Recent reports and media attention have brought heightened awareness to the fact that Native American women are victims of rape and other sexual violence at epidemic rates.1 More than one in four Native American women will be raped within her lifetime, and nearly half of all Native American women will experience sexual violence other than rape within their lifetime (Black et al., 2011).
Sexual assault examiner (SAE) and sexual assault response team (SART) programs were developed to improve the quality of psychological, health, and forensic services provided to survivors of sexual assault. To be consistent with the terminology that the Indian Health Service uses, this refers to healthcare professionals who are specially trained to provide sexual assault care as SAEs. SART, on the other hand, is used in conjunction with SAE to be inclusive of programs included in the study that reflect a SART model but may or may not offer sexual assault examination services SAE and SART programs have been shown to enhance the quality of care of survivors of sexual assault, collect better forensic evidence, and lead to further progression of cases within the justice system (Bechtel, Ryan, & Gallagher, 2008; Campbell, Patterson, & Bybee, 2012; Campbell, Patterson, & Lichty, 2005; Crandall & Helitzer, 2003; Fehler-Cabral, Campbell, & Patterson, 2011; Martin, Young, Billings, & Bross, 2007; Nugent-Borakove et al., 2006; Selig, 2000). Despite the evidence that care and outcomes improve because of these programs, not all health facilities have established SAE or SART programs. As such, staff may receive little or no training on the special considerations that sexual assault victims need (Littel, 2001; Martin, 2005; Martin et al., 2007).
Information regarding the access that Native American women living on tribal land have to facilities with a SAE or SART programs is limited. Some Indian Health Service (IHS)-operated and tribal-operated hospitals do perform sexual assault exams. In addition, the Omnibus Appropriations Act (2009), Public Law 111–8, created funding through the Domestic Violence Prevention Initiative (DVPI), which includes support for the IHS to develop SAE programs at several IHS facilities. In light of the increased availability of funding from the DVPI program, the purpose of this paper was to show the coverage of facilities with SAE or SART programs on Native American lands and demonstrate the extent to which IHS and tribal hospital provision of sexual assault exams improve access for Native American victims of sexual assault to appropriate services.
The data used for the analysis came from three sources: two national databases of facilities providing SAE and/or SART services and one list of IHS- and tribal-operated hospitals that self-identified that they perform sexual assault exams on-site. The national databases of the International Association of Forensic Nurses (IAFN) Sexual Assault Nurse Examiner (SANE) program listings (www.iafn.org) and the SANE-SART Resource Service program locator (www.sane-sart.com) were utilized in this project. Both the IAFN program locations and SANE-SART Resource Service program locator aim to provide universal listings of SAE and SART programs. The listings used in this study from IAFN and the SANE-SART Resource Service did not include IHS- or tribal-operated facilities. The database of IHS- and tribal-operated hospitals was provided by the IHS Division of Behavioral Health and included 29 hospitals that self-identified that they provide sexual assault exams on-site. At the time of the study, eight of these locations had received funding for SAE programs as a result of the DVPI.
The programs included in the database all offer a service or services aimed at supporting a person after a sexual assault. The programs included SANE programs but also included programs that do not have the same standards of practice. Some listings provide forensic care, whereas others, such as the SART programs, may or may not offer medical and forensic examination as a service. The services included across and within the three databases differ in the type(s) of care they offer and in their certifications and terminology. It was not within the scope of the study to distinguish between type(s) of services, nor was it the goal to assess the quality of the services. Each database used in this study has criterion for program inclusion. Refer to Table 1.
Data from IAFN as of August 2011 (n = 597) and data from the SANE-SART Resource Service as of June 2011 (n = 526) were merged into one database, resulting in a total of 1,103 records. The merged database was manually analyzed for duplicate locations between the two original databases. This resulted in a total of 873 locations prior to geocoding. Figure 1 outlines the process of merging facilities.
The IHS- and tribal-operated hospitals did not include any duplicate records. The 29 facilities included in this database were all unique from the 873 facilities in the merged database. Although the SANE-SART Resource Service program locator does list some tribal programs, these are community-based programs, whereas the listings shared by IHS only included hospital facilities. Some physical addresses and zip codes were added to the database using information available on the Internet, either on the facility Web sites, Google maps, or the IHS Web site. Zip codes were located and added for missing or incorrect entries using the U.S. Postal Services directory.
