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Esme Fuller-Thomson, PhD and Meredith Minkler, DrPH

Esme Fuller-Thomson is with the Faculty of Social Work, University of Toronto, Toronto, Ontario. Meredith Minkler is with the Department of Community Health Education and Health and Social Behavior at the School of Public Health, University of California, Berkeley.

Correspondence: Requests for reprints should be sent to Esme Fuller-Thomson, Faculty of Social Work, University of Toronto, 246 Bloor Street West, Toronto, Ontario, Canada, M5S 1A1 (e-mail: esme.fuller.thomson{at}utoronto.ca).

	ABSTRACT

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The objectives of this study were to determine the national prevalence and profile of American Indian and Alaska Natives with functional limitations. Data were obtained from 4763 American Indian and Alaska Native respondents aged 45 years or older in the Census 2000 Supplementary Survey. Functional limitations were reported by 28% of American Indian and Alaska Natives aged 45 years or older. These individuals were poorer, older, less educated, and less likely to be married or employed than American Indian and Alaska Natives without such limitations (for all comparisons, P < .001). American Indian and Alaska Natives have high disability rates, and many are not receiving benefits for which they qualify

	INTRODUCTION

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The health status of American Indian and Alaska Native older adults "ranks among the poorest of any minority in the nation."¹ Chronic illnesses, such as diabetes, have reached epidemic proportions in American Indian and Alaska Native communities.² Such illness often results in difficulties in performing basic functional activities, such as lifting, climbing stairs, and walking.³ In addition to the considerable impact on quality of life, disability among older adults is "a better predictor of medical and social-service needs than simple prevalence or incidence figures of disease."³ Despite the importance of documenting national data on functional limitations among older populations, little research attention has focused on this issue among older American Indian and Alaska Natives.⁴

This is the first nationally representative study of American Indian and Alaska Natives aged 45 years and over, comparing and contrasting the sociodemographic characteristics and service utilization patterns of those with and those without functional limitations. With increased awareness of the prevalence and characteristics of American Indian and Alaska Natives with functional limitations, health care professionals can more accurately track changes over time and target outreach, prevention, and other services for this population.⁵

	METHODS

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Sample
The nationally representative Census 2000 Supplementary Survey/American Community Survey (C2SS/ACS) had a response rate of 95.4%.⁶ The current study compared the characteristics and circumstances of self-identified American Indian and Alaska Native respondents aged 45 years and older with functional limitations (n = 1367) with those of their nondisabled American Indian and Alaska Native peers (n = 3396). The age 45 was chosen because chronic diseases occur earlier among American Indian and Alaska Natives, and American Indians are considered elders by the age of 45.²

Measures
American Indian and Alaska Native status was self-identified. Respondents were defined as having functional limitations if they reported that they had a long-lasting condition that "substantially limited one or more basic physical activities such as walking, climbing stairs, reaching, lifting, or carrying." Household annual income was on the basis of a summation of all possible sources of income for all household members. The poverty index reported the household income as a percentage of the poverty line for households of that size and composition. Other demographic variables analyzed included age, gender, marital status, labor force status, place of residence, and whether the respondent lived on a reservation.

Analysis Plan
Using the statistical software package SAS version 8.1 (SAS Institute Inc, Cary, NC), we analyzed the C2SS/ACS data to determine the prevalence of American Indian and Alaska Natives with functional limitations. The functionally impaired American Indian and Alaska Natives were compared with the nonfunctionally impaired using ² tests for categorical variables and independent t tests for ratio level variables. Furthermore, a multiple logistic regression analysis was completed to model the association of several demographic characteristics, determined a priori, with functional limitation status among American Indian and Alaska Natives aged 45 years and older. In the subsample of disabled American Indian and Alaska Natives who were living below the poverty line (n = 321), we determined the proportion using public assistance or food stamps. The numbers and percentages in the Results section were generated with a weighting variable designed by the US Census Bureau. This weight variable represents the probability of selection, including noninterview adjustments and controlling to the 2000 Census housing units and population level. More detailed information on the weighting variable, sampling strategy, and survey design of the C2SS/ACS is available from the US Census Bureau.⁷

