) and the Urban Indian Health Program (20 minutes). Stacy Bohlen, Executive Director, National Indian Health Board The third portion will highlight state partnerships with aforementioned agencies to identify and address health disparities experienced by AIAN. Three states of varying size, resources and proportion of AIAN population will discuss epidemiologic approaches used to identify health disparities and describe how they worked collaboratively to address identified issues for this vulnerable population[1]. For five minutes, state representatives will describe AIAN populations within their jurisdiction, then devoting ten minutes to discussion specific to analytic issues. Suggested states include Alaska, New Mexico and Minnesota (15 minutes per state or 45 minutes for the section). The session will conclude with a wrap-up by the moderator and an opportunity for questions of the panel (15 minutes). between the State of Minnesota and the Great Lakes Tribal Epidemiology Center addresses disparities in infant and maternal mortality through an infant death review project. Justification: While significant improvements have been seen in the area of AIAN maternal and child health in past decades, disparities continue to exist. According to the IHS Regional Differences in Indian Health (2000-2001) report, high birthweight (4,000 grams or more), alcohol and tobacco use during pregnancy, births to diabetic mothers, and infant mortality rates are higher for the AIAN population than for the U.S. population as a whole[2]. Leading causes of infant death also vary between populations, with Sudden Infant Death Syndrome responsible for 18% of AIAN infant deaths as compared with 10.7% of the U.S. population in 1997. Pneumonia and Influenza, a cause of death which signals a lack of access to basic health services, was responsible for 4.2% of AIAN infant deaths while not listed as a leading cause of death for the U.S. population in that same year2. Disproportionate death rates continue into adulthood. Age-adjusted suicide death rates are twice that of the U.S. population with rates in Alaska more than four times the U.S. rate (1997). Age-adjusted rates of death due to unintentional injuries are three times the national average (94.7/100,000) for the AIAN population as compared to a U.S. rate of 30.1/100,000 in 19972. Many of these same disparities have been identified through state Title V annual reporting, which provide progress for MCH Performance Measures. Yet a cursory review of the 2005 Needs Assessments from six western states revealed little evidence of partnerships between state Title V administrations, tribal governments and IHS clinic sites. One major factor identified by state personnel is a lack of understanding about the current system of care and resources to assist problem identification, data analysis and (culturally appropriate) program development for the AIAN population. Our purpose, therefore, is to provide resources for states to increase collaborative efforts for the benefit of pregnant woman, infants and children. Three states have been selected which are diverse in size and with unique health issues. These states will provide examples of innovative epidemiologic partnerships, providing information on challenges when identifying and addressing the health needs of vulnerable populations, successes achieved through collaborative efforts and lessons-learned. Attendees with be provided with the tools necessary to replicate such novel practices in their home states, with their own disparate populations. Moderator: Judith Thierry, D.O., M.P.H., MCH Coordinator, Indian Health Service. Captain Thierry, a board certified Pediatrician, provides technical assistance and MCH leadership to the Office of the Director and the Office of Public Health for the 1.9 million American Indians and Alaskan Natives under the care of the IHS. Working closely with MCH Coordinators across the county and in Urban areas, Dr. Thierry targets infant mortality (including SIDS, birth defects and preventable injuries), tobacco exposure, immunizations and breastfeeding as primary areas for improvement before the end of the current decade. AIAN Disparities and Indian Health System: Stacy A. Bohlen, Executive Director of the National Indian Health Board, (Sault Ste. Marie Chippewa). The National Indian Health Board (NIHB), a national non-profit organization, represents Tribal Governments in the area of health care delivery, whether tribes receive their care directly from the Indian Health Service or through contracting and compacting. The NIHB also works with federal and state governments as well as private foundations. The organization is responsible for policy analysis, research, program assessment, technical assistance and project management. Representing the tribal perspective, the National Indian Health Board works with Area Health Boards that work directly with the 558 tribal governments across the country. Ms. Bohlen will discuss disparities in health outcomes for the MCH population and describe the current Indian health system including the Indian Health Service, National and Area Tribal Health Boards and the Urban Indian Health Program. New Mexico: Alexis Avery, MPH, PhD, Epidemiology/ PRAMS New Mexico is a culturally diverse state with 9.8% (2006) of its population identified as AIAN and 22 federally recognized tribes residing within its boundaries[3]. A relatively small state with regard to births (28,835 in 2005)[4], New Mexico has developed a rich collection of data query systems and reports specifically on the AIAN population, which are available through the Department for Public Health website. These include the Racial and Ethnic Disparities Report Card - August 1, 2007, and the New Mexico American Indian Health Status Report 2005. Further, because federally recognized tribal affiliations are included on the New Mexico Birth Certificate, data can be analyzed beyond the broad category of AIAN. This allows the development of the New Mexico Tribal Report, which provides data by tribe for MCH measures including low/no-prenatal care, low birth weight, births to diabetic mothers, adolescent births and infant deaths. Minnesota: Sharon T. Smith, Tribal Health Liaison, Office of Minority & Multicultural Health sharon.t.smith@health.state.mn.us While residents of Minnesota generally have a higher level of health than residents of many other states, disparities continue to exist with the AIAN population, particularly within maternal and child health outcomes. Approximately 1% of the state’s population identifies as AIAN3 while in 2005, 2% of all births occurring the state were from this population[5]. This reflects the higher fertility rate and distinct shape of the AIAN population pyramid (as compared to that of the U.S. in general) which is shifted toward a younger population. In particular, postneonatal infant mortality occurs in 5.7/1000 in AIAN infants as compared to 4.2/1000 African American and 1.7/1000 White Minnesotans. Maternal mortality is also elevated within the AIAN population, with a pregnancy-associated death rate (1990-1999) nearly three times higher than that of the White race5. To combat this trend, Minnesota Title V staff work closely with the Great Lakes Tribal Epidemiology Center through an Infant Mortality Review process. Approximately twenty infant deaths have been reviewed in the past year, accompanied by maternal interviews. Through the review process, partners will work together to identify issues and create recommendations to reduce the number of maternal and infant deaths. Alaska: Thalia Wood, MPH, CLS, Children’s Health Unit Manager, Women's Children's and Family Health, Division of Public Health, Department of Health and Social Services thalia.wood@alaska.gov The state of Alaska, with frontier areas covering the majority of its 571,915 square miles and a population density of 1.1 persons per square mile, proves to be a challenging region with regard to health care access. With 13.1% of its population identifying as AIAN3, the familiar term “outreach” has a very different meaning in Alaska, where the Community Health Aides Program identifies and trains indigenous persons to provide care (under the supervision of physicians and mid-level health practitioners) to villages which may be hundreds of miles from the nearest IHS clinic facility. Prop-planes and basket sleds transport health personnel and patients alike over vast distances. It is in such a setting that the Indian Health Service sets the standard for innovation through the creative use of telemedicine, outreach programs and close collaborations with the Alaska State Department for Public Health. Alaska’s Pregnancy Risk Assessment Monitoring Survey (PRAMS) staff works closely indigenous people to assure that survey materials are culturally appropriate and because of this, the survey enjoys a high response rate (83.3% in 2001)[6]. This allows planners to identify major health disparities such as rates of maternal smoking which, during the last three months of pregnancy, exceed 50% as identified by PRAMS data in 2005[7].

