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RESEARCH 

Is men’s health a priority for tribal health 

directors? Results from a survey study 
Katherine E. Nowakowski1 Eric Bothwell2 Mose Herne3 Leo Nolan3 Joel Pacyna4 Wesley Petersen5 Jon Tilburt6 

1Stritch School of Medicine, Loyola University Chicago | 2160 South 1st Avenue Maywood, IL 60153, 2Men’s 

Health Network | P.O. Box 75972, Washington, D.C. 20013, 3Indian Health Service | 801 Thompson Avenue, 

Rockville, Maryland, 20852. 4Biomedical Ethics Program, Mayo Clinic | 200 First Street SW, Rochester, MN 

55905, 5Office of Health Disparities Research, Mayo Clinic | 200 First Street SW, Rochester, MN 55905 
6Division of General Internal Medicine, Mayo Clinic Health Care Policy and Research, Mayo Clinic, 200 First 

Street SW, Rochester, MN 55905 

*Corresponding author’s email: tilburt.jon@mayo.edu 

ABSTRACT 
Programs and initiatives addressing American Indian and Alaska Native (AI/AN) health disparities have 

recently shifted to better understanding, identifying and promoting successful programs designed to 

improve the health of AI/AN men. We sought to describe the priorities of front-line leadership of Indian 

Health Service, Tribal, and Urban (ITU) health programs, especially in relation to men’s health. We also 

sought to ascertain how potential future partners in men’s health research perceive the priorities 

established by the Indian Health Care Improvement Act (IHCIA). We surveyed directors of Indian Health 

Service, tribally operated facilities/programs, and Urban Indian clinics (I/T/U’s) on the relative 

importance of a range of health topics and issues and whether gender-based strategies were crucial to 

implementation. I/T/U directors identified diabetes (68%), alcohol and substance abuse (61%), 

mental/behavioral health (56%), obesity (53%) and addiction (40%) as the highest priority issues 

affecting both men and women. Only seven directors (6%) selected “men’s health” as a stand-alone 

priority. However, 80% said gender-tailored implementation was at least somewhat important for three 

or more of the priorities they selected. While neither men’s nor women’s health was identified as a 

standalone concern, health directors identified gender tailoring as a useful strategy for addressing many 

health issues. 

KEYWORDS: United States Indian Health Service; Men’s Health; Health priorities; Health services 

Citation: Nowakowski KE et al (2018) Is men’s health a priority for tribal health directors? Results from a 

survey study. Cancer Health Disparities 2:e1-e7. doi:10.9777/chd.2018.10003. 

 

 



 
 
 
 
 

 

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Introduction 

Health disparities for American Indian and Alaska 

Native (AI/AN) people are significant and far-

reaching. AI/AN people have higher mortality 

rates than the U.S. all-race population across a 

number of categories, including chronic liver 

disease, diabetes, unintentional injuries, suicide, 

and assault (homicide) (Indian Health Service, 

2015). Health disparities for many AI/AN 

populations have been widely reported in the 

literature (Cho et al., 2014; Herne et al., 2014; 

Veazie et al., 2014; White et al., 2014). Programs 

and initiatives addressing AI/AN health disparities 

have focused to a large extent on women and 

children’s health, but attention has expanded 

recently to better understand, identify and 

promote the health of AI/AN men.   

The Indian Health Care Improvement Act (IHCIA) 

was permanently reauthorized as part of the 

Patient Protection and Affordable Care Act in 2010. 

