Preventive Health Care among Rural American Indians in New Mexico

Preventive Medicine 28, 194–202 (1999)Article ID pmed.1998.0401, available online at http://www.idealibrary.com on

Preventive Health Care among Rural American Indians in New Mexico1

Frank D. Gilliland, M.D., Ph.D.,*,†,‡,2 Renate Mahler, M.A.,† W. Curtis Hunt, M.A.,† andSally M. Davis, Ph.D.,§

*Department of Medicine, †New Mexico Tumor Registry, Epidemiology and Cancer Control Program, and §Center for Health Promotionand Disease Prevention, University of New Mexico Health Sciences Center, Albuquerque, New Mexico 87131; and

‡Division of Occupational and Environmental Health, Department of Preventive Medicine, and Norris Comprehensive Cancer Center,University of Southern California Health Sci

Key Words: American Indian; ethnicity; epidemiol-ogy; survey methods; preventive health; immuniza-

Background. Incidence of and mortality from cardio-vascular disease, cancer, diabetes, and other chronicdiseases are rapidly increasing among American Indi-ans; however, the utilization of preventive services forthese conditions is not well characterized in these eth-nic groups.

Methods. We interviewed 1,273 American Indianadults in New Mexico, ages 18 years and older, by tele-phone regarding routine health checks, includingblood pressure, blood cholesterol, mammograms, clini-cal breast exams, Pap smears, influenza and pneumo-nia vaccinations, and diabetes using items from theCDC Behavioral Risk Factor Surveillance System.

Results. We found that utilization of preventive ser-vice was surprisingly high among rural American Indi-ans. Routine health checks and blood pressure checkswithin the past year were reported by more than 70%of the population. Blood cholesterol checks (41.1%) andpneumonia vaccinations (30.7%) were less commonlyreported. Utilization of cancer screening for the mostcommon women’s cancers was also high. Most womenreported ever having a Pap smear test (88.3%), a clinicalbreast examination (79.5%), and a mammogram (75.6%).The prevalence of diagnosed diabetes (8.8% overall and26.4% for ages 50 years and older) greatly exceeds thenationwide prevalence.

Conclusions. The utilization of preventive servicesdelivered by a unique governmental partnership ishigh among American Indians in New Mexico and, ex-cept for cholesterol screening, is comparable with rates

1 This research was initiated and analyzed by the investigators,but received financial support from the Centers for Disease Controland Prevention through a core grant awarded to the University ofNew Mexico Center for Health Promotion and Disease Prevention.

2 To whom correspondence and reprint requests should be ad-dressed at 2325 Camino de Salud, NE, Albuquerque, NM 87131-5306. Fax: (505) 272-8572.

194

ences Center, Los Angeles, California 90033

for the U.S. population. Because cardiovascular dis-ease is on the rise, more attention to preventive ser-vices in this arena is warranted. The high and increas-ing prevalence of diagnosed diabetes suggests thataggressive diabetes screening and interventions areneeded. q1999 American Health Foundation and Academic Press

tions; screening.

INTRODUCTION

During the last half of the twentieth century, theburden of preventable chronic diseases has increasedconsiderably among American Indians. Epidemiologicstudies show the leading causes of mortality within thispopulation are cardiovascular disease [1–4], diabetes[2,4–8], cancer [9], and respiratory diseases [10–15].According to the Strong Heart Study, cardiovasculardisease has become the leading cause of death, althoughvariability is noted by tribe and region [3]. Cancer- andHIV-related deaths are also on the increase. However,diabetes mortality increased substantially over the past2 decades and, if present trends continue, it may becomethe primary cause of death among American Indiansin the next century [16].

Although much has been documented about the prev-alence of preventable chronic diseases and illnessesamong American Indians, little information is availableabout the utilization of immunizations, medical screen-ing, and testing to prevent or reduce the morbidity andmortality associated with these conditions. Althoughsuch preventive services are available at no cost to mostrural American Indians through the Indian Health Ser-vice (IHS) or other programs, a number of nonfinancialbarriers have been documented, such as limited accessdue to distance and availability of transportation and a
reluctance to use the services that may not be culturallyappropriate for the patient. American Indians residing
0091-7435/99 $30.00Copyright q 1999 by American Health Foundation and Academic Press

All rights of reproduction in any form reserved.