2. IHS is divided into 12 Administrative regions called Area offices. Some areas cover multiple states. IHS service population is ~ 1.9 million Reservations are found in 35 states. IHS is divided into 12 Administrative regions called Area offices. Some areas cover multiple states. IHS service population is ~ 1.9 million Reservations are found in 35 states.

3. Indian Health Service, DHHS Health Care System “ITU” Federal - 12 Area Offices, 31 Hospitals, 52 Health Centers, 31 Health Stations, 2 School Clinics Tribal - 15 Hospitals, 254 Health Centers, 166 Alaska Village Clinics, 112 Health Stations, 18 School Clinics Urban Indian Programs - 34 community to comprehensive health care programs Population Served: Members of 562 federally recognized Tribes 1.9 million American Indians and Alaska Natives residing on or near reservations 600,000 American Indians in urban clinics Annual Patient Services (Tribal and IHS facilities): Inpatient Admissions:  58,281 Outpatient visits:  10,173,528 Appropriations: FY 2007 IHS budget appropriation: $3.2 billion FY 2008 proposed IHS budget appropriation: $3.3 billion IHS Third-Party Collections: FY 2007 - $628 million; FY08 (estimated) - $780 million (IHS Fact Sheet - http://info.ihs.gov/Profile08.asp online December 6, 2008) Physicians – 854 18% vacancy Nurses – 2524 20% vacancy Dentists – 281 32% vacancy Pharmacists – 499 11% vacancy Engineers - 401 Sanitarians - 143Population Served: Members of 562 federally recognized Tribes 1.9 million American Indians and Alaska Natives residing on or near reservations 600,000 American Indians in urban clinics Annual Patient Services (Tribal and IHS facilities): Inpatient Admissions:  58,281 Outpatient visits:  10,173,528 Appropriations: FY 2007 IHS budget appropriation: $3.2 billion FY 2008 proposed IHS budget appropriation: $3.3 billion IHS Third-Party Collections: FY 2007 - $628 million; FY08 (estimated) - $780 million (IHS Fact Sheet - http://info.ihs.gov/Profile08.asp online December 6, 2008) Physicians – 854 18% vacancy Nurses – 2524 20% vacancy Dentists – 281 32% vacancy Pharmacists – 499 11% vacancy Engineers - 401 Sanitarians - 143

