Person smoking a cigarette

Reducing Health Disparities in Native Populations

Christine Makosky Daley and Sean Daley lead a team of researchers in a holistic approach to well-being.

American Indians and Alaska Natives die of heart disease, cancer, unintentional injuries and diabetes―the leading causes of death―at higher rates than other Americans, according to the Indian Health Service, an agency of the U.S. Department of Health and Human Services. Overall, the life expectancy of Native people is 5.5 years less than the general U.S. population.

The education gap is also wide. American Indians and Alaska Natives are among the racial/ethnic groups with the highest high school dropout rate, according to the U.S. Department of Education. Of those aged 16 to 24, 9.5% are not enrolled in school and don’t have a high school credential.

The health disparities and achievement gaps are interrelated, say tribal health experts Christine Makosky Daley and Sean Daley, faculty members and founding directors of the Institute for Indigenous Studies at Lehigh’s College of Health. The Daleys, collaborators and spouses who work with a team of researchers, partner with Native communities on a holistic approach to closing the gaps and promoting well-being.

“Addressing those issues is not just about saving individual people,” says Makosky Daley. “It's about taking an entire community and impacting it in such a way that we can reduce those disparities and make the prevalence rates look a bit more similar to other racial or ethnic groups.” 

Makosky Daley led the Institute’s research efforts as co-director before temporarily stepping down to chair the College of Health’s new department of community and population health. Daley serves as the Institute’s director.

Curbing Cigarette Smoking

American Spirit Cigarettes

A key area of the team’s research has centered on curbing commercial tobacco use among American Indians, who, along with Alaska Natives, have the highest prevalence of cigarette smoking compared to all other racial/ethnic groups in the United States. Subsequently, they are at a higher risk of developing or dying from tobacco-related diseases, including lung cancer, heart disease and diabetes, according to the Centers for Disease Control (CDC).

The team’s work with All Nations Breath of Life, a 12-week smoking cessation program that Makosky Daley helped to develop beginning in 2004, recognizes that tobacco, along with such plants as sage, cedar and sweet grass, is a sacred plant for many, but not all, American Indian populations. The program has a higher six-month quit rate than any other program for Native Americans, Makosky Daley says.

“American Indians are really the only group of people that we know of who view tobacco in a different light than many others,” she says. “Tobacco's a sacred plant to many Native people … and so the idea of smoking has a different connotation.”

The program, led by Native people, combines weekly in-person group support with individual telephone counseling. Participants also receive educational brochures on topics that include stress and weight management, and coping with withdrawal. The program also includes a choice of pharmacotherapy, as well as incentives such as flute music to help with stress reduction.

“We talk about tobacco as being sacred and being an important part of life, and being one of the first medicines out there, so you shouldn't disrespect it by smoking it recreationally,” Makosky Daley says. “Many times when you're using tobacco for ceremony, you're not even smoking it. You're burning it. … We talk about that and actively say, ‘By smoking recreationally you're disrespecting a sacred plant, and that's not okay.’ It's a different messaging that we use.”

The team initially tested the program for efficacy in reservation communities through a randomized trial. It then implemented a study of 312 participants in multi-tribal, urban communities, where views on tobacco vary; the cessation rates were similar or better, Makosky Daley says. 

In the multi-tribal study, researchers followed up with participants at six months and 12 months to assess whether they continued to abstain from recreational cigarette smoking. The study took place primarily in Kansas and Missouri, with additional sites in Colorado, Texas and Michigan—areas that have high smoking rates and high mortality from lung cancer. 

According to the findings published in Nicotine & Tobacco, 53% of participants who completed the program were abstinent at 12 weeks (end of the program); at six months, 31%  of retained participants had quit smoking; at 12 months, 34% of those reached were smoke-free. 

The interventions are on-going. “Participants work really well together,” Makosky Daley says. “They have fantastic discussions about their different beliefs, and how tobacco is sacred for some people and not for others and used in different ways. ... So the fact that people were able to come together and have these wonderful discussions seemed to really help them.”

A next step is an implementation trial in four urban and reservation communities, funded by the National Institute on Drug Abuse (NIDA).