Geographic information systems (GIS) technology was used to determine facility locations in relationship to Native American land. Following data preparation, the cleaned databases were analyzed using Esri’s ArcGIS 10.0 software to geocode each facility and determine the 60-minute driving service areas that intersected with Native American lands. “Geocoding” refers to the process of determining the coordinates of a facility so that it can be spatially located within the GIS software. Each record’s exact geographic location was found by geocoding all 873 physical addresses, using Esri’s Data and Maps StreetMap of North America data set. Initial analysis with the ArcGIS software located 96% of facilities, with 259 facilities having less than 100% accuracy. An address with an error (e.g., wrong street number or incorrect zip code) can result in the system being unable to determine the exact coordinates of the facility. Each facility with less than 100% accuracy was further analyzed, resulting in the ArcGIS software locating 100% of facilities and an improvement in overall accuracy by 17%. With this improvement, the accuracy of all record locations was considered sufficient to proceed with the study.
With the database of the IHS- and tribal-operated hospitals, attempts to locate and verify facility locations were done prior to geocoding because of the smaller number of listings (n = 29). All IHS- and tribal-operated facilities in the study were located. Many of the IHS listings lacked a traditional physical address because of their rural locations, and as such, eight facilities had between 77% and 99% accuracy.
A total of 650 Native American lands were mapped using data from the U.S. Census Bureau’s 2000 American Indian Areas/Alaska Native Areas/Hawaiian Home Lands. To remove facilities that do not service Native American lands, a full circular buffer with a radius of 60 miles was created around the center point of each facility. The facility buffers were intersected with the mapped Native American lands, which included all 650 legal and statistical American Indian, Alaska Native, and Native Hawaiian entities for which the U.S. Census Bureau provides data for Census 2000..05.2
A total of 466 facilities with no tribal or IHS hospital affiliation were found to lie in a 60-mile range from an Native American land. Each remaining location was inspected with the ArcGIS Network Analysis tool, using the North American StreetMap for a 60-minute drive time. This analysis generated a perimeter around each facility, representing the geographic distance from the facility that can be driven within 60 minutes. A map of the resulting information is included as Figure 2.
The network analysis for IHS- and tribal-operated facilities was processed using the same analysis settings and perimeter generation as indicated above, but without the full circular buffer, which was unnecessary as all facilities serve Native American populations. Figure 3 is a map of the IHS- and tribal-operated facilities, and the 60-minute drive time perimeter in relation to Native American land.
Percentage of Service Area
In order to obtain a percentage of the 60-minute drive time service area that intersected with individual Native American lands, the total service area of a given facility that intersected with an Native American land was calculated and divided by the total area of the Native American land. Calculations were made separately for the national database of facilities and the IHS- and tribal-operated facilities. In instances where non-IHS/tribal facility coverage and IHS- and tribal-operated hospital coverage overlapped, obtaining a total coverage could not be achieved by merely adding the two percentages together on each land. In these cases, the intersecting service areas were merged, and the total coverage was calculated from that merged coverage area.
Of the 650 Native American lands analyzed, 30.7% of the total land area is within a 60-minute driving distance of a facility providing SAE or SART services. Facilities from the national database of SAE and SART programs cover 19.6% of all Native American lands, where “coverage” is defined as the area of Native American land that is within a 60-minute driving distance of one of the mapped facilities. IHS- and tribal-operated facilities included in this study cover 12.7% of all Native American lands. The 29 IHS- and tribal-operated hospitals were within a 60-minute driving distance of 35 Native American lands. Without the IHS- and tribal-operated hospitals, 14.3% of the area of those 35 lands had coverage by a facility with a SAE or SART program. Including the IHS- and tribal-operated hospitals, 36.3% of the area of those 35 lands was covered by a facility offering sexual assault exams.
The Winnebago Reservation located in Nebraska with a population of approximately 2,600; the Pueblo of Zuni located in New Mexico, home to an estimated 6,400 people; and the Omaha Reservation in Nebraska with a population of 5,200 (as of the 2000 census), each saw increases of more than 75 percentage points in coverage. For more information on the service coverage on each Native American land included in this study, please visit: http://gptchb.org/wp-content/uploads/2013/11/SAFE-in-Indian-Country-Data.pdf.
