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The Burden of Unintentional Injury Mortality Among American Indians/Alaska Natives in Michigan, Minnesota, and Wisconsin

Porter, Meghan A. MPH; Cirillo Lilli, Alexandra N. MPH; Schellinger, Chalyse N.

Journal of Public Health Management and Practice: September/October 2019 - Volume 25 - Issue - p S20–S28
doi: 10.1097/PHH.0000000000001018
Research Reports

Objectives: To characterize the burden of unintentional injury mortality among American Indians/Alaska Natives (AI/ANs) in Michigan, Minnesota, and Wisconsin and identify segments of the population that may especially benefit from policy and practice actions to reduce unintentional injury mortality risk factors.

Design: Surveillance of mortality data from CDC WONDER and WISQARS online databases.

Setting: The 3 states in the Indian Health Service (IHS) Bemidji Area: Michigan, Minnesota, and Wisconsin.

Participants: AI/ANs and whites who died from unintentional injuries in 2011-2015 in Michigan, Minnesota, and Wisconsin.

Main Outcome Measure: Unintentional injury mortality rates and AI/AN versus white unintentional injury mortality disparity ratios.

Results: For all types of unintentional injury mortality, from 2011 to 2015, AI/ANs in the Bemidji Area died at an age-adjusted rate that was 77% higher than that for whites, a statistically significant difference. For AI/ANs in the 3-state area, the top cause of unintentional death was poisoning. The poisoning rate was a statistically significant 2.64 times as high for AI/ANs as that for whites, the highest disparity seen by type. When analyzed by age, gender, and rural/urban residence, unintentional injury mortality rates were almost always higher for AI/ANs. AI/ANs also had a much higher burden of years of potential life lost.

Conclusions: Unintentional injury mortality significantly affects AI/ANs in the 3-state area and to a larger degree than for whites. However, some of the risk factors for unintentional injury are modifiable and, if addressed effectively, can reduce injury deaths. Governments, local leaders, organizations, and individuals can reduce AI/ANs' risk of unintentional injury by providing effective programming; encouraging or modeling behavior change; advocating for, creating, and enforcing laws and policies; and making infrastructure improvements. Increased attention to this topic and equitable efforts to reduce risk factors have great potential to reduce the burden of unintentional injury deaths for AI/ANs and all peoples.

Great Lakes Inter-Tribal Epidemiology Center, Great Lakes Inter-Tribal Council, Inc, Lac du Flambeau, Wisconsin.

Correspondence: Meghan A. Porter, MPH, Great Lakes Inter-Tribal Epidemiology Center, Great Lakes Inter-Tribal Council, Inc, 2932 Hwy 47 North, Lac du Flambeau, WI 54538 (

Funding for this publication was provided by the Department of Health and Human Services, Indian Health Service Epidemiology Program for American Indian/Alaska Native Tribes and Urban Indian Communities Cooperative Agreement (No. U1B1IHS0001).

The authors declare no conflicts of interest.

American Indians/Alaska Natives (AI/ANs) experience numerous health, social, and economic disparities compared with other racial/ethnic populations in the United States. These disparities are directly linked to the colonization of AI/AN people. Since first contact, indigenous populations have been subjected to negative experiences and violence including forced removal from their homelands and confinement upon reservations, criminalization of religious beliefs, destruction of their cultures through assimilation, and termination of federal recognition.1–4 This experience of colonization contributes to the health disparities experienced by AI/AN people and nations today; one effect is historical trauma.2–6 Nationally, AI/AN people have higher levels of poverty and worse access to health care, a higher prevalence than whites for many conditions such as diabetes, and higher rates of all-cause and many specific causes of mortality.7–11

AI/ANs nationally have higher unintentional injury mortality rates than whites.12–14 In 2008-2010, the US AI/AN age-adjusted mortality rate, adjusted for racial misclassification, was 91.9 per 100 000 compared with 39.5 for whites.13 Nationwide, unintentional injury mortality disproportionately affects young people. It is the top cause of death for those aged 1 to 44 years, with the highest burden seen among those aged 10 to 24 years where it accounts for 41.4% of all deaths.14 Few publications have addressed disparities in unintentional injury mortality among AI/ANs in the Bemidji Indian Health Service (IHS) Area. The Bemidji Area is one of 12 IHS administrative service areas across the nation. It includes the states of Michigan, Minnesota, Wisconsin, and the city of Chicago; 34 federally recognized Tribes and 4 urban communities with an IHS clinic are located in this region. States in this region make data on unintentional injury publicly available, but they do not report data for the entire IHS Area. Although IHS releases reports detailing many aspects of injury that include Bemidji Area–specific information,12,13 the analysis only examines data for select counties within the region where IHS delivers services, not the Area as a whole.

