Injury Prevention in Indian Country

Injury Prevention in Indian Country

Disproportionately high rates of unintentional injuries are a leading cause of death for American Indians and Alaska Natives. From their unique vantage point on the front lines of community health, nurses can make a life-saving difference in helping tribes reduce and prevent these deadly disparities.
When three young children from the same family were killed in a car accident on the Pine Ridge Indian Reservation in South Dakota about five years ago, the leaders of the Oglala Sioux Tribe realized that they needed to do more to reduce the high rates of child passenger fatalities in their community.
The tribe’s Department of Public Safety applied for a Tribal Injury Prevention Cooperative Agreement Program (TIPCAP) grant from the federal Indian Health Service (IHS) Injury Prevention Program. As a result, Pam Pourier, RN, was hired as her tribe’s full-time injury prevention coordinator. “The important thing about using Native nurses in injury prevention activities on their home reservations is that the nurses know, and can identify with, the community people,” she says.
Since then, Pourier has worked tirelessly to promote and increase the use of child-restraint car seats throughout the reservation’s nine districts. In addition to educating families about the importance of securing their kids in safety seats, she has distributed hundreds of free seats to parents who otherwise couldn’t afford them. Her efforts have made such an impact in the Oglala community that she has earned the nickname Super Car Seat Lady.

A Different Kind of Health Disparity
Injury prevention is a critical concern for the 566 federally recognized American Indian and Alaska Native (AI/AN) tribes in the United States. According to IHS, unintentional injury from preventable accidents—such as motor vehicle crashes, drownings, poisonings, fires, and falls—is the third leading cause of death in AI/AN communities (after cancer and heart disease). Even more troubling, accidental injuries are the number one killer of young AI/AN people between infancy and middle age.

Although American Indians and Alaska Natives make up only about 2% of the total U.S. population (as of the 2010 Census), their risk of dying from unintentional injuries is disproportionately high. Statistics from IHS, the Centers for Disease Control and Prevention (CDC), and the Alaska Native Tribal Health Consortium (ANTHC) reveal a litany of disparities:
AI/AN people have the highest motor vehicle-related mortality rates of any racial or ethnic group in the nation.
AI/AN infants younger than one year old are eight times more likely to die in motor vehicle accidents than non-Hispanic whites.
Death rates from poisoning and falls are twice as high for AI/AN people than for their Caucasian counterparts.
Alaska Native children are five times more likely to die of an accidental injury than U.S. children as a whole.
Overall, Alaska Natives die of unintentional injuries twice as often as non-Native Alaskans and almost three times as often as Americans in general.
What accounts for these unequal outcomes? The IHS Injury Prevention Program cites a number of interconnected factors, including: the high proportion of young adults in AI/AN communities; hazards associated with living in rural environments; limited resources for providing safety infrastructure, such as street lighting, on reservations; low seatbelt and car seat use among AI/AN people; the need for stronger enforcement of state and tribal traffic safety laws; and higher-than-average numbers of alcohol-related accidents.

Injury Prevention Nurses Needed
Whether they work at the federal level (e.g., for IHS clinics or the U.S. Public Health Service Commissioned Corps), for state public health departments, or for tribally operated health care systems, nurses can play an exceptional leadership role in planning and implementing community-based education and interventions to reduce and prevent injury disparities in Indian Country.
“Nurses are the first line of community outreach,” says Sharon Ponkilla, LPN, a contract health and public health nurse for the Absentee Shawnee Tribal Health System’s Injury Prevention Program in Norman, Oklahoma. “They go into the homes and they see firsthand how our tribal members are living.”
Even though nurses—and especially culturally and linguistically competent American Indian and Alaska Native nurses—are ideally suited to be injury prevention specialists in AI/AN communities, there are surprisingly few of them working in this field. “There aren’t that many Native injury prevention nurses in these programs, especially at the tribal level,” Pourier says. “I think there needs to be more.”
So does CAPT Nancy Bill, MPH, CHES, manager of the IHS Injury Prevention Program. “There’s certainly a need for more nurses to become involved in injury prevention efforts,” she agrees. “Nurses are so important in this initiative, because they bring in that clinical side that [injury prevention specialists from other disciplines] are not trained in. They see things that we don’t, because we don’t have that background.”
One of the best ways nurses can build a foundation for getting started in this much-needed work is through specialized training, recommends Jaylene Wheeler, coordinator of the ANTHC Injury Prevention Program. For example, IHS and ANTHC offer comprehensive injury prevention courses designed specifically for health professionals who work in AI/AN communities (see sidebar).

