The Unseen Picture: Issues with Health Care, Discrimination, Police and Safety, and Housing Experienced by Native American Populations in Rural America

Abstract Purpose Despite increased national attention to improving rural health, rural Native American populations face unique problems that are often unseen in aggregate research on the rural United States. The objective of this study was to examine rural Native Americans’ experiences with serious problems across domains important to health, using rural Whites as a comparison group. Methods Using 2 probability‐based national telephone surveys (2017 and 2019), we examined rural Native American adults’ reported problems in health care, discrimination, police and safety, and housing. We then compared Native American‐White differences in reported problems across domains. Findings Among rural Native American adults, 33% reported recent problems accessing health care when they needed it, 28% reported they or family members recently experienced major problems paying for medical bills, and 28% reported recent problems with health care quality. Several Native American‐White differences were reported, including experiencing racial violence (34% vs 5%, P < .001), discrimination in health care (19% vs 3%, P = .003), unfair police treatment (27% vs 5%, P = .002), and major housing problems (48% vs 26%, P < .001). Conclusions Rural Native American adults report ongoing and widespread problems with health care, discrimination, the police, safety, and housing. These findings support many national policy recommendations to improve federal funding and oversight for programs serving Native American populations living in rural areas.

populations living on tribal lands and in other rural areas. [9][10][11][12][13] Rural Native American populations face distinct and exacerbated health disparities compared to their White counterparts. 2,5,[14][15][16] Though precise estimates vary depending on both the definition of rural and the inclusion of race as American Indian/Alaska Native alone or multiracial, a significant share of Native Americans live in rural America, both within and outside of tribal lands. 17,18 However, because they comprise a low percentage of the total rural population, rural Native Americans are not typically well represented in national surveys. [4][5][6] The Centers for Disease Control and Prevention gathers data on the rural Native American populations' basic health status and behavioral indicators, 5 but research gaps remain examining their reported life experiences apart from the general rural population. To our knowledge, no prior probability-based studies using national samples have recently examined rural Native Americans' personally reported experiences with serious health care, discrimination, police and safety, or housing problems. We conducted 2 polls in 2017 and 2019 to examine their experiences, using rural Whites as a comparison group.

Study Design and Sample
Data used in this study were obtained from 2 original, nationally representative, probability-based cell and landline telephone polls of US adults. Rural was defined as geographic areas outside of metropolitan statistical areas. The first poll was conducted from January 26 to April 9, 2017, about experiences of discrimination against several minority groups in America. The second poll was conducted from January 31 to March 2, 2019, on economic-and health-related experiences facing adults in rural America. Both surveys were jointly designed by Harvard T.H. Chan School of Public Health, the Robert Wood Johnson Foundation, and National Public Radio and were fielded by SSRS, an independent survey research firm. Harvard researchers were not directly involved in data collection and de-identified datasets were used for analysis, thus the Harvard T.H. Chan School of Public Health Office of Human Research Administration classified these surveys as "not human subjects research." The final analytic samples included 317 Native American adults and 1,066 White adults aged 18 years and above living in the rural United States. Native Americans were oversampled in both surveys to obtain adequate sample sizes for the analysis. For race, re-spondents self-identified as Native American, American Indian, or Alaska Native. Multiracial respondents were asked which race they identified with most and were included in the sample if they identified mostly as Native American, and "Native American" was used in follow-up questions.
Survey completion rates were 74% (survey 1) and 76% (survey 2) among respondents who answered initial demographic screening questions. Overall response rates were 10% (survey 1) and 8% (survey 2), calculated based on the American Association for Public Opinion Research's (AAPOR) RR3 formula. 19 While these response rates are not ideal, they are consistent with response rates of telephone polls by prominent survey organizations. 20

Survey Instrument
Questions were developed following AAPOR best practices, after conducting a review of the existing survey data. Questionnaires were reviewed by external experts for bias, balance, and comprehension and were pretested among a subset of respondents before being conducted among the full samples. We analyzed 16 questions. Some questions (eg, discrimination) were only asked among a randomized half-sample of respondents to limit the burden on their time. For sensitive topics such as harassment, we used a validated method 21 to ask whether some experiences happened to the respondent or their family members. Question wording is available in online Appendix A.

Statistical Analyses
After calculating descriptive statistics, we calculated the percentages of adults reporting their experiences for each question using survey weights. We used pairwise t tests of differences in proportions to make uncontrolled comparisons between rural Native American and White respondents. We only report results with at least 10 percentage points' difference as robust enough to have statistical and practical implications, with statistical significance at P < .05.
To compensate for nonresponse bias and variations in the probability of selection, data were weighted by household size and composition, cell phone and landline use, and demographics using US Census data on gender, age, education, race/ethnicity, and region to reflect the true population distribution of Native American and White adults in the rural United States. We also used randomdigit dialing and random selection of respondents within households to attain a representative sample. Analyses were conducted using STATA version 15.0 (StataCorp LLC, College Station, TX).

