'Empowering our people' to address depression, violence, and sexual risk among Native Americans with recent binge alcohol use.

Background: This study was launched in response to an American Indian (AI) community's concern regarding the comorbid occurrence of substance use, poor mental health, and other risk factors on sexual health. The purpose of this manuscript was to assess the relationship between alcohol use, violence, depression and STI/HIV risk behaviors on the frequency of unprotected sex acts and number of sexual partners among AI adults.Methods: Specifically, this analysis examines sociodemographic characteristics, experience of sexual and physical violence, binge drinking, depression, and sexual risk taking among n = 281 AI adults ages 18-55. Regression models examine associations between the aforementioned risk factors, number of sex partners and number of unprotected sex acts, by depression status and sex, among participants.Results: Frequent binge drinking predicted frequency of unprotected sex for both males and females; ever experiencing physical violence was a powerful predictor of unprotected sex for females, but not males. Ever experiencing physical violence strongly predicted having multiple sexual partners for females but was related to decreased number of sexual partners for males. Females ever experiencing sexual violence had more sexual partners; this was not observed for males. Binge drinking predicted frequency of unprotected sex acts, regardless of depression status.Discussion: Interventions for AI adults seeking to reduce sexual health risk should reflect past violence victimization in sexual decision making, primarily among women. The significant role of binge alcohol use for modifying sexual decisions should be of prime focus and interventions should be personalized to address individuals' own alcohol use patterns. Additional research should explore how binge alcohol use moderates the relationship between depression and sexual risk.

Social Network Differences Between American Indian Youth Who have Attempted Suicide and Have Suicide Ideation.

Suicide is a crucial public health concern for American Indian and Alaska native (AIAN) communities. AIANs have the highest suicide rate compared to all other ethnic groups in the United States. Social relations are a salient fixture of AIAN culture. The primary aims of this study were to describe the personal networks of AI youth that have recently had a suicide attempt or suicidal ideation and to identify key network differences between the two groups. This study uses personal networks collected among AIs living on a reservation in the Southwest. Our sample included 46 American Indians that have recently attempted suicide or had suicidal ideation. We explored social network characteristics of the two groups descriptively as well as comparatively (t-tests). Our findings suggest that AI youth that have attempted suicide nominate more friends in their networks that have used alcohol and drugs compared to the networks of AI youth that have recent suicide ideation. Additionally, AI youth that recently attempted suicide have used alcohol and drugs with their network peers at a higher rate than youth that have had recent suicide ideation. Lastly, AI youth that have attempted suicide recently were significantly more likely to have more nominated friends in their networks that they had reached out to when they were struggling with suicide compared to their peers that have experienced recent suicide ideation. These results indicate a promising method moving forward to identify unique intervention strategies that extend beyond the individual.

Community Perspectives on Social Influences on Suicide Within a Native American Reservation.

Relative to the general population, Native Americans (NA) bear a disproportionate burden of suicide-related mortality rates. NA males and females aged 15 to 24 years experience suicide rates nearly 3 times than the U.S. all races rates in this age group. Although efforts have been made to understand and reduce suicide in tribal communities, a large portion has focused on individual characteristics with less attention given to social factors that may also inform suicide. This article aims to build on a local conceptual model of NA youth suicide by examining additional potential social factors through qualitative interviews. Findings from the thematic analysis resulted in the identification of seven perceived social influences: contagion, violence and abuse, discrimination and bullying, negative expectations, spirituality, social support, and cultural strengths. Public health approaches to reduce suicide should consider local social factors that resonate with tribal communities to build resilience.

Entrepreneurial, Economic, and Social Well-Being Outcomes from an RCT of a Youth Entrepreneurship Education Intervention among Native American Adolescents.

Background: Entrepreneurship education has demonstrated positive impacts in low-resource contexts. However, there is limited evidence of such programs evaluated among Native American (NA) youth in a rural reservation. Methods: A 2:1 randomized controlled trial evaluated the impact of the Arrowhead Business Group (ABG) entrepreneurship education program on entrepreneurship knowledge, economic empowerment, and social well-being among 394 NA youth. An intent to treat analysis using mixed effects regression models examined within and between study group differences from baseline to 24 months. An interaction term measured change in the intervention relative to change in the control. ABG participants were purposively sampled to conduct focus groups and in-depth interviews. Results: Significant intervention vs. control group improvements were sustained at 12 months for entrepreneurship knowledge and economic confidence/security. Significant within-group improvements were sustained for ABG participants at 24 months for connectedness to parents, school, and awareness of connectedness. Qualitative data endorses positive impacts on social well-being among ABG participants. Conclusion: Observed effects on entrepreneurship knowledge, economic empowerment, and connectedness, supplemented by the experiences and changes as described by the youth themselves, demonstrates how a strength-based youth entrepreneurship intervention focused on developing assets and resources may be an innovative approach to dually address health and economic disparities endured in Native American communities.

