Commentary: Advancing American Indian Health Surveillance with Tribal Colleges

The 2014 U.S. Surgeon General’s Report, The Health Consequences of Smoking-50 Years of Progress, provides an in-depth description of the public health community’s success in reducing cigarette smoking and other forms of tobacco use over the last five decades. Effective health surveillance systems implemented at the community, state and national level have documented significant changes in American’s beliefs, attitudes, and behaviors related to tobacco use. The most significant accomplishments charted by health surveillance systems is the decline of cigarette smoking among adults in the U.S. from 42 percent in 1965, to 18 percent in 2012. The positive gains against tobacco use can be attributed to a well-coordinated, science-driven response to a major public health crisis that has brought together public health professionals, policy makers, researchers and other tobacco control stakeholders across multiple sectors for a singular purpose.

Health surveillance and monitoring continues to be an integral pillar of public health and is present throughout all phases of planning, implementing and evaluating high quality interventions that aim to improve health and prevent disease. Unfortunately, good surveillance data is still not available across all tribal nations nor are surveillance activities being implemented regularly enough to observe longitudinal behavioral trends among those reservation and urban American Indian populations that have begun to establish initial bench marks. So the question is, how do we support the formation of intra-tribal coalitions mobilized around the improvement of public health and driven by data? Strengthening linkages between tribal-elected officials, traditional leaders, public health advocates and research institutions is perhaps an excellent place to begin. Projects like Legacy’s Tribal College Health Initiative support tribal self-determination and are important in building tribal capacity to collect, analyze, interpret and put to action health surveillance data.

Despite all that is known about the economic and health consequences of commercial tobacco abuse, an estimated 42 million Americans (18.1 percent) continue to smoke. American Indians and Alaska Natives have the second highest smoking prevalence (21.8 percent) after individuals of multiple race (26.1 percent); however, American Indian and Alaska Native smoking differs substantially by region and sampling techniques used to determine the prevalence of American Indian smoking at the national level still has a lot left to be desired.

While the public health model driving long-term change in tobacco-related outcomes can be described as a continuous cyclical process, the implementation of effective health surveillance systems has yielded comprehensive data pivotal in shaping public policy, informing health priorities and tracking success over time. Comprehensive data that is both population-specific and statically accurate allows us to tailor public health interventions to meet the needs of our target subpopulations.

A second opportunity for success that arises from the availability of tribally specific health surveillance data pertains to opinions related to smoking in public places. There is tremendous support for limiting smoking in tribal offices, restaurants, community centers and work areas. Legacy discovered that 93.9 percent of adult tribal members within one tribe believed that non-smokers are entitled to breathe air free of tobacco smoke in public places. In fact, the overwhelming majority of tribal members within all three tribal communities participating in the Legacy initiative believed that smoking should not be allowed anywhere in indoor environments. Opportunities to increase smoking cessation interventions to occasional “someday” smokers and expand coverage of protected clean indoor air are just two recommendations that come out of tribally specific health surveillance data.

Prior to 2005, less than one decade ago, tribally specific tobacco and other health surveillance data were nearly nonexistent. Data collected at the state and national level frequently had wide-ranging margins of error and were not precise enough to be meaningful to tribes. However, much progress has been made to improve data collection techniques, train the American Indian public health workforce, improve efficiency of data collection and reduce the overall expense of surveillance research. Not only have unique tools for collecting data among American Indian populations (I.E. American Indian Adult Tobacco Survey and the Community Health and Wellbeing Survey) become more available, but the approach to engage American Indian communities in the research process has been completely redefined with respect to the acknowledgement of tribal sovereignty and infrastructure development.

Collaborative partnerships connecting public health stakeholders in order to build research capacity and pool limited resources is increasingly becoming more important as tobacco control and other public health funding are not as consistently directed toward tribes. Chronic disease, behavioral health and education professionals can all benefit from good quality surveillance data and collaborative surveillance efforts are likely to yield the best possible outcomes where the data needs of a tribal community are maximized.

Legacy’s Tribal College Health Initiative was designed to develop capacity of tribal colleges to engage in health surveillance research. Tribal colleges and universities, which have an intimate connection with the communities in which they reside, are in an excellent position to participate in collaborative surveillance efforts. Ultimately, it is a coalition of stakeholders representing multiple sectors within a tribe that will make any research-based initiative a success, with each partner contributing their own special areas of expertise and resources. Tribal health departments and Indian Health Service’s Tribal Epidemiology Centers are obvious partners that frequently lead such operations. However, tribal colleges and universities bring important resources to the table which frequently include, but are not limited to:

1. An understanding of tribal leadership, political systems and the research review process;
2. Legitimacy from tribal governments;
3. Faculty that are frequently familiar with the research process even if their specific discipline is not in public health; and
4. A large pool of students, many of whom would greatly benefit from participating and receiving college credit for engaging in community-based participatory research that impacts their community.

The continued development of tribal collaborations assembled for the purpose of health surveillance implementation is essential to the sustainability of American Indian health surveillance efforts. In addition to tribal colleges, each stakeholder brings their unique expertise to improve the process. Among those most likely to be interested in health surveillance collaborations include tribal health departments, IHS tribal epidemiology centers, tribal health and human service committees (elected leadership), universities and epidemiological technical assistance centers, K-12 education institutions and behavioral health services, particularly prevention professionals. For more information about health surveillance or Legacy’s Tribal College Health Initiative please visit www.legacyforhealth.org.

Favian Kennedy MSW currently serves as the Executive Director of the Health Education and Promotion Council. He served as the principal investigator for Legacy’s Tribal Health College Initiative and can be contacted at Favian@heapc.org.