R
AMERICAN INDIAN P
in New Mexico benefit from an exceptionally well-coor-dinated partnership between federal, state, and tribalorganizations. The model collaboration is not typical ofother regions in the United States and other tribes maynot have access to a similar level of services.

To determine the extent to which prevention andearly detection services were utilized by the AmericanIndian population in New Mexico, we surveyed a sam-ple of this population through telephone interviews.The objectives of the survey were to estimate the preva-lence of routine health checkups, blood pressure andcholesterol screenings, screening mammography andclinical breast examinations, Pap smears, and influ-enza and pneumonia immunizations; to describe thevariation of these health prevention screenings and im-
munizations by age, sex, marital status, and income;
college graduate. Sample weights were computed as the

and to compare survey results, where possible, withdata from a survey of the U.S. population and the gen-eral New Mexico population using the same question-naire items.

METHODS

To assess population-based utilization of preventiveservices, we conducted the New Mexico American In-dian Behavioral Risk Factor Survey (AIBRFS). TheAIBRFS interviewed 1,273 rural New Mexico AmericanIndians 18 years and older residing throughout thestate of New Mexico. Almost two-thirds of the respon-dents (828) were women. Because 88% of the New Mex-ico American Indian population resides in rural areas,our survey focused on rural communities [17].

The AIBRFS consisted of an 80-item questionnaireadapted from the Behavioral Risk Factor SurveillanceSystem (BRFSS), a national surveillance system ad-ministered by the Centers for Disease Control and Pre-vention (CDC) [18]. Although questionnaire items wereworded exactly as on the BRFSS, the introduction,question order, and transitional phrases of the ques-tionnaire were adapted for use with rural AmericanIndians, based on suggestions from an American Indianadvisory committee. Question items about preventivehealth care addressed how frequently respondents re-ceived routine health checkups, blood pressure checks,blood cholesterol checks, screening mammograms, clin-ical breast exams, and Pap smear tests. We also askedwhether respondents had received a pneumonia vacci-nation or an influenza vaccination in the past year andwhether they had ever been diagnosed with high bloodpressure, high blood cholesterol, or diabetes. If they
were diagnosed as diabetic, respondents were askedtheir age at the time of diabetes diagnosis.
Data were collected by computer-aided telephone in-terviewing and by paper-and-pencil recording methods.Because data from a commercial survey firm indicated

EVENTIVE HEALTH 195

that relatively few (18.9%) of all rural New Mexico tele-phone numbers were unlisted (unpublished data, Sur-vey Sampling, Inc.), we used listed household telephonenumbers and targeted geographic areas known to havea large proportion of American Indian residents to in-crease the efficiency of our survey. We defined ruralareas as all areas of New Mexico except BernalilloCounty, Don

˜a Ana County, and the city of Santa Fe. To

ensure a good mix of gender and age groups in thesurvey, we included a screening question in the inter-view script asking for the respondent to be an AmericanIndian and to be the member of the household at least18 years of age who had most recently had a birthday.Quality control activities included standardized inter-viewer training, on-site supervision, and verificationcallbacks to a random sample of 60 survey respondentswithin 10 days of the initial telephone interview inorder to monitor the authenticity and accuracy of theinterviews. All data were edited, coded, and combinedinto one data set for analysis with the SAS (version6.12) and SUDAAN (release 7.0) softwares [19,20].

For comparison between rural New Mexico AmericanIndians and all New Mexicans and the U.S. population,we compared our AIBRFS survey data to the New Mex-ico and national surveillance data reported annuallyfor the BRFSS by the CDC [21]. Tribal affiliation andage of survey respondents were representative of Amer-ican Indian residents of the state. Because the sample ofrespondents included an overrepresentation of females,people with college education, and people with an an-nual household income over $15,000 compared to thegeneral population of American Indians age 18 or olderin New Mexico (Table 1), we adjusted survey results tothe age, sex, and education distribution of AmericanIndians in the state from the 1990 U.S. Census. Agecategories were 18–24, 25–34, 35–44, 45–54, 55–64,and 65 years or older. Education was categorized as lessthan high school, high school graduate, some college, or

inverse of the sample fraction for each age–sex–education category. Education information was missingfor 2 respondents. All proportions and means were com-puted on the remaining 1,273 respondents.