Predictors of Sexually Transmitted Infection Positivity Among Substance-Using Native American Adults.

BACKGROUND: Sexually transmitted infections (STIs) are a public health crisis with Native Americans suffering a high burden of disease. Studies across gender and racial/ethnic groups have found varying risk factors associated with STI positivity. Understanding how risk factors are associated with STI positivity can help design interventions for those most at risk. METHODS: Participants were Native American binge substance using adults enrolled in a randomized controlled trial evaluating a brief intervention to increase STI screening and reduce sexual risk-taking behaviors. Participants completed a self-report assessment at baseline that included questions about sexual risk factors and STI testing behaviors and diagnosis. This analysis includes those who had ever completed an STI test at baseline. Bivariate and multivariate analyses using logistical regression were utilized to identify associations between risk factors and past STI diagnosis. RESULTS: A total of 193 people were included in the analysis. Over half (50.6%) of the participants had ever been diagnosed with an STI. Risk behaviors varied by gender. More women with a self-reported history of STI reported having sex with someone they thought had an STI, past experience of physical/sexual violence, and having passed out from drinking. Men with a self-reported history of STI were more likely to report past marijuana and other drug use. Among women with a self-reported history of STI, having sex with someone they thought had an STI was associated with STI positivity, whereas other drug use was associated with STI positivity among men with a self-reported history of STI. CONCLUSIONS: Findings provide information for those working to reduce STIs in Native Communities to better identify and design programs for those at highest risk for STIs. Additional studies examining gender dynamics and sexual risk taking among native adults are warranted.

Evaluation of an Entrepreneurship Education Intervention for American Indian Adolescents: Trial Design and Baseline Sample Characteristics.

Entrepreneurship education is a strength-based approach and holds promise for promoting health equity for American Indian youth. Arrowhead Business Group (ABG) was developed by a tribal-academic research partnership and is being rigorously evaluated for impacts on psychosocial, behavioral, educational, and economic outcomes. This article describes: 1) the trial design and conceptual model under-girding the ABG program; 2) the sociodemographic, sociocultural, and family/household characteristics of participants at baseline; and 3) the baseline differences in key outcome indicators between study groups. Results demonstrate participants have baseline characteristics appropriate for study aims and are compared and contrasted with other youth from the participating tribal community and state in which the tribe resides. Findings inform future analyses to explore how baseline characteristics are associated with primary and secondary outcomes of the evaluation.

Characteristics of Substance Abuse and Self-Injury among American Indian Adolescents Who Have Engaged in Binge Drinking.

Binge drinking appears to be a risk factor, facilitator, and method of suicidal and non-suicidal self-injury for some American Indian (AI) youth. We examined characteristics, patterns, and motivations for binge use among AI adolescents (N = 69; 10-19 years-old) who recently engaged in binge drinking. The majority used alcohol alone (53.7%) or a combination of alcohol and marijuana (31.3%) for their binge event. Gender differences emerged with boys more severely affected than girls. Forty-seven percent reported lifetime suicidal thoughts. This study represents one of the first in-depth examinations of substance use and related behaviors among AI adolescents who have engaged in recent binge use.

Exploring risk and protective factors with a community sample of American Indian adolescents who attempted suicide.

American Indian adolescents are at disproportionate risk for suicide, and community-based studies of this population, which allow a deeper understanding of risks and resilience to inform interventions, are rare. This is a cross-sectional study of N = 71 Apache adolescents. Strengths include the role of the community and American Indian paraprofessionals in the design, implementation, and interpretation of findings. Participants were M = 16.0 years old, 65% female, and 69% multiple attempters. Risks included suicidal behavior among peers and family (68%), caregivers with substance problems (62%), and participant substance use history, namely alcohol (91%) and marijuana (88%). Areas of resiliency included lower depression scores (M = 23.1) and cultural activity participation. A multi-tiered intervention at individual, family, and community levels is needed.

Community-based surveillance and case management for suicide prevention: an American Indian tribally initiated system.