The IHCIA authorized the establishment of an 

“Office of Indian Men’s Health” in the Indian Health 

Service (IHS) to “coordinate and promote the 

health status of Indian men in the United 

States”(Heisler, 2011) without further 

appropriations. While the IHCIA was established 

with the best of intentions, we also noted that it 

lacked empirical grounding in the opinions of 

front-line, ITU health leadership. In order to 

address this gap in data, we partnered with the 

Men's Health Coalition to determine the extent to 

which men’s health as a free-standing health issue 

was prioritized among IHS, Tribal, and Urban 

(I/T/U) health program leadership. Also, by 

gauging ITU leaders’ perceived bandwidth for 

research in general, we sought to ascertain how 

potential future partners in men's health research 

perceive the IHCIA priorities. IHS Service Units, 

Tribally-Operated Health Programs and Urban 

Indian Health Programs (ITUs) lack a number of 

resources, including funds, providers and 

equipment. Programs tailored to the unique health 

needs of men, while potentially useful and 

effective, require time, personnel and money, 

which AI/AN communities may or may not feel 

capable of supporting. We surveyed I/T/U health 

directors on the relative importance of a wide 

range of health issues and topics, one of which 

was men’s health. We also asked how important 

gender-tailoring was for each health issue they 

ranked. Additional information concerning funding 

and other resources to support current programs 

was also collected. 

METHODS 

We sent a self-administered survey instrument to a 

national list of I/T/U health directors from all 12 IHS 

regions (See Figure 1) in the summer of 2014. The 

survey was a short 28-item questionnaire, and all 

items were developed by the research team. 

Respondents were asked to choose five health 

issues of greatest priority for their constituencies, 

estimate their capacity for research involvement, 

and gauge the importance of gender-tailored 

health programs in addressing health priorities 

identified. Survey recipients were presented with a 

list of 22 health issues derived from one of three 

sources: documented major health challenges, 

current prevention and treatment programs, or 

AI/AN health policy statements. Respondents were 

asked to pick one of the 22 listed health issues. 

They also could select “other” and specify the 

health issue in a free-text field. Following the issue 

selection, we asked participants to indicate the 

importance (very important, somewhat important, 

not important) of a gender-tailored program for 

addressing the selected health issue. The survey 



 
 
 
 
 

 

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contained five successive iterations of this two-

question set, and respondents were asked to use 

these question iterations as a way of indicating 

their “top five” health concerns of greatest priority 

for their constituencies (i.e. first iteration = first 

priority, second iteration = second priority, etc.). 

Only rank order priority was captured in this way 

(the survey was not designed to assess the relative 

“distances” between identified priorities). Our 

objective to ascertain the relative priority of men’s 

health was not disclosed in the survey materials. 

 

Figure 1. Comparison of IHS regions by count of sites invited to the survey  

(color gradient) and rates of response to the survey (percentages) 

In addition to the health priority items, respondents 

were queried about their past experiences about 

working with researchers (positive vs. negative 

experience), their capacity to take on new research 

projects and their interest in doing so, and their level 

of confidence that interventions developed from 

research in their constituencies would producing 

meaningful and lasting results. 

Anyone with a functioning email address was first 

sent an electronic survey, and those who did not 

respond were subsequently sent a paper survey 

(Group 1). The remaining group of participants 

received two waves of a paper survey. The 

electronic survey was deployed using REDCap 

(Harris et al., 2009). At the time of the first paper 

mailing, all participants (electronic respondents 

and all paper recipients in both groups) were 

mailed a copy of the book The Land Has Memory. 

Due to a typographical error for one item in the 

paper survey, trained phone survey staff also 

called paper survey respondents individually to 



 
 
 
 
 

 

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RESEARCH 

clarify their survey responses for one item. 

Instances of failure to reach participants and clarify 

their answers for these questions were reported as 

missing data for that item. The Mayo Clinic 

Institutional Review Board determined that the 

survey was exempt. 

RESULTS 

Out of the 566 Native American entities 

recognized by the federal government (Bureau of 

Indian Affairs, 2015), we were able to acquire 

contact information for 440 I/T/U directors. Email 

addresses were available for 372 (85%) of these 

contacts. Mailing addresses were available for all 

contacts; however, ten were undeliverable. The 

overall response rate was 114/430 (26.5%) (See 

Figure 2). Over 82% of respondents said funding 

deficiencies were a major challenge to their ability 

to implement programs and 31.7% of respondents 

currently had programs related to men’s health. 