RESULTS

We found that the utilization of preventive serviceswas unexpectedly high among this low-income and geo-graphically isolated population. Routine health exami-nations, influenza immunizations, and pneumonia vac-cinations were utilized by the majority of the rural
American Indian population (Table 2). Most respon-dents reported having had a routine health examina-tion within the previous year. Women and respondentsage 50 years or older were more likely to have had aroutine examination, but surprisingly, the prevalence

$35–50,000 177 15.3 8.2$50–75,000 78 6.7 3.7
.$75,000 30 2.6 0.9Refused/unknown 114 — —
a American Indian Behavioral Risk Factor Survey.

did not vary substantially among income or educationcategories. Influenza immunizations within the pastyear were reported by 60.3% of respondents ages 50years and older; however, the percentage receivingpneumonia vaccinations (30.7%) was considerablysmaller. More women than men, and more respondentswith less education than more education, reported in-fluenza immunizations and pneumonia vaccinations,suggesting that low literacy educational efforts may beeffective in increasing immunization status.

Screening programs for hypertension were highlysuccessful. Eighty-five percent of respondents reportedhaving a blood pressure check within the past year(Table 3); 21.3% reported being told they had high bloodpressure. More women than men reported having their
blood pressure checked. The frequency of hypertensionwas highest for respondents ages 50 years and olderand for respondents with incomes greater than $35,000.
Although the burden of cardiovascular disease hasincreased substantially over the past decades, other

D ET AL.

cardiovascular disease preventive efforts were less ef-fective than hypertension screening. Less than half ofrespondents reported having a cholesterol test; how-ever, a third had been tested in the past year (Table 4).The 11.0% of respondents reporting high cholesterol isan underestimate of the prevalence of hypercholesterol-emia in the study population because of the low propor-tion undergoing testing. Blood cholesterol testing var-ied by age, education, and income, with respondentsages 50 years and older and respondents with highereducational attainment and with higher incomes morelikely to have been tested. Reported high cholesterolvaried by age and education, with respondents ages 50years and older and respondents with higher educa-tional attainment more likely to report higher levels.As the educational attainment and incomes of ruralAmerican Indians increase in the future, improved car-diovascular disease screening may become pressing.

The proportion of all respondents (mostly Navajo andPueblo tribal affiliations) diagnosed with diabetes was8.8%, the proportion of those age 50 years or older was26.4% (Table 5). The average age at the time of diabetesdiagnosis was young, 43.3 years. The high prevalenceand early age at diagnosis suggest that screening fordiabetes warrants urgent consideration. Although con-fidence intervals were wide, the prevalence and age atdiagnosis for diabetes appeared to vary by sex, maritalstatus, education, and income.

Cancer screening has been emphasized for manyyears in rural American Indian communities. Becauseno proven screening modalities for the leading cancersamong American Indian men are available, we did notask men about cancer screening utilization. Of womenrespondents over age 40 years, 75.6% reported everhaving a mammogram, and an unusually high propor-tion of women followed screening recommendations(59.5%) and had had a mammogram in the previousyear (Table 6). Women ages 50 years and older weremore likely (81.2%) than those ages 40–49 years(68.4%) to report ever having a mammogram. Surpris-ingly, the overall prevalence of mammography did notshow substantial variation by marital status, educa-tion, or income.

Most women reported having had a clinical breastexamination at some point in their lives and most re-ported that the examination was performed within thepast year (Table 7). More married than single womenreported that they had ever had a clinical breast exami-nation. The prevalence of clinical breast examinationswas highest among college graduates and women withhigher incomes.

196 GILLILAN

TABLE 1

AIBRFSa 1995–1997 Survey Respondent CharacteristicsCompared with 1990 U.S. Census Data for American Indians

Residing in New Mexico

AIBRFS surveyrespondents Census data(n 5 1,273) (n 5 80,074)

n % %

Age18–24 209 16.4 20.125–34 320 25.1 29.535–44 316 24.8 20.745–54 213 16.7 12.655–64 135 10.6 8.2651 80 6.3 8.8

SexMale 445 35.0 47.3Female 828 65.0 52.7

TribeNavajo 687 54.0 61.5Pueblo 360 28.3 26.9Apache/other 226 17.8 11.6

Education,High school 251 19.7 17.4High school graduate 414 32.5 32.4Some college 413 32.4 21.9College graduate 195 15.3 4.9