The National Strategy for Suicide Prevention highlights the importance of improving the timeliness, usefulness, and quality of national suicide surveillance systems, and expanding local capacity to collect relevant data. This article describes the background, methods, process data, and implications from the first-of-its-kind community-based surveillance system for suicidal and self-injurious behavior developed by the White Mountain Apache Tribe with assistance from Johns Hopkins University. The system enables local, detailed, and real-time data collection beyond clinical settings, with in-person follow-up to facilitate connections to care. Total reporting and the proportion of individuals seeking treatment have increased over time, suggesting that this innovative surveillance system is feasible, useful, and serves as a model for other communities and the field of suicide prevention.

Nasopharyngeal carriage and transmission of Streptococcus pneumoniae in American Indian households after a decade of pneumococcal conjugate vaccine use.

BACKGROUND: Young children played a major role in pneumococcal nasopharyngeal carriage, acquisition, and transmission in the era before pneumococcal conjugate vaccine (PCV) use. Few studies document pneumococcal household dynamics in the routine-PCV7 era. METHODS: We investigated age-specific acquisition, household introduction, carriage clearance, and intra-household transmission in a prospective, longitudinal, observational cohort study of pneumococcal nasopharyngeal carriage in 300 American Indian households comprising 1,072 participants between March 2006 and March 2008. RESULTS: Pneumococcal acquisition rates were 2-6 times higher in children than adults. More household introductions of new pneumococcal strains were attributable to children <9 years than adults ≥17 years (p<0.001), and older children (2-8 years) than younger children (<2 years) (p<0.008). Compared to children <2 years, carriage clearance was more rapid in older children (2-4 years, HRclearance 1.53 [95% CI: 1.22, 1.91]; 5-8 years, HRclearance 1.71 [1.36, 2.15]) and adults (HRclearance 1.75 [1.16, 2.64]). Exposure to serotype-specific carriage in older children (2-8 years) most consistently increased the odds of subsequently acquiring that serotype for other household members. CONCLUSIONS: In this community with a high burden of pneumococcal colonization and disease and routine PCV7 use, children (particularly older children 2-8 years) drive intra-household pneumococcal transmission: first, by acquiring, introducing, and harboring pneumococcus within the household, and then by transmitting acquired serotypes more efficiently than household members of other ages.

Impact of more than a decade of pneumococcal conjugate vaccine use on carriage and invasive potential in Native American communities.

BACKGROUND: We assessed the impact of 12 years of pneumococcal conjugate vaccine (PCV7) use on pneumococcal nasopharyngeal carriage and serotype-specific invasive disease potential among Native Americans. METHODS: Families were enrolled in a carriage study from 2006 to 2008; nasopharyngeal specimens and risk factor information were collected monthly for 7 visits. Pneumococcal carriage prevalence was compared with that before (1998-2000) and during (2001-2002) PCV7 introduction. We compared invasive disease incidence and carriage prevalence before and after PCV7 introduction to estimate changes in serotype-specific invasive potential. RESULTS: We enrolled 1077 subjects from 302 households. There was an absolute reduction in carriage prevalence of 8.0% (95% confidence interval [CI], 4.5%-11.4%) in children aged <5 years and 3.1% (95% CI, 1.1%-5.1%) in adults. In children aged <5 years, vaccine-serotype carriage prevalence decreased by 22.8% (95% CI, 20.1%-25.3%), and nonvaccine serotype (NVT) increased by 15.9% (95% CI, 12.4%-19.3%). No significant change was detected in serotype-specific invasive potential after PCV7 introduction. CONCLUSIONS: Pneumococcal carriage prevalence decreased in all ages since PCV7 introduction; vaccine-serotype carriage has been nearly eliminated, whereas the prevalence of NVT carriage has increased. The increase in the NVT invasive disease rate seems to be proportional to the increase in colonization prevalence.

Toward understanding suicide among youths: results from the White Mountain Apache tribally mandated suicide surveillance system, 2001-2006.

OBJECTIVES: We examined suicide and suicide attempt rates, patterns, and risk factors among White Mountain Apache youths (aged < 25 years) from 2001 to 2006 as the first phase of a community-based participatory research process to design and evaluate suicide prevention interventions. METHODS: Apache paraprofessionals gathered data as part of a tribally mandated suicide surveillance system. We compared findings to other North American populations. RESULTS: Between 2001 and 2006, 61% of Apache suicides occurred among youths younger than 25 years. Annual rates among those aged 15 to 24 years were highest: 128.5 per 100 000, 13 times the US all-races rate and 7 times the American Indian and Alaska Native rate. The annual suicide attempt incidence rate in this age group was 3.5%. The male-to-female ratio was 5:1 for suicide and approximately 1:1 for suicide attempts. Hanging was the most common suicide method, and third most common attempt method. The most frequently cited attempt precipitants were family or intimate partner conflict. CONCLUSIONS: An innovative tribal surveillance system identified high suicide and attempt rates and unique patterns and risk factors of suicidal behavior among Apache youths. Findings are guiding targeted suicide prevention programs.