	RESULTS

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This study estimated that there were 239 000 American Indian and Alaska Natives aged 45 years and over living with a functional limitation in 2000, making up 27.9% of all American Indian and Alaska Natives in this age group. The percentage with functional limitations ranged from 18.7% in those aged 45 to 49 years to 66.6% in those aged 85 years and older. Forty-four percent of those living below the poverty level had functional limitations compared with 25% of those living above the poverty line. Half of all American Indian and Alaska Natives aged 45 years and over who were receiving public assistance had a functional disability.

As indicated in Table 1, American Indian and Alaska Natives with functional limitations were significantly older, poorer, less likely to be married, and more likely to have not finished high school than respondents without such limitations. Furthermore, those with functional disabilities were more than twice as likely to be out of the labor force and to be living below the poverty line than were their nondisabled peers.

	DISCUSSION

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More than one fourth of American Indian and Alaska Natives aged 45 years and over had a functional limitation in 2000. Those with limitations were much poorer, older, less educated, and less likely to be married or employed than American Indian and Alaska Natives without such limitations. Results of our study also revealed among disabled American Indian and Alaska Natives living in poverty relatively low utilization rates of services for which they were eligible (e.g., public assistance or food stamps).

The results of this study reveal a troubling level of functional limitations among American Indian and Alaska Natives and support earlier research suggesting that functional limitations begin substantially earlier in the American Indian and Alaska Native population.⁸ The elevated prevalence of a number of chronic conditions associated with functional limitations⁴ among American Indian and Alaska Natives may help explain these findings.

Our findings concerning the association between low socioeconomic status,^9–11 marital status,^12,13 and urban status¹⁴ and functional limitations within the American Indian and Alaska Native population are in keeping with the results of earlier studies. Of particular concern was our finding that among those aged 45 to 64 years, two thirds were out of the labor force and, thus, at risk for economic difficulties throughout later life. The fact that 88% of disabled American Indian and Alaska Natives living in poverty were not receiving public assistance indicates a need for better outreach and/or more appropriate programs.

Although our study was limited to the use of self-reported functional limitations, such self-report measures, nevertheless, are the most common way to assess levels of functional limitations in the research literature.³ Similarly, and although our study is limited by its cross-sectional nature, the high prevalence of functional limitations that emerged, compared with the considerably lower rates found in earlier studies of the general midlife and older population,³ indicate an important area for additional longitudinal research and research-based intervention.

Evidence indicates that older American Indian and Alaska Natives bear a high burden of disability, with many failing to receive benefits for which they are eligible. The high quality of data available through the C2SS/ACS on both the rates of functional limitations and service utilization, as well as the detailed data available on the most vulnerable groups within the midlife and older American Indian and Alaska Native population, should help researchers, practitioners, and policymakers alike better address the needs of this growing population group.

	Acknowledgments

 
The authors gratefully acknowledge the Retirement Research Foundation for its financial support for this study, Ban Cheah for his assistance with data analysis, Kenneth Bryson for his encouragement, the US Census Bureau for providing us access to this unique data set, and Leanne McCormack for her assistance with the preparation of this brief.

Human Participant Protection
This study was approved by the US Census Bureau’s institutional review board. All results presented in this paper are derived from secondary analyses of Census data. All results are aggregated at the national level such that no one individual can be identified.

	Footnotes

 
Peer Reviewed

Contributors
E. Fuller-Thomson and M. Minkler originated the study and supervised all aspects of its implementation. Both authors completed the analysis, interpreted findings, and wrote and reviewed drafts of the brief.

Accepted for publication March 5, 2005.