Income,$10,000 114 9.8 42.1$10–15,000 134 11.6 14.2$15–25,000 391 33.7 19.5$25–35,000 235 20.3 11.4

The reduction in mortality from cervical canceramong American Indian women is a great success storyfor preventive medicine. However, for mortality rates toremain low, high utilization of cervical cancer screeningneeds to be maintained. Overall utilization of Pap tests

Household income,$15,000 248 78.3 (71.2, 85.4) 58 56.5 (39.6, 73.3) 35.2 (18.8, 51.5)$15,000–$35,000 626 71.0 (66.2, 75.8)
.$35,000 285 73.9 (66.9, 80.7)
Overall 1,273 72.8 (69.4, 76.1)


continues to be high enough to maintain the reductionin mortality (Table 8), with 71.6% of women reporting

AMERICAN INDIAN PREVENTIVE HEALTH 197

TABLE 2

Percentage Receiving Routine Health Examinations and Influenza and Pneumonia Immunizations by Age, Sex, Marital Status,Educational Attainment, and Annual Household Income, AIBRFSa 1995–1997

Age 50 or older

Age 18 or olderInfluenza Ever had

Routine health immunization pneumoniaexamination in past year in past year vaccination

N % (95% CI) N % (95% CI) % (95% CI)

Age18–34 529 70.6 (65.5, 75.6) — —35–49 446 67.9 (62.1, 73.5) — —50 or older 298 84.6 (78.3, 90.8) 298 60.3 (51.4, 69.1) 30.7 (22.3, 39.0)

SexMale 445 60.6 (54.7, 66.4) 190 45.2 (30.4, 59.9) 21.0 (9.9, 32.0)Female 828 83.8 (80.7, 86.8) 108 71.5 (62.0, 81.0) 37.8 (26.5, 49.1)

Marital statusMarried 686 72.9 (68.2, 77.6) 190 59.3 (48.2, 70.4) 25.7 (16.2, 35.1)Single 584 72.5 (67.6, 77.3) 102 60.9 (46.1, 75.8) 39.2 (24.0, 54.3)

Education,High school 251 75.0 (68.3, 81.6) 79 61.4 (48.8, 73.9) 30.5 (18.6, 42.3)High school graduate 414 69.2 (64.2, 74.2) 75 62.5 (50.6, 74.4) 34.2 (23.0, 45.3)Some college 413 75.3 (70.5, 80.0) 90 52.9 (41.3, 64.3) 28.1 (17.5, 38.7)College graduate 195 67.1 (59.1, 75.1) 62 49.6 (35.0, 64.2) 23.2 (9.3, 37.0)

the most recent test to have been within the past year.
However, some groups may be at higher risk of invasivecervical cancer as suggested by lower prevalence of everhaving had a Pap test for single than for married womenand for women with less than a high school education.
DISCUSSION

Using an economical telephone-based surveillancesystem, we found that the utilization of preventivehealth services is unexpectedly high among rural Amer-ican Indians in New Mexico and is approximately equalto that among the U.S. general public and among allNew Mexicans, as reported by the Behavioral Risk Fac-tor Surveillance System of the Centers for Disease Con-trol and Prevention [18]. Although we lack data to di-rectly assess the factors that may explain the highutilization in this low-income and geographically iso-lated population, it is likely that they are due to the
emphasis on organized early detection and preventionprograms from the uniquely well-coordinated partner-ship between the Indian Health Service, the State andTribal Departments of Health, and the Centers for Dis-ease Control and Prevention and the provision of these
146 50.3 (36.0, 64.5) 22.6 (11.8, 33.3)69 64.6 (47.3, 81.8) 33.5 (16.1, 50.8)

298 60.3 (51.4, 69.1) 30.7 (22.3, 39.0)

services without fee at locations in the rural communi-ties by the Indian Health Service, the Department ofHealth, and the Centers for Disease Control and Pre-vention [17]. This model collaborative partnership maynot exist in other regions of the United States. As tribalgovernments assume the responsibility for their healthdelivery systems from the IHS, the effectiveness of thepartnerships in New Mexico in delivering early detec-tion and prevention services should be considered.