“We're heading into the communities, teaching them how to run the program, and they are implementing it themselves, which is really cool,” Makosky Daley says. “In research, it's great to be able to say, ‘we did this in a research study in a controlled setting and it worked.’ It's even better to be able to say, ‘in the real world, we hand this program to communities, and they can run it and keep it sustainable.’ So now we're checking for sustainability. We're seeing if we hand it to communities and teach them how to run it, can they? Is the program going to work in a real-world setting, when the researchers are very hands-off?”

Additionally, the researchers will conduct a randomized trial of an individualized, phone-based version of the smoking cessation program, also funded by NIDA. A pilot test of the program, which aims to provide participants with more flexibility, had similar quit rates to the group-based program. Makosky Daley says she is hopeful it will work.

“We believe that a community cannot be truly healthy until individuals in that community begin to take a leadership role in improving and maintaining health,” Makosky Daley says. “This can only be accomplished when the educational attainment of the community is enhanced, and the true empowerment of community members occurs.”

Story by Lori Friedman and Mary Ellen Alu


An Institute for Indigenous Studies

Tribal health experts Christine Makosky Daley and Sean Daley established the Institute for Indigenous Studies at Lehigh’s College of Health in 2020, initially serving as co-directors. Makosky Daley led the Institute’s research endeavors before temporarily stepping down to chair the college’s new department of community and population health, while Daley led the Institute’s educational programs. Daley now serves as director.

The Institute’s work takes a “holistic health approach” that aligns with a definition of health often used by Indigenous peoples themselves, they say. 

“Our definition goes beyond the World Health Organization’s stance that health is a state of complete physical, mental and social well-being,” Daley says. “We add to their definition emotional, spiritual, community and environmental—both natural and built—aspects of health.”

The new Institute merged two centers: the Center for American Indian Community Health, founded and led by Makosky Daley at the University of Kansas Medical Center in Kansas City, Kan., and the Center for American Indian Studies, founded and led by Daley at Johnson County Community College in Overland Park, Kan. The Institute builds on the legacy of both centers, already well-known and well-respected in Indian Country.

“Native peoples are often relegated to stereotypes and mascots, or seen as relics of the past,” says Daley. “Having an institute that educates people, at Lehigh University, the greater Lehigh Valley area and beyond, about contemporary Indigenous peoples and their communities would help break down the misconceptions and stereotypes.”

Eight research scientists who worked with the Daleys in Kansas joined them at the Institute: Justin Begaye, MSW, MPA (Navajo); Ryan Goeckner, MA; Jordyn Gunville, MPH (Cheyenne River Sioux); River Gunville, BS (Cheyenne River Sioux); Jason Hale, MA (Prairie Band Potawatomi); Charley Lewis, MPH (Paiute/Navajo); Joseph Pacheco, MPH, ABD (Quechua/Cherokee); and Luke Swimmer, MBA (Eastern Band Cherokee). In addition, Eduardo J. Gómez, associate professor and director of undergraduate programs at the College of Health, joined the Institute, bringing his expertise in health policy and a global focus.

Among its projects, the Institute is continuing and expanding its COVID-19 prevention efforts, through funding from the Patient-Centered Outcomes Research Institute. This effort includes the creation and distribution of culturally tailored educational materials about COVID-19 that were translated into 10 to 15 Indigenous languages; and a survey of 1,000 American Indians about knowledge, attitudes, beliefs and behaviors surrounding the pandemic.

Additionally, the Institute is conducting a phenomenological study of the lived experience of COVID-19 among reservation-dwelling American Indians in the U. S., including frontline workers, policy-makers and those who had COVID-19. “Native Voices” will become a full-length book detailing the Native experience during the pandemic.

“One of the problems when you look at data, in general, in public health, [is that] the American Indian voice is not there, and the American Indian statistics are not there. They get lumped in with other racial or ethnic groups,” Makosky Daley says. “It's really important to be able to have data specific to that community … so that any interventions, any health issues, can be addressed in these communities.” 

Christine Makosky Daley earned a doctorate in applied medical anthropology from the University of Connecticut, a master’s in health and social behavior from the Harvard School of Public Health, a master’s in medical anthropology from Arizona State University and a bachelor’s in anthropology from Douglass College at Rutgers University. 

Sean Daley earned a doctorate in sociocultural anthropology from the University of Connecticut, a master’s in American Indian Studies from the University of Arizona, and a bachelor’s American Indian studies and anthropology from Livingston College at Rutgers University.

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