Nurse-Led Success Stories
When Pourier came on board as the Oglala Sioux injury prevention coordinator in December 2010, her first step was to use her nursing assessment skills to evaluate the extent of the problem. “After reviewing all the data that was available, I saw that we had a loss of children [in motor vehicle accidents] that was just totally unacceptable,” she says. “Our child safety seat usage rate was 2%—probably because of the cost. Car seats are expensive.”
She also identified an urgent need to increase her tribal members’ awareness of how to actually use the safety seats her program would be giving them. “When we lost the three little ones in that one accident, those children had car seats but they weren’t buckled into them,” Pourier explains. “A car seat is not going to do your child any good if you’re not buckling them in or if the seat is not installed correctly.”
To bring her message that child restraints save young lives to as many community members as possible, Pourier has crisscrossed the approximately 3.1-million-acre reservation, giving presentations and handing out car seats at tribal Head Start programs and Family and Child Education programs. She also meets with groups of parents, grandparents, and other child caregivers, and she follows up regularly with what she calls “checkup events” to ensure that the car seats are being used.
Today, Super Car Seat Lady is a ubiquitous presence in the Pine Ridge area. To provide constant public service reminders about the difference child safety seats can make, she can be found everywhere from the Oglala Nation Powwow to her own weekly one-hour radio show. As her five-year grant period comes to a close, Pourier’s efforts have achieved remarkable results: The tribe’s car seat usage rates have soared to 71%.
At the Absentee Shawnee Tribal Health System, which serves Native people living in five Central Oklahoma counties, injury prevention services are provided by the Public Health Nursing Department at the Little Axe Health Center in Norman. The TIPCAP-funded program is led by a team consisting of Ponkilla (who is Absentee Shawnee); Injury Prevention Coordinator Rosie Tallbear (a member of the Cheyenne and Arapaho Tribes and the Crow Nation); and public health nurse Gloria Seeley, BSN, RN (a member of the Choctaw Nation). They focus primarily on three areas: adult motor vehicle safety, child passenger safety, and elder fall prevention.
The fall prevention initiative is based on a multifaceted public health nursing approach, Ponkilla says. “We do physical assessments, and we use the resources within our clinic to refer elders to the services they need,” she explains. “We do balance assessments and refer patients to physical therapists for strengthening. We send them to optometrists for vision exams.”
Tallbear and Ponkilla teach tai chi and exercise classes to help community elders improve their health and lower their likelihood of falling. Adds Ponkilla, “Our program partners with a [Department of Health and Human Services, Administration for Community Living] Native American Caregiver Support Program, Title VI, Part C grant that issues durable medical equipment, such as canes, walkers, and rollators, to elders ages 55 and older who need assistive devices to help them stay independent in their homes. We wish to keep our elders independent and living within their communities for as long as safely possible.”
The team also visits elders on the reservation to conduct home safety risk assessments. For instance, Seeley says, “We look for [potential risks] such as throw rugs. People can get their feet caught up in those, and there they are with a fall and possibly a broken hip.” As a result of the injury prevention program’s recommendations, the tribal government has helped elders fall-proof their homes by installing safety features such as bathroom grab bars, wheelchair-accessible showers, and additional lighting.