With an improved understanding of the epidemiology of unintentional injury mortality, prevention efforts will be better informed and, hopefully, be more effective at reducing deaths. In this report, we describe the burden of unintentional injury mortality among the AI/AN and white populations in the Bemidji Area (Michigan, Minnesota, and Wisconsin) by exploring the prevalence of unintentional injury deaths by injury type, sex, age, and rural/urban residence. In addition, we examine the burden of early death among AI/ANs and whites in the Bemidji Area. We identify segments of the population that may especially benefit from policy and practice actions that Tribal, federal, state, and local governments, leaders, organizations, and community members can take to reduce risk factors for unintentional injury and ultimately reduce unintentional injury deaths.

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We examined unintentional injury mortality through the use of 2 large online query systems, the Centers for Disease Control and Prevention (CDC)'s Wide-ranging Online Data for Epidemiologic Research (WONDER) and Web-based Injury Statistics Query and Reporting System (WISQARS). CDC WONDER mortality data originate from death certificates for residents of all 50 states and Washington, District of Columbia. Similarly, WISQARS' content is based on death certificate data. The data were retrieved from the systems that are available to the public and do not allow for the identification of individuals. Data in both these systems originate in death certificates. Institutional review board approval was not needed for this work.

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Unintentional injury mortality rates

The number of deaths, age-adjusted mortality rates, and 95% confidence intervals (CIs) were retrieved from CDC WONDER's Underlying Cause of Death database for AI/ANs and whites in Michigan, Minnesota, and Wisconsin aggregated and the United States for the years 2011-2015. Rates were calculated per 100 000 population and adjusted to the year 2000 standard population for the United States to accommodate for different age distributions in populations and to account for causes of mortality that affect different age groups differently. CDC WONDER does not release results containing fewer than 10 deaths and suppresses rates where fewer than 20 deaths occurred. Causes of death for which rates were suppressed or unreliable were not reported here; only causes of death with reportable rates for the 3-state area were included.

Rates were examined for AI/ANs and whites and analyzed by unintentional injury type, age, gender, and rural/urban residency. Manner of death was specified as unintentional. CDC WONDER uses bridged race categories. Ethnicity of the decedents was not taken into account for this analysis; both Hispanic and non-Hispanic individuals were included in each racial group. Standard 10-year age groups were used to determine age-specific mortality rates, with the exception of the youngest and oldest age groups. Because of small numbers of deaths in these populations, deaths of individuals 14 years and younger and 75 years and older were collapsed together. Urban classification was assigned to counties categorized as large central metro, large fringe metro, medium metro, and small metro. Rural classification was assigned to counties categorized as micropolitan (nonmetro) and noncore (nonmetro). Urban classification was based on place of residency, rather than place of death. International Classification of Diseases, Tenth Revision (ICD-10) underlying cause-of-death codes V01-X59, Y85-Y86 (total unintentional injury); W65-W74 (drowning); W00-W19 (falls); V02-V04, V09.0, V09.2, V12-V14, V19.0-V19.2, V19.4-V19.6, V20-V79, V80.3-V80.5, V81.0-V81.1, V82.0-V82.1, V83-V86, V87.0-V87.8, V88.0-V88.8, V89.0, V89.2 (motor vehicle crash); X40-X49 (poisoning); and W75-W84 (suffocation) were used to identify specific causes of death. Poisoning includes death by alcohol poisoning, legal and illegal drug overdoses, and exposure to other noxious substances.

Mortality disparity ratios indicate the degree of disparity between 2 groups by presenting the mortality rate of one group divided by the mortality rate of a second, reference group. The authors calculated the mortality disparity ratios using the white population as the reference group.

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Unintentional injury years of potential life lost

“Years of potential life lost” (YPLL) is a measure used to describe the magnitude of early death; in contrast to typical mortality measures, YPLL emphasizes the impact of premature death. YPLL is calculated by subtracting the age of an individual at the time of death from an age that people are “expected” to live until; the age of 65 years was used for this analysis. For a population, the total YPLL is determined by adding together all the YPLL for all people in the population. YPLL is just one method of measuring the impact of early death.