4. Urban Indian Health Organizations Nationwide (34) urban Indian health organizations. YRBS -Desceribe health risk behaviors in urban AIAN -Identify disparities with white youth -Published in latest MCH journal supplement Birth &Death files (PPOR) Identify periods of highest risk for infant mortality among AIAN in WA, OR and ID NSFG -Examine correlates of unintended pregnancy in AI/AN compared to non-AIAN women PRAMS -Examine stressful life events, social support and prenatal care among AIAN in WA and ORurban Indian health organizations. YRBS -Desceribe health risk behaviors in urban AIAN -Identify disparities with white youth -Published in latest MCH journal supplement Birth &Death files (PPOR) Identify periods of highest risk for infant mortality among AIAN in WA, OR and ID NSFG -Examine correlates of unintended pregnancy in AI/AN compared to non-AIAN women PRAMS -Examine stressful life events, social support and prenatal care among AIAN in WA and OR

5. Tribal Epidemiology Centers (TEC) Closing the Health Gap SIDS and Infant Mortality Initiative Building MCH Epidemiology Capacity Alaska Native Tribal Health Consortium -ANTHC Epi Center North West Portland Area Indian Health Board TEC Great Lakes Inter-Tribal Council TEC United South and Eastern Tribes TEC Inter Tribal Council of Arizona, Inc TEC Northern Plains Tribal Epidemiology Center AATCHB Seattle Indian Health Board/ Urban Indian Health Institute Tribal epidemiology centers: The findings of this capacity needs assessment highlight current areas of strength and need in providing MICH care to urban AI/AN. Findings document a need for additional pregnancy and infant health services at many sites. Available MCH data confirm a number of areas that put urban AI/AN at risk for adverse birth outcomes and significantly increased rates of infant mortality compared to the general population. Increased resources to support MCH services offered by UIHOs may effectively reduce observed disparities. http://www.sihb.org/UIHI.html Tribal epidemiology centers: The findings of this capacity needs assessment highlight current areas of strength and need in providing MICH care to urban AI/AN. Findings document a need for additional pregnancy and infant health services at many sites. Available MCH data confirm a number of areas that put urban AI/AN at risk for adverse birth outcomes and significantly increased rates of infant mortality compared to the general population. Increased resources to support MCH services offered by UIHOs may effectively reduce observed disparities. http://www.sihb.org/UIHI.html

6. Maps are useful to get the distribution of IHS programs across the US and how they aggregate states. They are quite regional. Some states are not represented. Remember again that the Seattle Indian Health Board Epi Center links back to slide 10 and the 36 programs in yet again a different distribution of states. Maps are useful to get the distribution of IHS programs across the US and how they aggregate states. They are quite regional. Some states are not represented. Remember again that the Seattle Indian Health Board Epi Center links back to slide 10 and the 36 programs in yet again a different distribution of states.

7. “Native Americans rank at or near the bottom of nearly every social, health and economic indicator.” AI/AN Alone 2,476,956 Multiple-Race 1,643,345 AI/AN Alone/Combination 4,199,301 2000 Census Bridged Population AI/AN 2,984,150 IHS Projections for 2000 AI/AN 2,484,773 AI/AN Alone 2,476,956 Multiple-Race 1,643,345 AI/AN Alone/Combination 4,199,301 2000 Census Bridged Population AI/AN 2,984,150 IHS Projections for 2000 AI/AN 2,484,773

8. Expenditure categories by Medicare, VA, US per capita, Medicaid acute care, federal prisons, IHS medical care.Expenditure categories by Medicare, VA, US per capita, Medicaid acute care, federal prisons, IHS medical care.

