Integrating Community-Engagement and a Multiphase Optimization Strategy Framework: Adapting Substance Use Prevention for American Indian Families.

Initiation of substance use often occurs earlier among American Indian (AI) youth than among other youth in the USA, bringing increased risk for a variety of poor health and developmental outcomes. Effective prevention strategies are needed, but the evidence base remains thin for this population. Research makes clear that prevention strategies need to be culturally coherent; programs with an evidence base in one population cannot be assumed to be effective in another. However, guidance on effective adaptation is lacking. This paper reports on cultural adaptation of an evidence-based program utilizing the multiphase optimization strategy (MOST) framework embedded within a community-engaged process to evaluate intervention components. The Strengthening Families Program for Parents and Youth 10-14 was adapted to become the Thiwáhe Gluwás'akapi Program for American Indian youth and families. Three program components were evaluated for their effectiveness with regard to outcomes (youth substance use, theoretical mediators of program effects on substance use, and program attendance) in a sample of 98 families (122 youth and 137 adults). Consistent with the MOST framework, the value of components was also evaluated with regard to efficiency, economy, and scalability. Expanding on the MOST framework for cultural adaptation, we also considered the results of the MOST findings regarding the acceptability of each component from the perspectives of community members and participants. The promise of a strategic component-based approach to adapting evidence-based interventions is discussed, including the benefits of engaging community to ensure relevance and considering both cultural and scientific rationale for each component to enhance impact.

Self-Efficacy About Sexual Risk/Protective Behaviors: Intervention Impact Trajectories Among American Indian Youth.

For adolescents, normative development encompasses learning to negotiate challenges of sexual situations; of special importance are skills to prevent early pregnancy, HIV, and other sexually transmitted diseases. Disparities in sexual risk among American Indian youth point to the importance of intervening to attenuate this risk. This study explored the impact of Circle of Life (COL), an HIV prevention intervention based on social cognitive theory, on trajectories of self-efficacy (refusing sex, avoiding sexual situations) among 635 students from 13 middle schools on one American Indian reservation. COL countered a normative decline of refusal self-efficacy among girls receiving the intervention by age 13, while girls participating at age 14 or older, girls in the comparison group, and all boys showed continuing declines.

Longitudinal Patterns of Stages of Change for Exercise and Lifestyle Intervention Outcomes: An Application of Latent Class Analysis with Distal Outcomes.

Stages of change measure an individual's readiness to alter a health behavior. This study examined the latent longitudinal patterns of stages of change (SoC) for regular exercise over time among individuals participating in a lifestyle intervention project. It also investigated the association between the longitudinal patterns of SoC and intervention outcomes using a new statistical method to assess the relationship between latent class membership and distal outcomes. We analyzed data from the Special Diabetes Program for Indians Diabetes Prevention Program, a lifestyle intervention program to prevent diabetes among American Indians and Alaska Natives. Latent class analysis (LCA) was conducted to identify the longitudinal patterns of SoC for regular exercise reported at three time points. LCA with distal outcomes was performed to investigate the associations between latent class membership and behavioral changes after the intervention. The parameters and standard errors of the LCA with distal outcomes models were estimated using an improved three-step approach. Three latent classes were identified: Pre-action, Transition, and Maintenance classes. The Transition class, where stage progression occurred, had the greatest improvements in physical activity and weight outcomes at both time points post-baseline among female participants. It also had the largest improvements in weight outcomes among male participants. Furthermore, the Pre-action class had more attenuation in the improvements they had achieved initially than the other two classes. These findings suggest the potential importance of motivating participants to modify their readiness for behavioral change in future lifestyle interventions.

Effectiveness of Circle of Life, an HIV-preventive intervention for American Indian middle school youths: a group randomized trial in a Northern Plains tribe.

OBJECTIVES: We assessed the effectiveness of Circle of Life (COL), an HIV-preventive intervention developed specifically for American Indian and Alaska Native (AI/AN) middle school youths. METHODS: By partnering with a tribal community, we conducted a longitudinal wait-listed group randomized trial with 635 seventh and eighth graders in 13 schools of a Northern Plains tribe. We surveyed participants at baseline, 3 months, and 12 months from 2006 to 2007. RESULTS: COL was found to increase HIV knowledge in the short term, but had no effect on sexual activity compared with those who did not receive it. However, COL was found to be effective for delaying the onset of sexual activity, with the greatest reduction in risk occurring for those receiving COL at early ages. CONCLUSIONS: Community partnership was key to successful project design, implementation, and analysis. The project confirmed the importance of the timing of interventions in early adolescence. COL may be a key resource for reducing sexual risk among AI/AN youths.