 

Figure 2. Survey response rate 

I/T/U directors most often identified diabetes 

(67.5%), alcohol and substance abuse (60.5%), 

mental/behavioral health (56.1%), obesity (52.6%) 

and addiction (40.4%) as being among the top five 

health issues (Table 1). In contrast, only seven 

directors (6.1%) selected men’s health as a priority. 

I/T/U directors indicated that gender-tailoring 

would be important for some of their top health 

priorities. Aside from women’s health and men’s 

health, sexual abuse and domestic abuse showed 

the strongest support for gender tailoring. However 

gender-tailoring was also considered very 

important for issues such as cancer screening 

(80%), suicide (60%) and mental/behavioral health 

(51.9%) (Table 1). Most also said gender-tailoring 

was at least somewhat important for addiction 

(94.9%), alcohol and substance abuse (92.9%), 



 
 
 
 
 

 

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RESEARCH 

tobacco (87.5%) and obesity (84.3%). Overall, 

80.2% of respondents said gender-tailoring was at 

least somewhat important for three or more of their 

priority health issues. There was no significant 

difference regarding importance of gender-tailoring 

between respondents with and without active men’s 

health programs (Fisher’s exact p >.14). 

Table 1. Importance of gender tailoring for each health priority in the top 5 among 114 health directors. 

  Gender tailoring is important, N (Row %) 

Issue N (%) Very Somewhat Not Missing 

Diabetes 77 (67.5) 22 (33.3) 31 (47.0) 13 (19.7) 11 

Alcohol and substance abuse 69 (60.5) 25 (44.6) 27 (48.2) 4 (7.1) 13 

Mental health/behavioral health 64 (56.1) 28 (51.9) 22 (40.7) 4 (7.4) 10 

Obesity 60 (52.6) 25 (49.0) 18 (35.3) 8 (15.7) 9 

Addiction and its consequences 46 (40.4) 16 (41.0) 21 (53.9) 2 (5.1) 7 

Cancer Screening 32 (28.1) 20 (80.0) 4 (16.0) 1 (4.0) 7 

Tobacco 26 (22.8) 6 (25.0) 15 (62.5) 3 (12.5) 2 

Facilities improvements 25 (21.9) 1 (6.3) 5 (31.3) 10 (62.5) 9 

Suicide 21 (18.4) 12 (60.0) 6 (30.0) 2 (10.0) 1 

Other 18 (15.8) 6 (42.9) 7 (50.0) 1 (7.1) 4 

Domestic violence 17 (14.9) 13 (92.9) 1 (7.1) 0 (0) 3 

Adapting to health care reform 16 (14.0) 3 (18.8) 7 (43.8) 6 (37.5) 0 

Access to basic dental services 14 (12.3) 0 (0) 6 (54.5) 5 (45.5) 3 

Social assistance issues 14 (12.3) 3 (27.3) 6 (54.5) 2 (18.2) 3 

Strengthening health work force (eg, CHRs) 14 (12.3) 3 (21.4) 6 (42.9) 5 (35.7) 0 

Women's Health 11 (9.7) 8 (100) 0 (0) 0 (0) 3 

Health IT 10 (8.8) 1 (12.5) 3 (37.5) 4 (50.0) 2 

Home health 9 (7.9) 3 (33.3) 6 (66.7) 0 (0) 0 

Men's Health 7 (6.1) 5 (83.3) 0 (0) 1 (16.7) 1 

Sexual abuse 3 (2.6) 2 (100) 0 (0) 0 (0) 1 

Communicable diseases 1 (0.9) 0 (0) 0 (0) 1 (100) 0 

Public safety 0 (0.0) 0 (0) 0 (0) 0 (0) 0 

Giving our people access to clinical trials 0 (0.0) 0 (0) 0 (0) 0 (0) 0 

 

DISCUSSION 

Our results suggest that I/T/U directors do not 

commonly view the establishment of gender-

specific programs as a health priority per se. Rather, 

their health priorities reflect large, well-known, 

community-wide topics: diabetes, alcohol and 

substance abuse, mental/behavioral health, obesity 

and addiction. However, when asked whether 

gender-tailoring was important for these health 

priorities, frequently they agreed.  