Culturally Competent Safety Messages
“Understanding the culture of individual AI/AN communities is vital to planning and implementing injury prevention programs,” Bill emphasizes. “Injury prevention practitioners should be aware of their community’s tribal history, traditional health and wellness practices, political structure, community infrastructure, demographics, and lifestyle.”
Native nurses who have firsthand familiarity with both the culture and the community are in a perfect position to engage tribal members in injury reduction interventions. “Rosie and I have worked among our tribe for years, and so our people trust us,” says Ponkilla. “That’s really key. You’ve got to have your nurses build a rapport with the community and establish that trust relationship.”
In addition, being thoroughly knowledgeable about a particular tribe’s traditional beliefs and attitudes can help nurses develop customized safety education messages that are more likely to resonate with people in that community, says Bill, who is a member of the Navajo Nation.
“For example, speaking about death is a taboo in Navajo culture,” Bill notes. “So when we educate that community about preventing motor vehicle fatalities by using occupant restraints, we focus on a positive message—the lives that could be saved, rather than the deaths. That approach has made a big difference in getting Navajo people’s attention, because it respects the culture.”
During the 16 years Bill worked in the field as the IHS Navajo Area injury prevention specialist, one of her biggest accomplishments was playing a leading role in an initiative that was highly successful in increasing seatbelt use in the Navajo Nation.
“Another Navajo belief is that if you talk about a problem, you bring it upon yourself,” Bill says. “So we implemented a program called Saved by the Belt. It gave recognition to people from the community who had been in horrible car crashes but were able to walk away safely because they were seatbelted. That really changed people’s attitudes about wearing seatbelts. If someone who didn’t understand the culture had come in and used tactics like showing pictures of people who were killed or injured in car accidents, it wouldn’t have worked at all.”
Cultural considerations also come into play when injury prevention nurses do elder home assessments. “Many of our elders use wood stoves,” says Ponkilla. “So we need to make sure they have smoke detectors and carbon monoxide detectors installed.”
Being culturally sensitive when interacting with AI/AN elders is an absolute must, Bill adds. “You can’t just go up to somebody’s home and go into the house. You have to be invited. And you need to know how to speak to an elder. The elders are very respected, and so you don’t talk down to them, for example. Knowing those cultural cues is important.”

The Alaska Native Perspective
Alaska Native communities have their own unique injury prevention issues, including high rates of injuries and deaths from snowmobile accidents, all-terrain vehicle crashes, hypothermia, boating accidents, ice-related falls, and hunting accidents.
“It’s a whole different culture up here,” says ANTHC’s Wheeler, who is a member of the Inupiaq and St. Lawrence Island Yupik People. “For many Alaska Natives who live in rural areas, it’s still very much a subsistence lifestyle—hunting and fishing. People are out at different times of the year gathering their food, and for the most part they’re doing that by taking a boat to go to their camp or to go up the river.”
Injury prevention nurses face special challenges in trying to provide Alaska Natives with the same kind of community-centered outreach that works so well with tribes in the “lower 48.” That’s because most of Alaska’s 229 tribes live in remote, geographically isolated rural villages, rather than on large, centralized reservations.
“Some of our tribal communities are accessible by road. But most are not; you can only get to them by plane,” Wheeler explains. “When we think about how to involve nurses in injury prevention work, we also have to think about what type of support is needed to help them reach Alaska Native people where they live.”
Wheeler, whose Anchorage-based program provides training and capacity-building services to tribal injury prevention staff in six Alaskan regions, offers this advice for how nurses can create targeted safety awareness campaigns that will connect with Alaska Native populations in a meaningful, empowering way:
“It’s not necessarily about developing new interventions. Often, it’s about taking evidence-based strategies or best practices that are already available and figuring out how to adapt them to make them culturally appropriate,” she says. “For example, in the Alaska Native community, we’re very much an oral culture. So telling stories is one way to reach [our] people that’s been around for generations.”
To bring that oral tradition into the social media age, ANTHC produced a series of digital storytelling videos and public service announcements featuring Alaska Natives talking about their personal experiences of why injury prevention is important to them. In one video, for instance, a woman shares her memories of friends and relatives who drowned in boating accidents. Then she explains how such tragedies can be prevented by wearing life jackets, learning to swim, and not overloading boats.
In other words, says Wheeler, “We didn’t change the [existing] safety tips. What we did was create an audiovisual tool for drawing Alaska Native people into the work that we’re doing, getting them excited about becoming advocates for injury prevention, and making them feel proud of the community and culture that we come from.”
Pam Chwedyk is a freelance health care writer based in Chicago. She is a former editor of Minority Nurse.