Unsettling Settler Colonialism in Research: Strategies Centering Native American Experience and Expertise in Responding to Substance Misuse and Co-occurring Sexual Risk-Taking, Alcohol-Exposed Pregnancy, and Suicide Prevention Among Young People.

Native American (NA) populations in the USA (i.e., those native to the USA which include Alaska Natives, American Indians, and Native Hawaiians) have confronted unique historical, sociopolitical, and environmental stressors born of settler colonialism. Contexts with persistent social and economic disadvantage are critical determinants of substance misuse and co-occurring sexual risk-taking and suicide outcomes, as well as alcohol exposed pregnancy among NA young people (i.e., adolescents and young adults). Despite intergenerational transmission of resistance and resiliencies, NA young people face continued disparities in substance misuse and co-occurring outcomes when compared to other racial and ethnic groups in the USA. The failure in progress to address these inequities is the result of a complex set of factors; many of which are structural and rooted in settler colonialism. One of these structural factors includes barriers evident in health equity research intended to guide solutions to address these disparities yet involving maintenance of a research status quo that has proven ineffective to developing these solutions. Explicitly or implicitly biased values, perspectives, and practices are deeply rooted in current research design, methodology, analysis, and dissemination and implementation efforts. This status quo has been supported, intentionally and unintentionally, by researchers and research institutions with limited experience or knowledge in the historical, social, and cultural contexts of NA communities. We present a conceptual framework illustrating the impact of settler colonialism on current research methods and opportunities to unsettle its influence. Moreover, our framework illustrates opportunities to resist settler colonialism in research. We then focus on case examples of studies from the Intervention Research to Improve Native American Health program, funded by the NIH, that impact substance use and co-occurring health conditions among NA young people.

All systems are interrelated: Multilevel interventions with indigenous communities.

Colonial historical trauma and ongoing structural racism have impacted Indigenous peoples for generations and explain the ongoing health disparities. However, Indigenous peoples have been engaging in multilevel, clinical trial interventions with Indigenous and allied research scientists resulting in promising success. In this paper, National Institutes of Health funded scientists in the field of Indigenous health have sought to describe the utility and need for multilevel interventions across Indigenous communities (Jernigan et al., 2020). We posit limitations to the existing socioecological, multilevel frameworks and propose a dynamic, interrelated heuristic framework, which focuses on the inter-relationships of the collective within the environment and de-centers the individual. We conclude with identified calls for action within multilevel clinical trial research.

Practices Surrounding Pain Management Among American Indians and Alaska Natives in Rural Southern California: An Exploratory Study.

OBJECTIVES: This exploratory study examined pain management practices among American Indians and Alaska Natives in the service area of a rural tribal clinic in Southern California. METHODS: Researchers invited 325 individuals to complete an anonymous survey in clinic waiting rooms and tribal gatherings. Analyses of the 295 eligible responses included calculating frequencies and conducting multiple logistic regressions and a Mantel-Haenszel analysis. RESULTS: Among respondents in this study, being male, younger, and having less education were strong predictors for riskier methods for managing pain. CONCLUSIONS: Understanding the methods individuals use to manage pain in a rural setting constitute a stepping-stone to develop strategies for reducing and preventing misuse and abuse of prescription medications and other drugs in rural American Indian and Alaska Native communities.

Impacts of alcohol availability on Tribal lands where alcohol is prohibited: A community-partnered qualitative investigation.

On a Northern Plains reservation where alcohol was prohibited, we investigated community members' views on the impacts of alcohol availability. Our methods combined elements of Tribal community participatory research with qualitative inquiry to elicit these perspectives. We used rapid appraisal techniques to conduct confidential interviews with 31 key leaders representing 7 relevant major community systems, and representing a variety of perspectives. Topics included respondents' understandings of the current systems of alcohol availability and use on the reservation, the impacts of these systems on reservation residents, and possible ways to measure these impacts. Respondents reported impacts on individuals, families, and the tribe overall. Alcohol-related problems shaped and were shaped by a constellation of social-ecological conditions: kinship, housing, employment, public/social service capacity, and the supply of alcohol in nearby off-reservation areas, as well as inter-governmental relationships and the spiritual life of reservation residents. A variety of social-structural determinants magnified alcohol impacts, so that the problem drinking of a small number of individuals could have broad effects on their families and the entire community. Our participatory qualitative methods enabled us to directly include the voices as well as the personal experiences and expertise of community members in this presentation. These methods may be broadly applied within policy analysis to identify ways to reduce harms related to alcohol and other drugs for Indigenous communities.