Although cardiovascular disease mortality has his-torically been low among the American Indian popula-tion in New Mexico, mortality is now increasing as life-styles become more westernized [1]. The increasingmortality indicates the need for prevention efforts thatfocus on modifiable risk factors for the disease amongAmerican Indians, including hypertension, hypercho-lesterolemia, diabetes, and smoking [4]. Screening forhypertension among this population appears to be wide-spread in the state, with 85% reporting having had ablood pressure check within the past year. The highproportion having blood pressure checks may reflect
the noninvasiveness of the screening test and the recenttribal emphasis on health fairs. Of these respondents,21.3% reported they were told they had high blood pres-sure, compared with 21.7% nationwide and 18.0% inthe state population [21]. We noted small differences

,$15,000 248 89.2 (83.3, 95.1) 15.9 (10.2, 21.5) 9.7 (4.8, 14.4)$15,000–$35,000 626 80.9 (76.4, 85.4) 20.6 (16.4, 24.6) 10.4 (7.2, 13.6).$35,000 285 87.8 (82.2, 93.4) 25.0 (17.2, 32.7) 11.5 (6.5, 16.4)

)
Overall 1,273 84.9 (82.0, 87.7

by sex in the prevalence of hypertension in the studypopulation (22.2% for men, 20.5% for women); however,nationwide and in the state population, women wereslightly more likely to report high blood pressure, 22.5%vs 20.6% for men nationwide and 19.4% vs 16.6% formen in the state population [21].

Cholesterol screening was not as common as screen-ing for hypertension in our study. Reports of ever havinga blood cholesterol check were lower among the studypopulation (41.1%) than the overall nationwide rate(67.9%) and the state population rate (62.5%) [21]. Re-spondents with higher education levels and higher in-come were more likely to report a blood cholesterolcheck. This finding suggests that an educational inter-vention targeted for lower education and income groupsmay be warranted.

The study population reported a higher overall preva-lence of diabetes (8.8%) than reported nationwide(4.5%) and among the state population (3.8%) [21]. Re-ported diabetes prevalence among women is 9.2% inthe study population, 4.6% nationwide, and 3.8% in thestate population; among men the prevalence is 8.3% in
the study population, 4.4% nationwide, and 3.0% in thestate population [21]. For study respondents age 50years or older, the prevalence of 26.4% indicates thehigh burden from diabetes in American Indian commu-nities beyond the widely recognized Pima communities
21.3 (18.1, 24.4) 11.6 (9.0, 14.1)

in Arizona. The higher prevalence among lower educa-tion and lower income groups warrants further investi-gation. Because mortality from diabetes among Ameri-can Indians in New Mexico increased approximately10-fold in the period 1958–1992 [16], and diabetes isa major risk factor for cardiovascular disease amongAmerican Indians, the high current prevalence of diabe-tes suggests that mortality from diabetes and cardio-vascular diseases may continue to increase unless vig-orous efforts for primary and secondary prevention areurgently implemented. Although smoking prevalencehas remained low among American Indian residents ofNew Mexico, there is a serious need for interventionsto keep young people from becoming addicted to tobaccoproducts [22].

In 1993, the CDC identified influenza and pneumoniaas the sixth leading cause of death in the United States[23]. Healthy People 2000 set an objective of 60% ofall individuals 65 years of age and older to receive aninfluenza and pneumonia vaccination each year [24].We found that rural American Indians in New Mexico

198 GILLILAND ET AL.

TABLE 3

Percentage Receiving Blood Pressure Checks and Prevalence of High Blood Pressure by Age, Sex, Marital Status, EducationalAttainment, and Annual Household Income, AIBRFSa 1995–1997

Blood pressure Ever told you had Told more than once youcheck in past year high blood pressure had high blood pressure

N % (95% CI) % (95% CI) % (95% CI)

Age18–34 529 83.8 (79.4, 88.1) 12.5 (8.8, 16.0) 5.6 (2.6, 8.5)35–49 446 81.4 (76.6, 86.2) 23.6 (18.0, 29.0) 10.8 (7.4, 14.2)50 or older 298 92.2 (86.8, 97.5) 38.7 (29.9, 47.5) 26.4 (18.4, 34.4)

SexMale 445 77.6 (72.4, 82.7) 22.2 (17.1, 27.1) 11.2 (7.5, 14.8)Female 828 91.5 (89.0, 93.9) 20.5 (16.5, 24.5) 11.9 (8.4, 15.4)