Trajectories of substance use among young American Indian adolescents: patterns and predictors.

Substance use often begins earlier among American Indians compared to the rest of the United States, a troubling reality that puts Native youth at risk for escalating and problematic use. We need to understand more fully patterns of emergent substance use among young American Indian adolescents, risk factors associated with escalating use trajectories, and protective factors that can be parlayed into robust prevention strategies. We used growth mixture modeling with longitudinal data from middle-school students on a Northern Plains reservation (Wave 1 N = 381, M age at baseline = 12.77, 45.6% female) to identify subgroups exhibiting different trajectories of cigarette, alcohol, and marijuana use. We explored how both risk (e.g., exposure to stressful events, deviant peers) and protective (e.g., positive parent-child relationships, cultural identity) factors were related to these trajectories. For all substances, most youth showed trajectories characterized by low rates of substance use (nonuser classes), but many also showed patterns characterized by high and/or escalating use. Across substances, exposure to stress, early puberty, and deviant peer relationships were associated with the more problematic patterns, while strong relationships with parents and prosocial peers were associated with nonuser classes. Our measures of emergent cultural identity were generally unrelated to substance use trajectory classes among these young adolescents. The findings point to the importance of early substance use prevention programs for American Indian youth that attenuate the impact of exposure to stressful events, redirect peer relationships, and foster positive parent influences. They also point to the need to explore more fully how cultural influences can be captured.

Toddler socioemotional behavior in a northern plains Indian tribe: associations with maternal psychosocial well-being.

M.C. Sarche, C.D. Croy, C. Big Crow, C. Mitchell, and P. Spicer (2009) provided first-ever information relating the socioemotional development of American Indian toddlers to the immediate context of their mothers' lives. The current study sought to replicate and build on their earlier work by examining the impact of additional maternal risk factors, identified in previous research with non-American Indian populations, on the development of American Indian toddlers: maternal depression, negative social influences, and mother's feelings of isolation. At 27 months, American Indian mothers (N = 110) completed the Parent Demographic Questionnaire, which measured maternal psychosocial characteristics (e.g., depressed affect, social support, drug and alcohol use, isolation) and demographics. Mothers also completed the Infant-Toddler Social Emotional Assessment (A.S. Carter & M.J. Briggs-Gowan, 2006) and the Parent-Child Dysfunctional Interaction subscale of the Parenting Stress Index (R.R. Abidin, 1995, 1997). Some results replicated the original study, but others did not. Reports of a dysfunctional mother-child relationship related to externalizing and internalizing problems, replicating the earlier study. This study also found associations between a dysfunctional mother-child relationship and socioemotional competence as well as dysregulation. The previous finding of a relationship between American Indian identity and socioemotional competence was supported. Adding the effects of maternal depressed affect and isolation significantly increased prediction of toddler behavior problems.

Lifetime prevalence of posttraumatic stress disorder in two American Indian reservation populations.

Posttraumatic stress disorder (PTSD) has been found to be more common among American Indian populations than among other Americans. A complex diagnosis, the assessment methods for PTSD have varied across epidemiological studies, especially in terms of the trauma criteria. Here, we examined data from the American Indian Service Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project (AI-SUPERPFP) to estimate the lifetime prevalence of PTSD in two culturally distinct American Indian reservation communities, using two formulas for calculating PTSD prevalence. The AI-SUPERPFP was a cross-sectional probability sample survey conducted between 1997 and 2000. Southwest (n = 1,446) and Northern Plains (n = 1,638) tribal members living on or near their reservations, aged 15-57 years at time of interview, were randomly sampled from tribal rolls. PTSD estimates were derived based on both the single worst and 3 worst traumas. Prevalence estimates varied by ascertainment method: single worst trauma (lifetime: 5.9% to 14.8%) versus 3 worst traumas (lifetime, 8.9% to 19.5%). Use of the 3-worst-event approach increased prevalence by 28.3% over the single-event method. PTSD was prevalent in these tribal communities. These results also serve to underscore the need to better understand the implications for PTSD prevalence with the current focus on a single worst event.

Trauma and conditional risk of posttraumatic stress disorder in two American Indian reservation communities.

