Research Highlights:
- Native American tribal members identified five priorities to improve awareness of and access to care for heart disease: heart health education; cultural considerations; inclusive, multigenerational community engagement; improved resources for general health and wellness; and accessible, patient-centered health care with local cardiac care.
- The researchers will use these community insights to develop a heart disease health program, which tribal members will help design and participate in.
DALLAS, May 7, 2025 — Native American tribal members said improved cultural awareness and health education are vital to successfully reduce the high rate of undiagnosed heart disease among indigenous American people, according to new research published today in the Journal of the American Heart Association, an open access, peer-reviewed journal of the American Heart Association.
According to the 2020 American Heart Association Scientific Statement: Cardiovascular Health in American Indians and Alaska Natives, heart disease is a leading cause of death among Native American people, causing death more often and earlier among indigenous communities than in the general U.S. population. The statement noted that the prevalence of heart disease among Native American adults is more than 12%, compared to heart disease prevalences of 1% to 8% among Asian, Black, Hispanic and white adults. However, underreporting of indigenous American data could underestimate the true extent of cardiovascular disease in this population, because the U.S. Centers for Disease Control and Prevention reports that Native American adults are 60% less likely to be diagnosed with heart disease than non-Hispanic white adults.
"Native American adults are disproportionately impacted by poor outcomes related to cardiovascular disease and that is exacerbated by several factors, most notably by the limited access to cardiac diagnosis and medical care," said study senior author Sarah de Loizaga, M.D., a pediatric cardiologist at Cincinnati Children's Hospital Medical Center in Cincinnati. "Many programs that have aimed to address these barriers have demonstrated only partial success, limited by challenges of sustainability and feasibility. Therefore, we undertook this study to gather information to help design a viable program that meets the specific needs of the community."
To build such a public health program, de Loizaga's research team engaged community members from one Native American tribe in eastern Arizona to better understand their specific community's needs and priorities around heart health. After recruiting more than 150 tribal members, researchers asked open-ended questions to tribal members to gain insight into their personal experience with heart disease in a series of interactive, large group sessions. Additionally, the researchers gathered perceptions related to the participants' communities, to heart health care and health care in general, and into strategies needed to address health.
Tribal members identified five overarching priorities for a successful heart health program:
- There is a need for increased heart-health education and awareness: Participants expressed that heart problems are not seen as a priority within the tribe because people do not understand the symptoms, preventive measures or risk factors associated with heart disease.
- Tribal cultural considerations are crucial: Participants discussed the inherent privacy concerns and denial of health issues among many in their communities, especially regarding sharing personal health issues, so a heart health program should be "culturally in-tune" and recognize the importance of traditions and tribal culture.
- There should be inclusive, multigenerational community engagement: Participants expressed the need for community involvement across all ages and in all communities, including involvement with schools to reach young people.
- Improved resources for general health and wellness are needed: Basic community needs are not currently being met for wellness, nutrition and physical fitness activities; additionally, substance use/addiction, depression, poverty, neglect and lack of support are significant health challenges Native American communities face.
- Accessible, patient-centered continuity of healthcare with local cardiac care is needed: Community members cited many structural barriers, including distance to resources (healthy groceries, medical facilities/care), lack of transportation and cost of healthy foods and medical care, along with concerns for privacy and establishing rapport and trust with clinical professionals, as major roadblocks.
"The more novel findings of our research were around some of the cultural considerations and specific needs of the community that could be barriers to heart health care. For example, among many of these communities, there is a belief that seeking care can also 'invite' something bad to happen; in other words, if you had not gone looking for heart disease it may never have happened," de Loizaga said. "Ensuring tribal traditions and beliefs are incorporated and respected within the program is vital. It was also apparent that community members want to be actively engaged in developing the programs that would benefit all generations."
While this research is not generalizable to other tribal nations in the U.S., which could be considered a limitation of the study, de Loizaga noted the research was not intended to be generalizable but rather localized and contextualized to the tribe involved in this study.
"By taking a community-based approach, we aimed to develop a program that was culturally appropriate, but also more relevant and sustainable for the future," de Loizaga said.
She said this approach to a community-wide problem became very personal for the participants and for the researchers.
"While not reported in our manuscript, it was also surprising how many tribal members shared the personal impact of heart disease – losing a sister, parent or other loved one to heart disease. While we are obviously aware of the statistics, being present and having witnessed individuals share their personal stories and losses provides a different level of appreciation of those numbers – as well as our efforts to address them," de Loizaga said.
This study was funded through the American Heart Association's Health Equity Research Network on Improving Access to Care and other Health Inequities in Rural America, a $20 million commitment launched in 2023 as part of the multi-pronged approach of the American Heart Association's ongoing work to improve health in rural America. More than half of the native population of the U.S. lives in rural areas or reservations.
"This rural health research network was established to address data that finds that along with higher rates of heart disease and stroke, people living in rural areas of the U.S. have a 20% higher death rate than people in metropolitan and urban areas," said Keith Churchwell, M.D., FAHA, American Heart Association volunteer president, an associate clinical Professor of Medicine at Yale School of Medicine in New Haven, Connecticut and adjunct Associate Professor of Medicine at the Vanderbilt School of Medicine in Nashville, Tennessee.
"People living in rural communities, including Native American reservations, have higher levels of obesity, diabetes and hypertension and higher rates of tobacco use – all factors that negatively impact heart and brain health. They have also been plagued by increasing prevalence of substance use disorders associated with opioids and methamphetamines. All these risk factors contribute to poor health," he said.
Churchwell noted that, additionally, higher rates of poverty, lower levels of education, lack of public transportation and shortages of health care facilities and professionals contribute to the unique obstacles rural communities face in achieving good health.
"This current study is an excellent example of how this research initiative is exploring innovative ways to address these challenges, as well as determining how tried-and-true methods can be used to make meaningful change," Churchwell said.
Study details, background and design:
- A total of 163 tribal members participated, ranging in age from 14 to 81 years and with a wide range of educational backgrounds and professions. Members included nurses, community leaders, a local grocery store manager and others. Most participants (68%) were women.
- The Group Level Assessments conducted in this study were the first step in a year-long process to work with the community and design a heart health program. For this step, researchers collaborated with the community research leadership board to recruit study participants through word of mouth, flyers and social media posts.
- Together with a community research leadership board established for this project, four Group Level Assessment sessions were held throughout the tribal land. Themes from each session were combined and distilled into priority areas.
- Within this process, participants are the experts of their lives and communities, and accordingly, they generated, analyzed, and prioritized data from their perspectives.
- The study was conducted in October of 2023 with one tribe in Eastern Arizona. Researchers did not identify the specific name of the tribe for confidentiality purposes.
- Researchers have since done one-on-one interviews to expand on the identified themes. They also held four design workshops in which they collaborated with community members on barriers and facilitators for heart disease education and support programs and identified and proposed program components.
Co-authors and disclosures are listed in the manuscript.