AI/AN communities have a number of pressing 

health issues that cross the gender divide. Despite 

credible regularly monitored data that document 

that AI/AN male mortality from suicide, diabetes, 

and alcohol can exceed AI/AN females two to five 

fold in some age cohorts (Cho et al., 2014; Herne et 

al., 2014; Veazie et al., 2014; White et al., 2014), the 

sheer magnitude of the health challenges 

encountered by AI/AN community health leaders 

may overshadow consideration of gender-based 

priorities and gender-tailored health services.  



 
 
 
 
 

 

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A growing body of literature examines sex 

differences in biological processes and disease, 

giving rise to clinical attention to gender as it relates 

to health promotion and disparities. In the AI/AN 

community, a few studies have explored such 

gender differences (Bella et al., 2006; Blackett et al., 

2005; Blackett et al., 2012; Brave Heart et al., 2012; 

Manzo et al., 2014; Rink et al., 2012; Spillane et al., 

2012). These gender-sensitive studies identify 

plausible opportunities for discrete medical 

interventions that may improve health outcomes for 

specific conditions in AI/AN men. For I/T/U 

directors, focusing prevention and treatment efforts 

in a way that addresses gender disparities may offer 

promise in reducing the overall disparities 

experienced in AI/AN communities.  

Gender tailoring could improve the effectiveness of 

care, could better reach a full range of community 

members, and could facilitate infrastructure to 

increase access to care. Development and 

implementation of AI/AN men’s health initiatives 

should be considered in the context of other 

pressing health priorities. Efforts to utilize gender-

specific strategies to promote health would need to 

leverage already existing resources and would need 

to conform to the priorities of the communities 

involved. Gender tailoring of high priority health 

issues may be a strategy to achieve those 

overarching health priorities. More research is 

necessary to define and realize the potential impact 

of these strategies. 

Due to limited resources, we were not able to 

collect data on patient perspectives about health 

priorities. Future research could explore whether 

patients have perspectives about health priorities 

that resemble the perspectives of I/T/U directors, 

including whether gender tailoring of those 

programs would be important. Some research—

mainly qualitative focus groups—has been done in 

AI/AN patients, but most of the available literature 

reports on disease-specific studies (e.g. diabetes 

programs (Shaw et al., 2013), etc.) and does not 

interact with global perspectives from AI/AN 

patients regarding how they might prioritize the 

services available to them. 

A significant limitation of this study is the response 

rate. A 26% response rate among I/T/U directors is 

modest; it by no means represents all I/T/U 

directors. Also, this survey merely measured the 

perceived importance of men’s health as a free-

standing health issue and gender-tailored 

approaches to health. It did not ask respondents to 

make resource-sensitive value judgments of various 

health programs with or without gender-tailoring.  

AI/AN communities experience stark health 

disparities and a number of pressing health issues. 

Men’s health programs may be helpful tools for 

addressing these realities if they focus on gender-

specific approaches to improving health outcomes 

for community-specific priorities. 

Acknowledgements 

This study was funded in part by the Mayo Clinic 

Office of Health Disparities Research. 

Conflict of interest 
The authors declare that no competing or conflict of 

interests exists. The funders had no role in study 

design, writing of the manuscript, or decision to 

publish. 

Authors’ contributions 
JT, EB, MH, and LN contributed to the design of the 

study; KN, JP, and JT analyzed the data; KN wrote the 

initial draft of the manuscript; and KN, JP, JT, EB, MH, 

LN and WP provided critical feedback and revisions. 



 
 
 
 
 

 

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