Prevalence and Correlates of Current and Former Smoking among Urban Transit Workers.

Transit workers constitute a blue-collar occupational group that have elevated smoking rates relative to other sectors of employed adults in the United States. This study analyzed cross-sectional tobacco survey data from 935 workers (60% African American; 37% female) employed at an urban public transit agency in California. Prevalence of current and former smoking was 20.3% and 20.6%, respectively. Younger workers were less likely than older workers to be current or former smokers. Having a complete home smoking ban was associated with decreased likelihood of being a smoker [odds ratio (OR) = 0.04, 95% confidence interval (CI) = 0.01-0.17], as were neutral views about whether it is easy for a smoker to take a smoking break during their shift (OR = 0.50, 95% CI 0.28-0.88). Current smoking among the sample is > 50% higher than the adult statewide prevalence. Potential points of intervention identified in this study include perceived ease of worksite smoking breaks and establishing home smoking bans. Tailored cessation efforts focusing on older transit workers more likely to smoke are needed to reduce tobacco-related disparities in this workforce.

Improving the Health of Cambodian Americans: Grassroots Approaches and Root Causes.

BACKGROUND: Cambodian Americans experience great disparities in health compared to other Americans, yet may be underserved by conventional healthcare systems. Community-based participatory research (CBPR) is a means to engage underserved communities in health research and programming. We describe results of our efforts to engage the Cambodian grassroots members as well as formal leaders in Oakland, California. OBJECTIVES: In addition to a community advisory group, we convened a Community Work Group (CWG), composed of 10 grassroots community women of varying ages and backgrounds. The project aimed to leverage the lived experiences of these women and their understandings of health and wellness in identifying specific health issues and developing culturally resonant strategies. METHODS: The CWG met weekly with staff facilitators using methods for collective analysis including theater, body mapping, and other expressive arts. RESULTS: The approach proved logistically challenging, but resulted in novel analyses and strategies. The group identified trauma, along with poor access to education, unemployment and underemployment, social isolation, and generation gap, together with community violence, as root causes of key behavioral health issues, namely, alcohol abuse, gambling, prescription drug misuse, and domestic violence. Strategies proposed and implemented by the group and project staff were a community garden, Cambodian New Year's celebrations, and a museum exhibit on the Cambodian refugee experiences. CONCLUSIONS: Grassroots community engagement can support projects in identifying social determinants of health and developing the capacities of community members to conduct research and actions to improve health.

Stigma among California's Medical Marijuana Patients.

The enactment of California's Proposition 215 stipulates that patients may use marijuana for medical reasons, provided that it is recommended by a physician. Yet, medical marijuana patients risk being stigmatized for this practice. This article examines the way in which medical marijuana patients perceive and process stigma, and how it affects their interactions and experiences with others. Eighteen semi-structured interviews of medical marijuana patients were carried out using a semi-structured interview guide. Most patients circumvented their own physicians in obtaining a recommendation to use medicinal marijuana, and also used a host of strategies in order to justify their medical marijuana use to family, friends, and colleagues in order to stave off potential stigma. The stigmatization of medical marijuana thus has a profound effect on how patients seek treatment, and whether they seek medical marijuana treatment at all.

Evaluating the implementation process of a citywide smoke-free multiunit housing ordinance: insights from community stakeholders.

We evaluated the implementation process of Richmond, California's citywide smoke-free multiunit housing ordinance. We conducted semistructured focus groups with multiunit housing tenants, owners, and managers. Residents understood the harms of secondhand smoke but lacked accurate information about the ordinance and questioned its enforceability. They shared concerns that the city lacked cessation resources for smokers wishing to quit because of the ordinance. To increase compliance with the ordinance, tenants, owners, and managers need accurate information.

Implementing a reward and reminder underage drinking prevention program in convenience stores near Southern California American Indian reservations.