Data relating to YPLL were retrieved from WISQARS, an interactive Web-based query system from CDC, for each of the 3 states of Michigan, Minnesota, and Wisconsin for AI/ANs and whites for the aggregated years 2011-2015. Both Hispanics and non-Hispanics were included in the queries for each race. Three-state area aggregates were calculated by summing the number of deaths, YPLL, and population from each respective state. WISQARS does not allow for selection of specific ICD-10 codes—rather, a user selects the name of the cause of interest. The manner of death selected for the queries was “unintentional.” Information for causes of death was reported here only if the specific cause of unintentional injury YPLL comprised at least 5% of the total unintentional injury YPLL for AI/ANs.

The authors calculated the crude YPLL rates per 100 000 population by dividing the number of YPLL by the population younger than 65 years and multiplying by 100 000. YPLL disparity ratios were calculated similarly to the mortality disparity ratios, with the white YPLL rate serving as the denominator.

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Unintentional injury mortality

Table 1 presents the number, age-adjusted rate per 100 000 population, 95% CI, and disparity ratio for AI/AN and white unintentional injury deaths in the 3-state area between 2011 and 2015. The US AI/AN and white rates and CIs are also presented. The age-adjusted rates per 100 000 population and 95% CIs for AI/AN and white unintentional injury deaths in the 3 states are presented graphically by characteristic in Figure 1 and by type in Figure 2. In this time period, there were a total of 782 deaths to AI/ANs and 42 340 deaths to whites in the 3-state area. When age-adjusted and scaled to the sizes of each population, the unintentional injury mortality rate was 77% higher for AI/ANs than for whites in the 3-state area, a statistically significant difference. Nationally, it was also significantly higher for AI/ANs but only 14% greater. The 3-state AI/AN rate was 51% higher than the national AI/AN rate, whereas the 3-state white rate was 2% less than the national white rate.







Males had a higher age-adjusted rate than females within both race groups examined, but between races, AI/AN males died at a rate that was 65% higher than that for white males. AI/AN females died at a rate that was 94% higher than white females. Both differences were statistically significant.

Residents of rural areas generally had higher unintentional injury mortality than residents of urban areas. Still, between races, rural AI/ANs had a mortality rate almost twice as high (disparity ratio 1.95) as rural whites and urban AI/ANs had a 60% higher mortality rate than urban whites. These differences were also statistically significant.

The top cause of unintentional injury death for AI/ANs in the 3-state area was poisoning, whereas falls was the top cause for whites in the 3-state area. Poisoning death occurred for AI/ANs at a rate 2.64 times as high as poisoning deaths for whites, a statistically significant difference. Mortality caused by falls occurred more often for whites than for AI/ANs (12.6 and 10.0 per 100 000, respectively), though the difference was not statistically significant. Although drowning was the rarest of the 5 types of unintentional injury investigated, it had the second largest disparity between AI/ANs and whites (disparity ratio 2.11, statistically significant). Nationally, motor vehicle crashes were the most common cause of unintentional injury death among AI/ANs, followed closely by poisoning, whereas poisoning was the most common cause among whites.

The number, crude mortality rate per 100 000 population, CIs, and disparity ratio for AI/AN and white unintentional injury mortality by age group are shown in Table 2. For all age groups with the exception of the 75 years and older group, AI/ANs had higher mortality rates than whites, and only among 65- to 74-year-olds in the 3-state area was this difference not significant. The greatest disparity was for the 35- to 44-year-old age group, where the AI/AN mortality rate was nearly 3 times as high as the white rate. In addition, the rates for all the age groups between 25 and 64 years of age were at least twice as high for AI/ANs as those for whites. Nationally, the greatest disparity between AI/ANs and whites was seen among those 14 years and younger (disparity ratio 1.53, statistically significant, not reported) and was still less than the disparity seen in the 3-state area for that age group.



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Unintentional injury YPLL

Table 3 displays the YPLL by type of unintentional injury for AI/ANs and whites in the 3-state area from 2011 to 2015. Unintentional injury mortality overall caused 19 359 and 557 230 YPLL for AI/ANs and whites, respectively, in the 3-state area. More than a quarter of all-cause YPLL among AI/ANs in the 3-state area were due to unintentional injury mortality, with unintentional poisoning alone accounting for 13% of all YPLL. Meanwhile, unintentional injury caused one-fifth of total all-cause YPLL for whites in the 3-state area, and poisoning accounted for just over 9% of the white all-cause YPLL. For total unintentional injury YPLL and all specific causes of unintentional injury examined, the rates for AI/ANs were more than twice as high as those for whites. The greatest disparity was for poisoning where the AI/AN YPLL rate was 2.54 times as high as the white rate.



