Introduction

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Injuries, from both unintentional and intentional causes, are third behind heart disease and cancer as the leading cause of death among all American Indians and Alaska Natives (Native Americans).1 Injuries are the leading cause of death among all children in the United States, but Native American children are disproportionately affected by injuries, with rates about 2.5 times 2 the rate for all U.S. children.

In 1993, the Centers for Disease Control and Prevention (CDC) and the Indian Health Service (IHS) published the Injury Mortality Atlas of Indian Health Service Areas, 1979�87, which summarized the geographic distribution of injury mortality among 3 Native Americans of all ages by IHS Area. Although similar, the current Atlas focuses on the problem of injuries among Native American children and youth (ages 0� years) residing in IHS Areas. The purpose of the Atlas is to provide background information and data to public health practitioners and policy makers to help identify critical injury problems and set intervention priorities for intervention among this vulnerable population.

The Atlas contains composite maps of all IHS Area rates and individual Area maps for eight causes of injury death. It includes study results of Native American children and youth (0� years) who live in one of the twelve IHS Areas. The Atlas provides information on several causes of injury deaths: motor vehicle-related, pedestrian-related, firearm-related, suicide, homicide, drowning, fire, and suffocation.

The IHS has long recognized the high incidence of misclassification of Indian race on state death certificates, 4, 5 particularly in the California, Oklahoma, and Portland Areas. Research shows that all IHS Areas have this problem to some degree, but it ranges from as low as 1% for the Navajo Nation to a 4 high of 30% for California. The problem of misclassification is addressed in this report. Death rates presented are those that have been adjusted for misclassification. In Regional Differences in Indian Health, the IHS also presents death rates by Area that adjust 6 for misclassification of American Indian race.

The Atlas is intended for use as a reference tool for public health professionals and decision makers who are interested in reducing injuries among Native American children and youth. Its format allows one to visually recognize injury patterns across IHS Areas and to compare rates in IHS Areas with national rates. The Atlas is also intended to raise awareness of specific Areas or groups at elevated risk of injury death within the IHS and to help focus the issue of injuries as a public health problem among Native American children and youth.

Native American children and youth in the IHS Areas are at greater risk of preventable injury-related death than other children in the United States. The injury maps show how widely this risk varies by IHS Area. Although it is promising that death rates from motor vehicle crashes, pedestrian events, drowning, and fire decreased from 1989 to 1998, the overall injury disparity compared 7 with rates for white children and youth persists. During this period, rates increased for firearm-related death and homicide, but the rates remained unchanged for suicide. Given the variation in the injury problem and Native American tribal culture, interventions need to be tailored to local settings and problems. To ensure successful interventions, considerations of local practices and cultures should be addressed. Such efforts are needed to help reduce or eliminate the injury disparity gap between Native American children and other children in America.