BACKGROUND: Underage drinking is associated with a number of social and public health consequences. Preventing access to alcohol is one approach to reducing underage drinking. OBJECTIVES: This study assesses the efficacy of a culturally tailored "reward and reminder" program aimed at reducing convenience store alcohol sales to youth living on or near nine American Indian reservations. METHODS: First, tribal council proclamations were sought to support underage drinking prevention, including reward and reminder efforts. Then, decoys (volunteers over 21 years of age but judged to look younger) attempted to purchase alcohol without identification. Clerks who asked for identification were given "rewards" (gift cards and congratulatory letters), whereas clerks who did not were given "reminders" of the law regarding sales to minors. Following an initial baseline of 12 purchase attempts, three repeated reward and reminder visits were made to 13 convenience stores selling alcohol within 10 miles of the reservations (n = 51 total attempts). RESULTS: Five of nine tribal councils passed resolutions in support of the program. The baseline sales rate without requesting ID was 33%. Similarly, 38% of stores in the first reward and reminder visit round failed to request identification. However, in the following two reward and reminder rounds, 0% of the stores failed to request identification. CONCLUSIONS: These results indicate that environmental community-level underage drinking prevention strategies to reduce alcohol sales near rural reservations are feasible and can be effective. SCIENTIFIC SIGNIFICANCE: Environmental prevention strategies within reservation communities support integrated supply and demand reduction models for reducing underage drinking.

Acceptability of the use of motivational interviewing to reduce underage drinking in a Native American community.

Thirty-six Native American tribal leaders and members living on contiguous rural southwest California reservations were surveyed concerning their view of the acceptability of a motivational interviewing (MI) intervention with youth (aged 8-18 years) who are drinking and their families. The results suggest the following: (1) a substantial proportion of reservation youth would be willing to accept MI for behavior change; (2) relatively few are actually ready to change; (3) most reservation youth are in the precontemplation stage of change; and (4) MI may be well suited as an intervention to prevent underage drinking in that population. The study's limitations are noted.

Law in practice: obstacles to a smokefree workplace policy in bars serving Asian patrons.

The California smokefree workplace ordinance (AB13) has been well-received, even in bars where deeply established traditions of smoking may exist. However, a closer investigation of bars where indoor smoking persists revealed that bar workers in some ethnic minority communities continue to be exposed to secondhand smoke in their workplaces. To identify sociocultural factors that may impede the adoption of AB13, the researchers conducted 150 observations and 29 patron and staff interviews in 50 California bars serving Asian patrons in Los Angeles and San Francisco counties. Observers witnessed indoor smoking in 82% of the bars. Interviews revealed that social relationships, social interactions, and a tendency to avoid confrontation complicated the positive reception of AB13 within these bars. Accounting for sociocultural factors provides a nuanced understanding of the challenges involved in implementing tobacco control policy in such diverse settings and may allow for culturally appropriate tobacco policy development and implementation in other jurisdictions.

Unintended consequences of smoke-free bar policies for low-SES women in three California counties.

BACKGROUND: To amplify earlier studies of unintended consequences of public policies, this article illustrates both negative and positive unanticipated consequences of smoke-free workplace policies in California bars for women of low SES. METHODS: The article relies on thematic analysis in 2008 of qualitative data gathered between 2001 and 2007 from three mixed-method studies of tobacco use in and around bars where indoor smoking is prohibited. RESULTS: Unanticipated consequences primarily occurred when bars did comply with the law and smokers went outside the bar to smoke, particularly when smokers stood on the street outside the bar. Key negative consequences for women who smoked outside of bars included threats to their physical safety and their public image. For women living near bars, increased smoking on the street may have increased their exposure to secondhand smoke and disruptive noise. For some women, however, unanticipated negative consequences were identified with noncompliant bars. Smokers were conjectured to congregate in the smaller number of bars where smoking was still allowed, resulting in increased exposure to secondhand smoke for low-SES women working in these bars. A common positive unintended consequence of the tobacco control ordinance was increased social circulation and solidarity, as smokers gathered outside bars to smoke. CONCLUSIONS: Smoke-free workplace laws in bars can have both negative and positive consequences for workers and smokers, and low-income women in particular.

Social Organization in Bars: Implications for Tobacco Control Policy.

This paper considers social roles and relationships of the patrons, staff and owners of bars as critical factors determining adherence to public health policies, and specifically California's smokefree workplace law. Specific elements of social organization in bars affecting health policy include the community within which the bar is set, the unique identity the bar creates, the bar staff and patrons who enact this identity, and their bar society. These elements were found to contribute to the development of power relations within the bar and solidarity against the outside world, resulting in either resistance to or compliance with smokefree workplace policy.