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AI/ANs in Michigan, Minnesota, and Wisconsin experienced inequities in unintentional injury mortality for nearly all characteristics and types examined as compared with whites in the 3-state area and the nation. Disparities also existed when comparisons were made with AI/ANs nationwide. Although rates in Table 1 and Figures 1 and 2 were age-adjusted to account for the younger AI/AN population compared with whites, AI/AN 3-state rates were higher than the white 3-state rates in all characteristics examined except for one (type of injury: falls) and were significantly higher in all characteristics except for 2 types of injury (falls and suffocation). Injury is an important cause of early death for AI/ANs in the 3-state area, with about a quarter of all YPLL attributable to unintentional injury. The YPLL rates illuminate this disparity more clearly: the YPLL rate for AI/ANs in the 3-state area was more than twice as high as that for whites.

Males generally have higher rates of unintentional injury mortality than females,12–14 and this pattern was seen here within each race group. However, in the 3-state area, the disparity between AI/AN females and white females was larger than the male disparity. Unintentional injury prevention targeted specifically to females should receive increased consideration in AI/AN communities. In addition, although it is known that rural residents experience higher numbers of unintentional injury morbidity and mortality than urban residents,15,16 rural AI/ANs experienced unintentional injury mortality at almost twice the rate of rural whites. Prevention efforts targeting rural AI/ANs are particularly important.

When analyzed by type of injury, the highest disparity was seen in poisoning, which includes alcohol poisoning and prescription and illegal drug overdoses. Furthermore, poisoning accounted for 13% of the all-cause YPLL, indicating a large impact on younger people. The impact of substance abuse may be particularly pronounced in AI/AN communities due, in part, to historical trauma.2 A tool of colonialism, alcohol has had a negative effect on AI/AN communities for centuries.1,2 In 2015, AI/ANs were the racial/ethnic group with the highest percentage of individuals with alcohol use disorder (9.7%), significantly higher than the national average (5.9%).17 Excessive alcohol consumption increases the risk of unintentional injury mortality, not only for alcohol poisoning but also as a contributor to other causes of injury such as motor vehicle crashes.7,13,16,18 Opioid overdoses are another component of the poisoning category, and while opioid abuse is a challenge facing communities across the country, it has impacted AI/ANs and Tribal communities nationally and in the 3-state area particularly hard.19–22 Opioid abuse is of such a concern that Tribes are taking legal action alleging that opioid manufacturers, distributers, and retailers have swamped their lands with opioids and did not prevent diversion of the drugs; Tribes also allege that state consumer protection laws were violated.21 Within the 3-state area, the Midwest Alliance of Sovereign Tribes declared an emergency as a call to action against the opioid epidemic.19 More resources and attention should be directed to poisoning and alcohol and drug use surveillance, treatment, and prevention, especially in AI/AN communities.

The greatest disparity for AI/ANs in the 3 states, by age, was for young and middle-aged adults (25-54 years). With the exception of the oldest age group, the highest mortality rate was found in 45- to 54-year-olds for AI/ANs and among the 65- to 74-year-olds for whites. More examination is needed, but this difference in age groups may be related to the cause of death that affects each population the most: the greatest number of unintentional injury deaths for AI/ANs were due to poisoning, whereas falls, which affect older people more, were the leading cause of death for whites.

AI/ANs in the Bemidji Area are affected by both modifiable and nonmodifiable risk factors for unintentional injury. The AI/AN population is younger than the white population, and those of younger ages are generally more susceptible to unintentional injury due to risk-taking behavior. It has also been reported elsewhere that AI/ANs have a higher prevalence of substance abuse disorders than the general population.17,23 Historical trauma is a risk factor for substance abuse, and interventions addressing this issue should be considered.2–4,6 In addition, more AI/ANs reside in rural areas. While urbanicity is generally considered a modifiable risk factor, it may be more difficult for AI/ANs to relocate than other racial groups. Because AI/AN nations are tied via treaty to specific lands, for AI/AN people to move from their reservation to an urban area would require potentially giving up more than just a community, family, and their home as is commonly conceptualized. It might also require leaving their native language, culture, and proximity to sacred sites. Through the IHS's use of the Purchased and Referred Care Program, which uses an individual's county of residency as part of determining an AI/AN person's eligibility for IHS health care, access to care may also be tied to rural residency for AI/ANs.24

Risk factors may be most effectively addressed when interventions delivered in AI/AN communities are culturally appropriate and recognize the influence of historical trauma on AI/ANs' health and behavior. For substance abuse programs in particular, incorporating a historical trauma lens and integrating culture have been identified as being very important. Interventions designed with these issues in mind may be more accepted by the community and successful in affecting change.2,4,6,25