Marital statusMarried 686 85.0 (81.1, 88.8) 24.5 (19.7, 29.3) 13.8 (9.7, 17.7)Single 584 84.7 (80.5, 88.9) 17.5 (13.6, 21.4) 8.9 (5.9, 11.7)

Education,High school 251 84.0 (78.2, 89.8) 24.6 (17.9, 31.2) 13.8 (8.2, 19.2)High school graduate 414 85.2 (81.3, 89.1) 17.3 (13.5, 21.0) 8.1 (5.4, 10.7)Some college 413 85.2 (81.1, 89.2) 20.9 (16.6, 25.0) 11.9 (8.6, 15.1)College graduate 195 88.8 (83.4, 94.0) 22.3 (15.1, 29.5) 15.3 (9.1, 21.4)

Household income

met this goal for influenza immunizations, with 60.3%of people 50 years and older having received the immu-nization compared with 50.4% nationwide and 60.9%in the state population [21]. Pneumonia vaccinationfor rural American Indians was similar to that of the

,$15,000 248 41.6 (33.5, 49.7) 33.3 (25.5, 41.0) 11.3 (6.1, 16.4)$15,000–$35,000 626 39.7 (34.7, 44.7) 32.3 (27.6, 36.9) 9.9 (7.2, 12.5).$35,000 285 55.7 (47.8, 63.6) 42.9 (35.0, 50.6) 13.8 (9.0, 18.5)

)
Overall 1,273 41.1 (37.5, 44.6

general population of the United States and New Mex-ico. Prevalence of vaccination for individuals ages 65and over was 30.7% for New Mexico American Indians,28.7% nationwide, and 31.8% for the state population[21]. Although the prevalence of immunizations ap-pears to be similar across populations, the substantialrisk for respiratory infectious disease among AmericanIndians indicates the need for further public healthefforts to improve the immunization status for this pop-ulation, especially for pneumococcal pneumonia.

American Indian women nationwide have been atincreased risk for cervical cancer; however, vigorousscreening efforts organized by the IHS and CDC overthe past 20 years have resulted in a marked reductionof the incidence rates for invasive disease and mortalityfrom cervical cancer, but an increase in in situ disease[25]. Although secondary prevention has been success-ful in reducing invasive cervical cancer incidence, thehigh rates of in situ disease are indicative of the contin-ued need for aggressive screening using Pap smears.Reports of ever having a Pap smear test were slightlyhigher among the study population (88.3%) than re-ports nationwide (80.2%) and among the state popula-
tion (80.0%) [21]. Reports of a Pap smear were similaracross age groups in our study, but were fewer for un-married women and for women with lower education,suggesting that interventions need to be tailored forthese groups. Our findings differ from those of Wilcox
33.0 (29.6, 36.4) 11.0 (8.8, 13.1)

and Mosher [26], who reported that the Pap smear testis less prevalent among 14- to 55-year-old AmericanIndian women than among women nationwide [26]. Asimmunization strategies for cervical cancer are devel-oped, rapid implementation of mass immunizationshould be considered.

Although incidence rates for breast cancer amongAmerican Indians in New Mexico are among the lowestin the United States, and no data exist for efficacy ofmammography among American Indians, mammo-graphic screening for breast cancer has recently beenadopted in New Mexico as a preventive health screeningtool by the Indian Health Service and by tribal govern-ments in collaboration with the CDC screening pro-gram. Mammograms were reported by 75.6% of oursurvey respondents, compared with 60.2% nationwideand 61.4% for the state population [21]. Reports of everhaving a clinical breast examination were also higheramong our study group (79.5%) than nationwide(68.3%) and among the state population (66.9%) [21].Programs for early detection of breast cancer that targetrural and low income populations have been widelyadopted throughout the United States; however, the low

AMERICAN INDIAN PREVENTIVE HEALTH 199

TABLE 4

Percentage Receiving Blood Cholesterol Checks and Prevalence of High Blood Cholesterol by Age, Sex, Marital Status, EducationalAttainment, and Annual Household Income, AIBRFSa 1995–1997

Ever had blood Had cholesterol Ever told you hadcholesterol check checked in past year high cholesterol

N % (95% CI) % (95% CI) % (95% CI)