PURPOSE: To determine conditional risk of posttraumatic stress disorder (PTSD) in two culturally distinct American Indian reservation communities. METHOD: Data derived from the American Indian Service Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project, a cross-sectional population-based survey that was completed between 1997 and 2000. This study focused on 1,967 participants meeting the DSM-IV criteria for trauma exposure. Traumas were grouped into interpersonal, non-interpersonal, witnessed, and "trauma to close others" categories. Analyses examined distribution of worst traumas, conditional rates of PTSD following exposure, and distributions of PTSD cases deriving from these events. Bivariate and multivariate logistic regressions estimated associations of lifetime PTSD with trauma type. RESULTS: Overall, 15.9 % of those exposed to DSM-IV trauma qualified for lifetime PTSD, a rate comparable to similar US studies. Women were more likely to develop PTSD than were men. The majority (60 %) of cases of PTSD among women derived from interpersonal trauma exposure (in particular, sexual and physical abuse); among men, cases were more evenly distributed across trauma categories. CONCLUSIONS: Previous research has demonstrated higher rates of both trauma exposure and PTSD in American Indian samples compared to other Americans. This study shows that conditional rates of PTSD are similar to those reported elsewhere, suggesting that the elevated prevalence of this disorder in American Indian populations is largely due to higher rates of trauma exposure.

Impact of targeted health promotion on cardiovascular knowledge among American Indians and Alaska Natives.

The National Heart, Lung, and Blood Institute developed the Honoring the Gift of Heart Health (HGHH) curriculum to promote cardiovascular knowledge and heart-healthy lifestyles among American Indians and Alaska Natives (AI/ANs). Using data from a small randomized trial designed to reduce diabetes and cardiovascular disease (CVD) risk among overweight/obese AI/ANs, we evaluated the impact of an adapted HGHH curriculum on cardiovascular knowledge. We also assessed whether the curriculum was effective across levels of health literacy (defined as the 'capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions'). We examined change in knowledge from baseline to 3 months for two groups: HGHH (N = 89) and control (N = 50). Compared with controls, HGHH participants showed significant improvement in heart attack knowledge and marginally significant improvement in stroke and general CVD knowledge. HGHH participants attending ≥1 class showed significantly greater improvement than controls on all three measures. Although HGHH participants with inadequate health literacy had worse heart attack and stroke knowledge at baseline and 3 months than did participants with adequate skills, the degree of improvement in knowledge did not differ by health literacy level. HGHH appears to improve cardiovascular knowledge among AI/ANs across health literacy levels.

Latent class analysis of stages of change for multiple health behaviors: results from the Special Diabetes Program for Indians Diabetes Prevention Program.

This study sought to identify latent subgroups among American Indian and Alaska Native (AI/AN) patients with pre-diabetes based on their stages of change for multiple health behaviors. We analyzed baseline data from participants of the Special Diabetes Program for Indians Diabetes Prevention (SDPI-DP) Program, a lifestyle intervention program to prevent diabetes among AI/ANs. A total of 3,135 participants completed baseline questionnaires assessing stages of change for multiple health behaviors, specifically exercise, healthy eating, and weight loss. Latent class analysis was used to identify subgroups of people based on their answers to stages of change questions. Covariates were added to the latent class analyses to investigate how class membership was related to sociodemographic, behavioral, and psychosocial factors. Three classes were identified based on the distributions of the stages of change variables: Contemplation, Preparation, and Action/Maintenance classes. Male and retired participants were more likely to be in more advanced stages. Those who exercised more, ate healthier diets, and weighed less were significantly more likely to be in the Action/Maintenance class. Further, the participants who had higher self-efficacy, stronger family support, and better health-related quality of life had higher odds of being in the Action/Maintenance class. In conclusion, we found that stages of change for multiple behaviors can be summarized by a three-class model in this sample. Investigating the relationships between latent classes and intervention outcomes represents important next steps to extend the findings of the current study.

Epidemiology and etiology of substance use among American Indians and Alaska Natives: risk, protection, and implications for prevention.

BACKGROUND: The epidemiology and etiology of substance use and disorder in American Indian and Alaska Native (AI/AN) communities have received increasing attention over the past 25 years and accumulating evidence provides important insights into substance use patterns in these populations. OBJECTIVES AND METHODS: We provide a descriptive sketch of the AI/AN population in the United States today, present a brief review of the literature on the epidemiology and etiology of substance use within these populations, and discuss key implications of this literature for prevention efforts. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: Patterns of alcohol use and abuse in AI/AN populations are complex and vary across cultural groups, but alcohol clearly impacts both physical health and mental health within these communities. Tobacco use - and associated health consequences - is typically higher in these populations than among other US groups, although significant variation across Native communities is apparent here as with alcohol. Evidence regarding drug use and disorder is less extensive and thus less conclusive, but evidence demonstrates higher rates of use as well. Etiological explanations for substance use and disorder cut across individual characteristics (e.g., genetics) or experiences (e.g., exposure to trauma), to social contexts (e.g., family disruption), and to cultural factors (e.g., historical trauma). Protective factors likely cut across these multiple levels as well and deserve more focused attention for informing prevention efforts. The development of effective prevention strategies, built through collaboration between researchers and Native communities, drawing from the wisdom of both, is a high priority.