Although the disparities in unintentional injury presented here are large, they are not entirely insurmountable. Different groups within the AI/AN community and outside it can use their available resources and influence to improve these outcomes by addressing modifiable risk factors. First, as sovereign nations, Tribes have the legal authority to pass and enforce laws to address risk factors that contribute to unintentional injury death on their lands.26 Similarly, states and the federal government can recognize the disparity and do more to prevent such deaths by funding more research, interventions, and infrastructure changes in these communities.19,27 In particular, numerous strategies exist to reduce mortality from the 2 causes of unintentional injury that impact AI/AN people in the 3-state area the most: poisoning and motor vehicle crashes.12,18,28–32 Particular consideration should be made to ensure these efforts are culturally appropriate. Local leaders and organizations have the influence to call attention to the disparities, advocate for these interventions, and see they are implemented well.19,27 Finally, individuals have the ability to change their own behaviors or influence those they care about to change their behaviors. The capacity of each of these groups extends beyond what is mentioned here, but with increased awareness of the disparate burden of unintentional injury deaths among AI/ANs, there can and should be productive action to avert these largely preventable deaths.

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There are many limitations that must be considered when interpreting the data presented here. First, the data were not adjusted for racial misclassification. Misclassification of race on death certificates is an issue that plagues AI/AN data quality nationally and almost always means that AI/AN rates are an underestimate of actual rates. An examination of unintentional injury by IHS found that mortality rates in specific counties within the Bemidji Area increased from 75.8 to 93.3 per 100 000 population after adjusting for race misreporting.13 The area had the sixth highest mortality out of the 12 IHS areas but had one of the greatest increases due to adjusting.13 It is likely that if the AI/AN 3-state rates reported in this article were adjusted for racial misclassification, rates would be even higher than currently presented. Manner of death may also be misidentified (eg, a self-inflicted intentional injury death may be misclassified as an unintentional injury death).33,34 Evidence that this may occur among AI/ANs has been noted in Minnesota.22

In addition, small populations and a small number of deaths limited the ability to examine a more complete list of causes of injury or by certain factors (such as more detailed age groups).

A 3-state aggregate population was analyzed in this article, which did not allow for examination of unintentional injury within specific communities. AI/AN Tribes vary substantially, and differences likely exist in the most common types of injury as well as the degree of disparity. While it is possible to generate community-specific data, this type of analysis was not conducted for this report in order to maintain the confidentiality of Bemidji Area communities. Small numbers of deaths at the community level and resulting unreliability in rates likely would hinder the completeness of Tribe-specific analyses.

Furthermore, rural populations are known to have higher unintentional injury morbidity and mortality than urban populations and a higher proportion of AI/ANs than whites in the 3-state area reside in rural areas.15,35 To some extent, this may be a factor in AI/ANs' overall higher mortality rates from unintentional injury. We were not able to control for urbanicity in our analysis. In addition, the degree of residential urbanicity was dichotomized into either rural or urban, and although this is a commonly used classification, this method masks the variation within these categories.16

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In the 3-state area of Michigan, Minnesota, and Wisconsin, AI/ANs experience a much larger burden of unintentional injury mortality than whites in almost every type and by almost every characteristic analyzed. Unintentional injury death often comes suddenly and without warning, but there are still risk factors that can be reduced and actions that can be made to reduce its possibility. More attention should be paid to the amount of unnecessary deaths and the disparity, and resources and efforts should be greatly increased to prevent it. The authors call on all peoples, whether AI/AN or not, to join the effort to reduce AI/AN unintentional injury mortality.

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Implications for Policy & Practice

  • Information about the disparate burden of unintentional injury among AI/ANs in the IHS Bemidji Area (Michigan, Minnesota, and Wisconsin) may be used to assist governments and organizations in prevention efforts.
  • Because these data were not adjusted for racial misclassification, unintentional injury mortality rates for AI/ANs and disparities as compared with whites in the area likely were greater than reported here.
  • Unintentional injury mortality is likely amenable to policy and practice changes, especially when developed with cultural appropriateness and historical trauma in mind.
  • Because of their status as sovereign nations, Tribes have the unique opportunity to implement policy and practice changes in their communities that may not be open to state and local governments.
  • Numerous interventions have been shown effective in reducing mortality from the 2 causes of unintentional injury that impact AI/AN people in the 3-state area the most: poisoning and motor vehicle crashes.
  • Prevention efforts targeting AI/AN females, as well as ones focusing on rural-dwelling AI/ANs, are opportunities to decrease some of the disparities that exist within the AI/AN population in the area.
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American Indians/Alaska Natives; Bemidji Area; mortality; unintentional injury

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