Prevention Implications and Priorities

 

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Despite decreases in Native American child and youth death rates for motor vehicle crashes, pedestrian events, drowning, and fire, the disparity in injury rates between Native Americans and whites persists. Native American children and youth have not benefited to the same degree as white children in many areas of injury prevention practice (i.e., traffic safety, water safety, and residential fire safety). However, there are several proven and promising injury interventions that could be tailored to local tribal settings. Additional information on the circumstances of these injuries is needed to effectively target prevention efforts. Some of these approaches are discussed below.

Motor Vehicle-Related
Traffic safety can be improved in Native American communities where there is a need for increased use of child restraints and seat belts and for reductions in alcohol-impaired driving.8  Primary enforcement (stopping a driver solely for restraint violation) of seat belt laws combined with active enforcement and public awareness are the most effective strategies for increasing seat belt use.9  Most Native American tribes are considered sovereign nations, which pass and enforce their own traffic safety laws. Several tribes have passed seat belt laws; however, enforcement of these laws is often 8 challenging for tribal police departments.

Native Americans have the highest alcohol-related motor vehicle death rates of all racial groups,10  putting their children and youth at an elevated risk when they ride with an impaired driver. Researchers estimate that in states with American Indian and Alaska Native reservations, 65% of motor vehicle-related deaths among Native Americans involve alcohol.11  Young drivers are at particular risk because of inexperience, nighttime driving, too many passengers in the car, and patterns of alcohol use. Many tribes have the authority to restrict driving privileges on the reservations, conduct sobriety checkpoints, and set curfew ordinances to help 8 reduce deaths related to motor vehicle crashes among teens.

The highest rates of pedestrian-related death occurred in two age groups: 1 to 4 years and 15 to 19 years. Most deaths occurred on public roadways, but over half of the 1 to 4 year olds who were killed as pedestrians were killed in non-traffic settings, such as private driveways. More information is needed about the circumstances of these pedestrian-related deaths, but many involve young children being backed over by large vehicles such as pick-up trucks (Nancy Bill, IHS Headquarters, personal communication, 2004). Parents and caregivers of young children should be aware of the risk that children face when playing around vehicles.12,13,14  Prevention strategies might involve working with local housing authorities to install circular driveways in new homes to reduce the need to back up, installing fencing to separate play areas from vehicle driveways, and increasing the use of audible back-up warning systems.14

Violence
Suicide rates for Native American youth and children did not decline over the 10-year period and were especially high in Alaska, Aberdeen, and Tucson IHS Areas. Additional research is needed to determine the risk factors and reasons for the substantially higher rates in the Alaska, Aberdeen, and Tucson Areas and for the protective factors in other IHS Areas with lower rates. Native Americans 15 to 19 years of age have the highest suicide rates of any racial group in the United States. Preliminary work shows many risks and protective factors related to suicide in this population,15  including access to firearms and alcohol.16,17

The IHS provides technical assistance to suicide prevention  programs and alcohol- and substance-abuse treatment centers.18 Individual tribes have launched a number of suicide prevention programs that stress cultural relevance and the need for  community involvement,19 but none have been rigorously evaluated. The American Indian and Alaska Native Community Suicide Prevention Center and Network in New Mexico has shown promising results in the past in reducing Native American youth suicide; the organization uses a community-based approach involving school-based youth, mental health referral assistance, and family outreach.20

Native American children and youth have somewhat lower homicide than suicide rates, and their rates are well below those for blacks. However, in terms of nonfatal violence, results from the National Crime Victimization Surveys from 1993 to 1998 indicated that Native Americans 12 to 19 years old are assaulted at rates well above those for any other minority.21  Programs that show promise at preventing youth violence have been recently summarized22  and include specific violence-prevention practices in four key areas: parents and families, home visitation, social and conflict resolution skills, and mentoring.

Homicide among Native American children (0�years) is also an important Native American issue. Such homicides are typically  perpetrated by family members.23 One intervention that has shown effectiveness in preventing child maltreatment is the home visitation program conducted by nurses or other health professionals.24

Firearms
Over 500 Native American children and youth died from firearm-related injuries from 1989 to 1998, including 52% of suicides and 40% of homicides. Firearms were also involved in 115 unintentional deaths. Some proposed measures to reduce the risk of a firearm-related death or injury in the home are behavior oriented (e.g., education about safe storage and handling of guns or counseling).25,26  Other measures are product oriented (e.g., changing firearms design or personalization to make firearms more difficult to use unintentionally or intentionally if stolen or obtained illegally).27  There have also been legislative efforts to reduce the potential for firearm-related violence (e.g., licensing requirements, gun storage laws).28, 29, 30  Most of these measures have not been adequately evaluated making it difficult to determine which measures are effective in reducing firearm-related deaths or injuries.31 Two Alaska Native villages have piloted a program to provide free gun safes to their residents to promote safe firearm storage.32