Patterns of substance use initiation among young adolescents in a Northern Plains American Indian tribe.

BACKGROUND: Substantial evidence documents problematic substance use in Northern Plains American Indian communities. Studies suggest that disparities can be traced to disproportionate rates of early substance use, but most evidence comes from the retrospective reports of adults or older adolescents. OBJECTIVE: To use a prospective longitudinal design to examine substance use initiation patterns as they emerge among young American Indian adolescents. METHODS: Four waves of data were collected across three consecutive school years from middle school students on a Northern Plains reservation (N = 450). Discrete-time survival analyses were used to estimate risks of initiation of cigarettes, alcohol, and marijuana from age 10 to 13. RESULTS: Risk for cigarette initiation was relatively high at age 10 and stable until age 13. Marijuana risk was low at age 10 but increased sharply by age 12. Alcohol initiation lagged, not surpassing risk for cigarette initiation until age 13 and remaining below risk for marijuana initiation throughout middle school. Hazards for girls trended higher than those for boys across all substances, but differences did not reach significance. CONCLUSION: Initiation patterns among these American Indian adolescents differed from patterns reported in other US groups, particularly with respect to deviation from the sequence characterized the initiation of marijuana before alcohol that is predicted by the gateway theory. SCIENTIFIC SIGNIFICANCE: Findings suggest that prevention efforts with youth in this community should begin early with a primary focus on marijuana use. They also suggest the importance of examining sequences of substance initiation among youth in other American Indian communities.

Circle of life: rationale, design, and baseline results of an HIV prevention intervention among young American Indian adolescents of the Northern Plains.

In spite of significant disparities in sexual health outcomes for American Indian youth, no studies exist examining the effectiveness of HIV-prevention interventions. Circle of Life is an HIV-prevention intervention specifically developed for American Indian middle-school youth. We describe the rationale, methodology, and baseline results of a longitudinal randomized trial of Circle of Life conducted among American Indian youth aged 11-15 in a reservation community. The innovative design includes two pre-intervention waves to determine patterns of behavior prior to the intervention that might be associated with a differential impact of the intervention on sexual risk. We used one-way analysis of variance and chi-square tests to test for significant differences between randomized group assignment at each baseline wave and generalized estimating equations (GEE) to test significant differences in the rate of change in outcomes by group longitudinally. We present the collaborative and adaptive strategies for consenting, assenting, and data collection methodology in this community. Achieved response rates are comparable to other similar studies. Results from the two baseline waves indicate that few outcomes significantly varied by randomized intervention assignment. Ten percent of youth reported having had sex at Wave 1, rising to 15% at Wave 2. Among those who had had sex, the majority (>70%) reported using a condom at last sex. The project is well positioned to carry out the longitudinal assessments of the intervention to determine the overall impact of the Circle of Life and the differential impact by pre-intervention patterns of behavior across youth.

A longitudinal study of self-esteem, cultural identity, and academic success among American Indian adolescents.

Latent growth curve modeling was used to estimate developmental trajectories of self-esteem and cultural identity among American Indian high school students and to explore the relationships of these trajectories to personal resources, problem behaviors, and academic performance at the end of high school. The sample included 1,611 participants from the Voices of Indian Teens project, a 3-year longitudinal study of adolescents from 3 diverse American Indian cultural groups in the western United States. Trajectories of self-esteem were clearly related to academic achievement; cultural identity, in contrast, was largely unrelated, with no direct effects and only very small indirect effects. The relationships between self-esteem and success were mediated by personal resources and problem behaviors.

Maternal correlates of 2-year-old American Indian children's social-emotional development in a Northern Plains tribe.

The developmental experiences of very young American Indian children today are not well documented in the current literature. The present study sought to explore the social-emotional development of American Indian toddlers living on a Northern Plains reservation, as a function of maternal variables. Mothers completed self-report questionnaires about their experiences and their children's development. Observer ratings of children's development also were conducted. Maternal stress, substance use/abuse, perceptions of stress in the mother-child relationship, social support, and American Indian cultural identity were significantly related to children's social-emotional development. This study is the first to explore these relationships in a Northern Plains American Indian sample of young children and their mothers. Results suggest possible points of intervention for improving the developmental outcomes of very young American Indian children.