Age18–34 529 27.6 (22.9, 32.1) 23.1 (18.8, 27.3) 4.7 (2.9, 6.4)35–49 446 51.4 (45.3, 57.4) 37.5 (31.6, 43.2) 15.0 (10.6, 19.4)50 or older 298 58.5 (49.1, 67.8) 50.1 (41.0, 59.1) 19.9 (13.3, 26.5)

SexMale 445 40.0 (34.1, 45.7) 31.4 (25.9, 36.9) 11.0 (7.5, 14.4)Female 828 42.1 (37.7, 46.5) 34.5 (30.3, 38.6) 11.0 (8.4, 13.6)

Marital statusMarried 686 43.6 (38.5, 48.7) 35.0 (30.1, 39.8) 10.8 (7.7, 13.8)Single 584 38.2 (33.0, 43.2) 30.7 (25.9, 35.4) 10.8 (7.9, 13.7)

Education,High school 251 35.8 (28.6, 42.9) 29.6 (22.8, 36.4) 9.4 (5.2, 13.6)High school graduate 414 39.5 (34.5, 44.5) 31.6 (26.8, 36.2) 10.7 (7.6, 13.7)Some college 413 46.7 (41.3, 52.0) 38.1 (32.9, 43.1) 12.7 (9.3, 16.0)College graduate 195 71.3 (64.0, 78.6) 49.0 (40.7, 57.1) 18.2 (11.9, 24.4)

Household income

incidence and mortality rates for breast cancer amongAmerican Indians in the southwestern United States,and the high cost of mammographic screening, suggestthat this program may have a high cost per life saved.Research is needed to evaluate the effectiveness and

D

College graduate 127 93.8 (89.7, 97.8) 72.5 (64.4, 80.6)Household income

200 GILLILAN

TABLE 5

Prevalence of Diabetes and Age at Diagnosis of Diabetes by Age,Sex, Marital Status, Educational Attainment, and Annual

Household Income, AIBRFSa 1995–1997

Ever diagnosed Age at diagnosiswith diabetes of diabetes

N % (95% CI) Mean (95% CI)

Age18–34 529 3.5 (0.7, 6.3) 27.3 (23.4, 31.1)35–49 446 4.8 (2.6, 6.9) 31.5 (28.2, 34.7)50 or older 298 26.4 (18.3, 34.4) 51.7 (46.5, 56.7)

SexMale 445 8.3 (4.4, 12.2) 40.4 (33.8, 46.9)Female 828 9.2 (6.2, 12.1) 45.9 (39.7, 51.9)

Marital statusMarried 686 10.3 (6.6, 13.9) 41.3 (36.4, 46.0)Single 584 6.8 (3.8, 9.8) 46.6 (37.8, 55.3)

Education,High school 251 13.1 (7.6, 18.5) 45.4 (37.7, 53.1)High school graduate 414 6.0 (3.9, 8.0) 42.7 (37.6, 47.7)Some college 413 4.8 (2.9, 6.7) 37.6 (32.6, 42.4)

,$15,000 177 77.7 (68.7, 86.6) 65.4 (55.8, 74.9)College graduate 195 8.8 (3.8, 13.6) 35.6 (30.0, 41.2)Household income $15,000–$35,000 400 80.2 (74.8, 85.5) 63.4 (57.2, 69.5)

.$35,000 172 85.9 (78.8, 93.0) 68.5 (59.6, 77.4),$15,000 248 9.0 (4.5, 13.4) 43.8 (35.1, 52.4)$15,000–$35,000 626 8.5 (4.8, 12.0) 42.2 (35.0, 49.2) Overall 828 79.5 (75.5, 83.4) 63.1 (58.5, 67.6)
.$35,000 285 6.8 (3.5, 10.1) 40.8 (35.6, 46.0)
Overall 1,273 8.8 (6.3, 11.2) 43.3 (38.5, 48.0)


TABLE 6

Mammography Utilization by Age, Marital Status, EducationalAttainment, and Annual Household Income,

AIBRFSa 1995–1997

Women age 40 or older

HadEver had mammogram

mammogram within past year

N % (95% CI) % (95% CI)

Age40–49 193 68.4 (60.3, 76.4) 49.2 (40.4, 57.9)50 or older 190 81.2 (71.8, 90.4) 67.5 (56.8, 78.0)


College graduate 72 75.3 (64.1, 86.4) 53.8 (41.5, 66.1)
Household income,$15,000 75 79.0 (68.2, 89.6) 57.6 (42.7, 72.4)$15,000–$35,000 180 78.4 (70.7, 86.0) 60.8 (51.2, 70.3).$35,000 90 72.2 (58.8, 85.6) 53.7 (38.8, 68.5)

Overall 383 75.6 (69.3, 81.9) 59.5 (52.3, 66.7)


ET AL.