10. Proportions tell the story 4 – 7 x the rate Proportions tell the story 4 – 7 x the rate

11. From the IHS photo archives – Navajo Hogan elder and youth Two ends of the life spectrum Education on traditions, respect as a way of life, From the IHS photo archives – Navajo Hogan elder and youth Two ends of the life spectrum Education on traditions, respect as a way of life,

12. In some areas – Rocky Boy Reservation several tribal census tracts for example in Northern Montana the < age 24 population is 66%In some areas – Rocky Boy Reservation several tribal census tracts for example in Northern Montana the < age 24 population is 66%

14. YRBS 2003, Navajo Nation High Schools, BIE Funded Schools, Arizona Public Schools & the U.S. Navajo Nation High Schools Bureau of Indian Education (BIE) Schools Arizona Public Schools US 2003 YRBS Systems issues 70% of AIAN graduate from high school – 10% lower than US races population Navajo Nation High Schools Bureau of Indian Education (BIE) Schools Arizona Public Schools US 2003 YRBS Systems issues 70% of AIAN graduate from high school – 10% lower than US races population

15. Infant Mortality by UIHO Service Areas The Health Status of Urban Indians and Alaska Natives: An Analysis of Select Vital Records and Census Data Sources March 2004 Source: Urban Indian Health Institute, a division of the Seattle Indian Health Board The Health Status of Urban Indians and Alaska Natives: An Analysis of Select Vital Records and Census Data Sources

16. How can this population as an indicator for other groups with in the state This does not break out pregestational or gestational diabetes or insulin requiring or non insulin requiring. Stephen Bacak, Myra Tucker – reported on 5 tertieary medical centers (Phoenix, Alaska, Oklahoma and two on Navajo) maternal morbidity, realted to c-sections. Skilled birth attendants – midwives involved in over 90% of cases. Case management of diabetics is the norm, Centering pregnancy – group prenatal care Doulas Public health nurse prenatal are a priority. C-section rates are lower than the US – VBAC rate is sustained How can this population as an indicator for other groups with in the state This does not break out pregestational or gestational diabetes or insulin requiring or non insulin requiring. Stephen Bacak, Myra Tucker – reported on 5 tertieary medical centers (Phoenix, Alaska, Oklahoma and two on Navajo) maternal morbidity, realted to c-sections. Skilled birth attendants – midwives involved in over 90% of cases. Case management of diabetics is the norm, Centering pregnancy – group prenatal care Doulas Public health nurse prenatal are a priority. C-section rates are lower than the US – VBAC rate is sustained

17. IHS All Areas 19.8% Of those with low birth weight infants roughly 25% smoked Variation by area is to be noted. IHS IMR has an elevated post neonatal rate due to SIDS Partnerships with CDC – SUIDI – trainings of EMS, community health representatives and other first responders Sharon Smith will elaborate on what Minnesota is providing. IHS All Areas 19.8% Of those with low birth weight infants roughly 25% smoked Variation by area is to be noted. IHS IMR has an elevated post neonatal rate due to SIDS Partnerships with CDC – SUIDI – trainings of EMS, community health representatives and other first responders Sharon Smith will elaborate on what Minnesota is providing.

18. Aberdeen Area Tribal Chairman’s Health Board - Northern Plains Tobacco Control Project Segmented emotional messaging or does it reach a wider population Culturally specific Northern Plains Culturally sensitive – well healthy babies, twins Clear air AIAN tobacco use rates exceed US all races rates Partnership with OWH, CDC, NIAAA, NIH OWH, looking to address tobacco and Low SES women GED or no HS more likely to smoke and smoking by age 14 – life time and heavy use is supported. Remember the YRBS adolescents were smoking at 40 – 50% Aberdeen Area Tribal Chairman’s Health Board - Northern Plains Tobacco Control Project Segmented emotional messaging or does it reach a wider population Culturally specific Northern Plains Culturally sensitive – well healthy babies, twins Clear air AIAN tobacco use rates exceed US all races rates Partnership with OWH, CDC, NIAAA, NIH OWH, looking to address tobacco and Low SES women GED or no HS more likely to smoke and smoking by age 14 – life time and heavy use is supported. Remember the YRBS adolescents were smoking at 40 – 50%