Discussion and Implications for Nursing Practice
This study was able to answer two separate questions: What was the impact on coverage with the addition of IHS- and tribal-operated hospitals providing services for victims of sexual assault, and what percentage of Native American land is covered by a facility with a SAE or SART program? In response to the former question, on the Native American lands with a program within a 60-minute driving distance, the IHS- and tribal-operated hospitals increased coverage by 22%, bringing the total coverage for those 35 lands to 36.3%. However, even with this funding, less than one third of all 650 lands analyzed are within a 60-minute driving distance of a SAE or SART program. A total of 381 Native American lands remain without any facilities within a 60-minute driving distance. Studies evaluating the effectiveness of SAE and SART programs have shown that these programs improve the quality of healthcare and judicial outcomes (Bechtel et al., 2008; Campbell et al., 2012; Fehler-Cabral et al., 2011). As such, Native American women living on the 69% of land that is uncovered must drive more than an hour to access these evidence-based programs.
Native American women may be more likely to access post sexual assault care at an IHS facility. Women living on or near Native American lands often have prior experience accessing healthcare services at an IHS- or tribal-operated hospital and may feel that IHS facilities provide more culturally responsive care than other local facilities. However, the IHS- and tribal-operated hospitals included in this study only cover 12.7% of all 650 Native American lands. Given this information, further investigation is needed to determine whether Native American women are willing and able to access SAE or SART services at other facilities.
Data resulting from this study indicate which lands have the lowest coverage based on available information; 381 lands have no coverage at all. The top five uncovered reservations with the largest land areas are (a) the Uintah and Ouray Reservation located in northeast Utah; (b) the Standing Rock Sioux Reservation located in North Dakota and South Dakota; (c) the Wind River Indian reservation in Wyoming; (d) the Colville Reservation in Washington State; and (e) Fort Berthold in North Dakota. Hidast, and Arikara Nations. A further 28 lands have less than 25% coverage, and a total of 431 Native American lands have coverage on less than half of the land. This study indicates that further funding of programs like the DVPI, which funds SAE programs at 8 of the 29 IHS- and tribal-operated hospitals, particularly on lands that currently have little to no coverage currently, would increase access to appropriate services for Native American survivors of sexual assault.
This study does not indicate the population within Native American lands, and as such, we are unable to say what percentage of Native American population a SAE or SART program covers. In addition, many of the Native American lands included are statistical areas. This was particularly true in Oklahoma with Oklahoma Tribal Statistical Areas and Alaska with Alaska Native Village Statistical Areas. The Oklahoma Tribal Statistical Areas represent American Indian reservations that existed before Oklahoma became a state in 1908. The Alaska Native Village Statistical Areas represent areas where a substantial portion of the Alaska Native population lives seasonally or year-round. In addition, the study did not include Native American populations living in urban areas, although IHS does have urban-based facilities. The criteria used in this study of considering a 60-minute driving distance to be a facility’s “service area” is stringent as people living on Native American lands often have to drive more than 60 minutes to access health services. As such, analyzing locations within 60 miles and a 60-minute driving distance of Native American lands left out facilities that would be within a 2- or 3-hour driving distance. IHS policy requires facilities be within 120 minutes driving distance of Native American lands. More research is needed to determine what percentage of the 466 facilities with no IHS or tribal affiliation meet the IHS criterion, and what the overall impact of an expanded driving distance would be on Native American land coverage.
The online databases from which the listings were taken have grown since the listings were received in the summer of 2011. In addition, although steps were taken to ensure the highest quality of data, some programs listed may no longer be active or may have changed locations. Although both the SANE-SART Resource Service and IAFN databases attempt to be comprehensive, they rely on programs to submit their information. As such, some programs may be missing from the list of facilities included in this study. Finally, our listings included a range of programs for sexual assault survivors. Listings from the two national databases included both SAE and SART programs, which differ in nature. The IHS- and tribal-operated facilities that were included self-identified that they provide exams for survivors of sexual assault but may not all have SAE or SART programs. As a result, this study can speak to the availability of services for sexual assault survivors but cannot prove with full certainty where forensic and medical services are in comparison to sexual assault response services more broadly. Further research is needed to determine whether the facilities that are accessible to people living on Native American lands offer high-quality, evidence-based services for victims of sexual assault.
The authors thank the following for their assistance with this project: Carolyn Aoyama, Kim Day, Madison Giroux, Staci Hunter-LaCroix, Larry Layne, Dr. Linda Ledray, and Mary Beth Martin.
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1Native American includes American Indian, Alaska Native, and Native Hawaiian
2Full descriptions of all lands can be found at http://www.census.gov/geo/reference/gtc/gtc_aiannha.html