Residential fires account for the majority of fire-related deaths (93%) among Native American children and youth in our study. Fire death rates were highest for Native American children under five years of age. Dramatic improvements have been made in reducing fire-related death among Native American children and youth, with rates decreasing 64% from 1981 to 1998. Despite this decrease, the Aberdeen, Bemidji, and Alaska Areas had substantially higher fire-related death rates than all other IHS Areas, with rates more
than five times the U.S. national rate. Having a working smoke alarm in the home is proven to reduce the risk of death from a house 33 fire by as much as 71%. Some studies find that up to half the smoke alarms in Native American homes are inoperable and are often disconnected due to nuisance alarms.34 To help prevent such alarms, Kuklinski and others recommend installing photoelectric 34 alarms in place of ionization alarms. One promising intervention program is Sleep Safe, which is a smoke alarm distribution and
education program targeting children and families in Native American Headstart Schools. Sleep Safe, supported by the IHS and the U.S. Fire Administration, has funded programs in Headstart schools and distributed over 11,000 smoke alarms to Native American families (Harold Cully, Oklahoma City Area IHS,
personal communication, 2003).55

Drowning
Drowning rates were highest among Native Americans 1�years of age and those 15� years. Child and youth drowning rates for Native Americans decreased 62% from 1981 to 1998. Although this trend is encouraging, Native American drowning rates are still high compared to rates for whites. The Alaska IHS
area had the highest drowning rate and was seven times greater than the U.S. national rate. The Phoenix, Billings, Navajo, and Bemidji areas also had high drowning rates and were at least two times greater than the U.S. national rate. Just under half of the Native American drowning occurred in swimming pools or quenching tanks, 5% occurred in bath tubs, and 28% were related to recreation or water craft.

Four-sided isolation fencing around swimming pools has proven to be effective at preventing drowning among young children. In-ground pools with four-sided fencing had 60% fewer incidents of drowning compared with pools without four-sided isolation fencing (www.CPSC.gov). Three Tragic Seconds is a multimedia drowning prevention education program aimed at parents and caregivers of young children. CDC is working with the Children's Hospital of Orange County, California, and the National SAFE KIDS Campaign to implement the Three Tragic Seconds program in two communities in Arizona and Florida (www.cdc.gov/ncipc/factsheets/drown-activities.htm). Once a child is in the water, it is very important that a parent or guardian provide supervision. Swimmers can further reduce their risk by choosing swimming pools with lifeguard services, although this 35 may not be feasible around natural bodies of water. Proper swimming instruction and water-safety training can prepare a participant to deal with potentially hazardous aquatic environments such as strong currents, waves, and riverbed rocks. Environmental modifications can also be made to prevent drowning in natural bodies of water (i.e. lakefront slope gradients to prevent sudden, unseen water drop-offs).35

Older children and teenagers are more likely to drown in natural bodies of water than in swimming pools. Alcohol is a risk factor for drowning and is involved in 25% to 50% of drowning incidents among teenage boys (www.cdc.gov/ncipc/factsheets/drown.htm). In indigenous communities in Canada, alcohol is a factor in half of all drowning related to boat travel. In Canada, only about 10% of victims of boating drowning were wearing a personal flotation device (PFD).36

Distribution of PFDs and programs to education and distribute float coats have been used to increase boaters' safety in Alaska Native villages (Ron Perkins, Alaska Injury Prevention Center, personal communication, 2003). These programs involve a public awareness campaign combined with sales of low-cost float coats. Another promising program being supported by the U.S. Coast Guard in Alaska is the Kids Don't Float Program. This is a PFD loaner program at village community beaches and boat launching areas combined with an educational component for children and teenagers (www.chems.alaska.gov/Injury_Prevention/KidsDontFloat.htm).

Suffocation and Choking
Most suffocation deaths among Native Americans occurred among infants due to mechanical airway obstruction rather than aspiration of food or other small objects. It is now accepted that infants can suffocate if put to sleep on their faces, especially if placed on soft surfaces or loose bedding.3738  Recent survey data indicate that Native Americans are usually less likely than whites to put their infants to sleep on their backs. Bed sharing is another possible risk factor for infant suffocation.39 The National Infant Sleep Position Study found that parents of other races were more likely than white parents to share their beds with infants.40 There is anecdotal evidence that in some Native American infant suffocation deaths, alcohol intoxication of parents or caregivers while sleeping with their infant was a factor (Dr. David Grossman, Harborview Injury Prevention Research Center, personal communication, 2003). Parental education about safe sleep practices for their infants is recommended. The Portland Area 41Indian Health Service initiated such a program in 1993.41