	References

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1. National Indian Council on Aging. The needs of Indian elders. Senate Committee on Indian Affairs. Available at: http://www.nicoa.org/policy_baldridge.html. Accessed August 4, 2004.

2. Kramer BJ. Chronic disease in American Indian populations. In: Markides KS, Miranda MR, eds. Minorities, Aging, and Health. Thousand Oaks, CA: Sage; 1997:181–204.

3. Jette AM. Disability trends and transitions. In: Binstock RH, George LK, eds. Handbook of Aging and the Social Sciences. 4th ed. San Diego, CA: Academic Press;1996:94–116.

4. John R, Hennessy CH, Denny CH. Preventing chronic illness and disability among Native American elders. In: Wykle ML, Ford AB, eds. Serving Minority Elders in the 21st Century. New York, NY: Springer; 1999:51–72.

5. Schacht RM, White M, Daugherty R, LaPlante M, Menz F An analysis of disability and employment outcome data for American Indians and Alaska Natives. Flagstaff, AZ: American Indian Rehabilitation Research and Training Center; 2003.

6. US Census Bureau. American Community Survey Quality Measures Available at: http://www.census.gov/acs/www/UseData/sse/res/00.htm. Accessed January 12, 2005.

7. US Census Bureau. Accuracy of the data (2000). Available at: http://www.census.gov/acs/www/Downloads/ACS/Accuracy00.pdf. Accessed March 14, 2005.

8. US Commission on Civil Rights. The health care challenge: Acknowledging disparity, confronting discrimination, and ensuring quality. Volume 1: The role of governmental and private health care programs and initiatives. Available at: http://www.law.umaryland.edu/edocs/usccr/pdf%20files/Preservation%20Resources%20PDF/cr12h34z.pdf. Accessed April 2, 2003.

9. Guralnik JM, LaCroix AZ, Abbott RD, et al. Maintaining mobility in late life: Demographic characteristics and chronic conditions. Am J Epidemiol. 1993;137: 845–857.[Abstract/Free Full Text]

10. Kaplan GA, Pamuk ER, Lynch JW, Cohen RD, Balfour JL. Inequality in income and mortality in the United States: Analysis of mortality and potential pathways. Br Med J. 1996;312:999–1003.[Abstract/Free Full Text]

11. US Census Bureau. Americans with disability: Table 1 Prevalence of disability by age, sex, race, and Hispanic origin, 1997 Survey of Income and Program Participation. Available at: http://www.census.gov/hhes/www/disable/sipp/disab97/ds97t1.html. Accessed November 19, 2002.

12. Seeman TE. Health promoting effects of friends and family: the impact of the social environment on health outcomes in older adults. Am J Health Promotion. 2000;14:362–370.[ISI][Medline]

13. McNeil J. Americans with disabilities: 1997 household economic studies, current population reports (P70–73). US Census Bureau. Available at: www.census.gov/hhes/www/disable/sipp/disab97/asc97.html. Accessed November 19, 2002.

14. Chapelski EE. Long-term care among American Indians: A broad lens perspective on service preference and use. In: Markides KS, Miranda MR, eds. Minorities, Aging, and Health. Thousand Oaks, CA: Sage;1997: 367–395.

This article has been cited by other articles:

				R. T. Goins, M. Moss, D. Buchwald, and J. M. Guralnik Disability Among Older American Indians and Alaska Natives: An Analysis of the 2000 Census Public Use Microdata Sample Gerontologist, October 1, 2007; 47(5): 690 - 696. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) All Versions of this Article: AJPH.2004.053462v1 95/11/1945    most recent Submit a response Purchase Article View Shopping Cart Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via ISI Web of Science (2) Citing Articles via Google Scholar Google Scholar Articles by Fuller-Thomson, E. Articles by Minkler, M. Search for Related Content PubMed PubMed Citation Articles by Fuller-Thomson, E. Articles by Minkler, M. Related Collections Aging Disability Native Americans Surveys Other Statistics/Evaluation/Research