Results
The characteristics of rural adults from 2 surveys included in this study are presented in Table 1. Most rural Native Americans did not have a college degree, and a majority lived in households earning < $50,000 annually. Among rural Whites, most did not have a college degree, while approximately half lived in households earning < $50,000 annually. Table 2 shows reported experiences with health care, discrimination, police and safety, and housing problems. For health care, 33% of rural Native Americans reported problems accessing health care when they needed it in the past few years, while 28% reported they or family members experienced major problems paying for medi-cal bills in the past few years. In addition, 28% of rural Native Americans reported recent problems with health care quality. There were no statistically significant differences between rural Native Americans and Whites on any health care measures.
On the topic of discrimination, more than 1 in 5 rural Native Americans reported experiencing racial discrimination in several areas, including when trying to find housing (24%), discrimination in police interactions (22%), and avoiding calling the police due to concerns about discrimination (21%). About 1 in 5 rural Native Americans (19%) reported experiencing racial discrimination when going to a doctor or health clinic, while 14% reported avoiding seeking needed health care due to fear of unfair treatment. Higher shares of rural Native Americans reported problems across all discrimination measures compared to rural Whites (Whites reporting housing discrimination: 4%, P = .015; discrimination in police interactions: 7%, P = .024; avoided calling police: 0%, .015 * Reported homelessness is a major problem in the local community b 520 19 16 .564 * Rural Native American adults significantly different from rural White adults at P < .05. a Authors' analysis of 2 surveys of 317 Native American and 1,066 non-Hispanic White adults living in the rural United States (total N across both surveys, all analyses use weighted data). Do not know/refused responses included in the total N for each question. Full question wording is available in online Appendix A. b Question only asked among a half-sample of respondents to limit the time burden. c Housing question only asked among respondents who have ever tried to rent a room or apartment, or to apply for a mortgage or buy a home. d Questions asked if events have happened to you or a family member because you or they are [Native American or White]. P = .004; discrimination in health care: 3%, P = .003; avoided health care: 4%, P = .046).
When it comes to police and safety, 37% of rural Native Americans reported race-related threats or harassment against themselves or family members and 34% reported racial violence against themselves or family members. More than 1 in 4 rural Native Americans (27%) rated their local community as unsafe from crime, 27% also reported they or Native American family members were unfairly stopped or treated by the police, and 23% reported they or family members were unfairly treated by the courts because of their race. Higher shares of rural Native Americans reported problems across all police and safety measures compared to rural Whites (Whites reporting racial threats/harassment: 10%, P ≤ .001; racial violence: 5%, P ≤ .001; community unsafe from crime: 10%, P = .016; unfair police treatment: 5%, P = .002; unfair treatment by courts: 8%, P = .039).
In housing, 48% of rural Native Americans reported any major housing problems while living in their current residence, including problems with drinking water safety, electricity, and mold or other environmental problems. Online Appendix B contains details on housing problems. Financially, 20% of rural Native Americans reported major problems paying for housing within the past few years, while 19% reported homelessness as a major problem in their local community. Compared to rural Whites, higher shares of rural Native Americans reported major housing problems (Whites: 26%, P < .001) and major problems paying for housing (Whites: 9%, P = .015). There was not a statistically significant difference between Native Americans and Whites for viewing homelessness as a problem.

Discussion
This study provides a snapshot of rural Native American adults' reported life experiences across areas that may drive their poor health outcomes observed in other studies, 5,15 with 4 important findings.
First, despite living in the post-Affordable Care act era, at least one-quarter of the rural Native American population reported facing serious problems with health care costs, access, and quality. Similar shares of rural Native American and White adults reported these health care problems, suggesting greater rural-urban disparities in health care than racial disparities within rural areas. Several provisions in the Affordable Care Act have the potential to improve health care for both rural communities and Native American populations. However, in order to meaningfully improve health care access, affordability, and quality, policy makers should also address long-standing underfunding of the Indian Health Service and other common barriers to care for rural Americans, including access to specialists. 12,13,22,23 Second, it is concerning that one-fifth of the rural Native American population reported discrimination in clinical health care encounters and 1 in 7 avoided seeking health care due to anticipated discrimination. These results underscore significant policy opportunities identified elsewhere to eliminate discrimination and unfair treatment of Native Americans, in health care and beyond. 14, 24 Third, rural Native American adults widely reported experiencing violence, harassment, discrimination, and unfair treatment by the police and courts, which is consistent with prior research findings without regard to rurality. 11,12,[25][26][27] While national attention to racism within policing has increased in recent years, it has largely centered on the experiences of Black Americans. 10,28 Additional, focused attention is needed to improve law enforcement and reduce discriminatory policing practices impacting Native American populations living in rural areas. 11,12,25,26 Fourth, nearly half of rural Native American adults reported at least one major problem while in their current residence, which is consistent with other research documenting housing shortages in Indian Country, and substandard housing where housing exists. 10,12 More research and funding are needed to support rural Native American populations' unique housing problems, as distinct from rural communities generally.

Limitations
Several limitations should be considered when interpreting our results. Although we oversampled rural Native American adults, both the sample size and some ques-tions that were only asked of half the sample constrained our ability to examine heterogeneity within their diverse experiences across different geographies, cultures, heritage, traditions, and tribal affiliations. Future research should explore these differences, as well as protective factors that may improve experiences and health outcomes in areas we studied. Self-reported data may introduce recall bias, and responses to sensitive topics may be underreported. 21 We also were not able to compare rural Native Americans to their nonrural counterparts. Because the sample was not evenly distributed geographically across Native American and White populations, regional differences may have impacted reported experiences. Our low response rate is an important limitation, though prior studies suggest that low response rates do not bias results if respondents are representative of the study population. 20,29 If surveys with low response rates use probability-based samples and are weighted using Census parameters, they are expected to yield accurate estimates in most cases. 20,[29][30][31] However, selection bias may remain related to the measured experiences. Despite these limitations, this study allowed us to examine experiences of rural Native Americans, which is difficult in survey research due to sampling challenges. [4][5][6]

Conclusions
Rural Native American populations report widespread serious problems with health care, discrimination, the police and safety, and housing, which are all likely to be exacerbated by the COVID-19 pandemic. 32 These problems are often unseen in the larger picture of research on rural America, as they differ from serious problems reported by rural Whites. Our findings support many national policy recommendations to increase federal funding and improve oversight for programs serving Native American populations living in rural areas, with goals of improving their health outcomes and reducing health disparities. [8][9][10][11][12][13][14]