Religiosity and Spiritual Engagement in Two American Indian Populations.

Social scientific investigation into the religiospiritual characteristics of American Indians rarely includes analysis of quantitative data. After reviewing information from ethnographic and autobiographical sources, we present analyses of data from a large, population-based sample of two tribes (n = 3,084). We examine salience of belief in three traditions: aboriginal, Christian, and Native American Church. We then investigate patterns in sociodemographic subgroups, determining the significant correlates of salience with other variables controlled. Finally, we examine frequency with which respondents assign high salience to only one tradition (exclusivity) or multiple traditions (nonexclusivity), again investigating subgroup variations. This first detailed, statistical portrait of American Indian religious and spiritual lives links work on tribal ethnic identity to theoretical work on America's "religious marketplace." Results may also inform social/behavioral interventions that incorporate religiospiritual elements.

Marijuana initiation in 2 American Indian reservation communities: comparison with a national sample.

OBJECTIVES: We examined disparities in age-related patterns of marijuana initiation in 2 culturally distinct American Indian reservation communities (from the Northern Plains and the Southwest) compared with a national sample. METHODS: We used discrete-time survival models to estimate age-related risk for initiation with data from 2 population-based studies: the American Indian Service Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project and the baseline National Comorbidity Survey. RESULTS: Among respondents who were born before 1960, peak risk for marijuana initiation in all samples was at age 18 years, and risk was greatest in the national sample. Among those who were born later than 1960, risk peaked at age 16 years and was highest in the American Indian samples. Males were at increased risk compared with females, especially in the older cohort and the Southwest tribal sample. CONCLUSIONS: Findings of disproportionate risk for marijuana initiation among younger members of the tribal samples raise concerns that American Indian reservation youths may be increasingly vulnerable to drug use and its concomitants, which suggests a need for more aggressive prevention efforts in these communities.

The relationship of cumulative and proximal adversity to onset of substance dependence symptoms in two American Indian communities.

The proximal and distal effects of adversity on the onset of symptoms of substance dependence during adolescence were explored in two culturally distinct American Indian (AI) reservation communities (Northern Plains and Southwest). Data (N=3084) were from the American Indian Service Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project (AI-SUPERPFP). The age-related risk of symptom onset increased gradually from age 11 through age 16, remained relatively high through age 18, then declined rapidly. Both tribe and gender were related to onset of dependence symptoms; men and Northern Plains tribal members were at greatest risk and Southwest women were at particularly low risk of symptom onset across adolescence. For all tribe and gender groups, both proximal and cumulative distal experiences of adversity were associated with substantially increased risk of symptom onset. The relationship of adversity to onset of substance dependence symptoms remained strong when previous symptoms of psychiatric disorder and childhood conduct problems were considered. These findings suggest that efforts to help children and adolescents in AI communities develop constructive mechanisms for coping with adversity may be especially valuable in substance dependence prevention.

Culture, context, and sexual risk among Northern Plains American Indian Youth.

American Indian adolescents have two to four times the rate of sexually transmitted diseases (STDs) compared to whites nationally, they shoulder twice the proportion of AIDS compared to their national counterparts, and they have a 25% higher level of teen births. Yet little is known about the contemporary expectations, pressures, and norms that influence American Indian youth or how those might be shaped by today's lived cultural experiences, which frustrates attempts to mitigate the apparent disparity in sexual health. This paper used data from focus groups, in-depth interviews, and surveys with American Indian adolescents and young male and female adults from a Northern Plains tribe to contextualize sexual risk (and avoidance). Placing the findings within an adapted indigenist stress-coping framework, we found that youth faced intense pressures for early sex, often associated with substance use. Condoms were not associated with stigma, yet few seemed to value their importance for disease prevention. Youth encountered few economic or social recriminations for a teen birth. As such, cultural influences are important to American Indian sexual health and could be a key part of prevention strategies.

Disparities in drug use and disorder: comparison of two American Indian reservation communities and a national sample.

Population-based samples provided estimates of drug use and disorder in two American Indian populations. Comparison to a national sample revealed tribal-national, intertribal, and intratribal gender and age differences. Findings suggest that disparities in drug use and disorder are complex, characterized by important variations across diverse American Indian tribal cultures.