TABLE 7

Percentage of Women Receiving Clinical Breast Exams by Age,Marital Status, Educational Attainment, and Annual

Household Income, AIBRFSa 1995–1997

Ever had Had clinicalclinical breast exam

breast exam within past year

N % (95% CI) % (95% CI)

Age18–34 323 73.2 (66.7, 79.6) 60.1 (53.2, 66.9)35–49 315 83.0 (77.5, 88.5) 62.7 (56.1, 69.1)50 or older 190 88.0 (80.3, 95.6) 69.7 (59.2, 80.2)




TABLE 8

Percentage of Women Receiving Pap Smears by Age, MaritalStatus, Educational Attainment, and Annual Household Income,

AIBRFSa 1995–1997

Had PapEver had smear within

Pap smear past year

N % (95% CI) % (95% CI)

Age18–34 323 83.8 (78.8, 88.7) 71.9 (65.7, 78.1)35–49 315 96.8 (94.4, 99.1) 73.9 (68.0, 79.7)50 or older 190 86.8 (77.9, 95.6) 68.0 (57.4, 78.4)


College graduate 127 95.9 (92.4, 99.2) 70.3 (61.9, 78.6)
Household income,$15,000 177 91.4 (85.3, 97.3) 78.0 (70.0, 85.9)$15,000–$35,000 400 88.4 (83.7, 93.0) 70.5 (64.4, 76.4).$35,000 172 90.7 (85.1, 96.2) 69.8 (61.0, 78.5)

Overall 828 88.3 (85.0, 91.5) 71.6 (67.3, 75.7)


R
AMERICAN INDIAN P
costs of community-based mammography among Amer-ican Indian populations.

We demonstrated that our innovative surveillancesystem for rural American Indians was successful inassessing population-based utilization of preventiveservices. As expected in any telephone-based method,our system included more respondents with higher edu-cation and income than the general population of ruralAmerican Indians; however, we did survey sufficientnumbers of respondents with low income and educationto allow adjustment of our estimates to reflect those forthe population as a whole. Our adjusted percentageschanged little from the crude estimates, suggesting thatsocioeconomic factors are not strong predictors of utili-zation. Furthermore, our adjusted estimates will be un-biased if utilization by American Indians who havelower income and education does not depend onwhether they have telephones. Studies in other popula-tions have found biases arising from behavioral differ-ences among populations with and without telephones,such as those found by Pearson et al. [27] and Petersonet al. [28]. However, any biases are likely to be smallamong rural American Indian communities in NewMexico, because the availability of phones in rural NewMexico depends on proximity to major roads and less onother socioeconomic differences among this population.Further research is needed to validate our assumptionthat utilization of services by low-income American In-dians does not differ by whether they have a telephone.

The utilization of preventive services is high amongAmerican Indians in New Mexico and, except for choles-terol screening, is comparable with rates for the U.S.population. Because cardiovascular disease is on therise, more attention is warranted for preventive ser-vices in this arena. The high and increasing prevalenceof diagnosed diabetes suggests that aggressive diabetesscreening and prevention interventions are needed.Our study suggests that the easily accessible and freeprograms of the model collaboration between the IHS,CDC, and state and tribal health departments are effec-tive in providing preventive services to rural low-income populations. Expanded surveillance of the utili-zation of preventive services among American Indiansis needed to monitor trends during the coming years asthe health care system for American Indians undergoesconsiderable changes. Our ability to identify and inter-view 1,273 rural New Mexico American Indians about
disease, disease prevention screenings, and immuniza-tions at a rate of approximately one per hour indicatesthat it is possible to develop timely surveillance datain meeting Healthy People 2000 objectives with rural New Mexico American Indians.
ACKNOWLEDGMENTS

The authors thank Jacqueline Two Feathers and Felicia Garciafor interviewing research respondents. The authors also thank theanonymous reviewers for their helpful comments.

EVENTIVE HEALTH 201

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Preventive Health Care among Rural American Indians in New Mexico