Changing epidemiology of invasive pneumococcal disease among White Mountain Apache persons in the era of the pneumococcal conjugate vaccine.

BACKGROUND: Prior to the introduction of the 7-valent pneumococcal conjugate vaccine (PCV7), the rate of invasive pneumococcal disease (IPD) was 8-fold higher among White Mountain Apache persons of all ages than it was among the general US population, . We aimed to assess the impact of PCV7 and 23-valent pneumococcal polysaccharide vaccine on the rate of IPD among White Mountain Apache persons. METHODS: From 1991 through 2006, we conducted active laboratory- and population-based surveillance among Native American residents of the White Mountain Apache reservation. Charts were reviewed and pneumococcal isolates were collected for serotype testing. Three time periods were defined: the pre-PCV7 baseline period (1991-1997), the PCV7 efficacy trial period (1998-2000), and the PCV7 routine-use period (2001-2006). RESULTS: We identified 246 cases of IPD; the mean annual IPD rate fell from 126 cases per 100,000 person-years in the period 1991-1997 to 87 cases per 100,000 person-years in the period 2001-2006 (p = .01). The rate of IPD attributable to PCV7 serotypes of Streptococcus pneumoniae decreased by 252 cases per 100,000 person-years (92%) among children aged <5 years, and that attributable to non-PCV7 serotypes of S. pneumoniae decreased by 87 cases per 100,000 person-years (44%) among children aged <5 years. Among adults, the rate of IPD remained unchanged; PCV7 serotypes of S. pneumoniae accounted for only 25% of adult cases during the period 1991-1997. CONCLUSIONS: Since the introduction of PCV7, the rate of IPD among White Mountain Apache children aged <5 years has decreased to the lowest rate ever (122 cases per 100,000 person-years), but it remains 5.7-fold greater than the rate of IPD among children in the general US population. In contrast to some other high-risk populations, there is no evidence of non-vaccine-type replacement disease in this age group. Among White Mountain Apache adults, the rate of IPD remains substantially higher than that observed in the general US population. Vaccines with broader serotype coverage are needed to further reduce the disparity in the rate of IPD between the White Mountain Apache and general US populations.

Invasive pneumococcal disease among White Mountain Apache adults, 1991-2005.

BACKGROUND: Certain Native American populations have high rates of invasive pneumococcal disease (IPD). We aimed to determine the disease spectrum and risk factors of White Mountain Apache adults (age, >or=18 years) with IPD and the use and effectiveness of pneumococcal polysaccharide vaccine (PPV) in this population. METHODS: We conducted active surveillance for IPD between 1991 and 2005. Medical records were reviewed, and isolates were serotyped. Vaccine use was assessed in 2004-2005 among White Mountain Apache adults with an indication for pneumococcal vaccination. The effectiveness of PPV was determined through an indirect cohort method. RESULTS: Among the 115 IPD cases (in 109 persons), the mean age was 43 years; 62% were male; 91% had risk factors, and alcoholism predominated (73%). Alcoholic patients were younger (mean age, 40.1 years; P<.001) and more often male (70%; P=.001) compared with nonalcoholic patients. The case fatality rate was 15%; all deaths occurred among those with risk factors. Only age 65 years or older was associated with increased risk of death. Of 447 White Mountain Apache persons at high risk, 76% had received PPV. Vaccination rates were highest among subjects with pulmonary disease (95%) and diabetes (89%) and lowest among those aged 50 to 64 years (40%). Of the 115 IPD cases for which serotypes were available, 77% were due to serotypes contained in PPV. The effectiveness of PPV against serotype-specific IPD, as measured by the indirect cohort analysis of IPD cases, was 68% (95% confidence interval, 3%-90%). CONCLUSIONS: Among White Mountain Apache adults with IPD, alcoholism is common and contributes to the younger age and male predominance of cases. Pneumococcal vaccination rates are high, and there is suggestive evidence of the effectiveness of PPV in this population. Additional preventive strategies, including risk factor modification and vaccination of younger high-risk adults, should be pursued.