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.

Preventing alcohol use post-bariatric surgery: patient perspectives on a technology-based approach.

BACKGROUND: Nearly two-thirds of patients engage in alcohol use after bariatric surgery, while a substantial number meet criteria for alcohol use disorder after their procedure. Given that pre-surgical education may not be sufficient, alternative methods of preventing post-surgical drinking are needed. We sought feedback on a proposed technology-based intervention to reduce alcohol use for individuals who have undergone bariatric surgery. METHODS: Twenty patients who consumed alcohol post-surgery completed qualitative interviews where they provided opinions on sample intervention content, delivery method, timing, and other aspects of a two-session web-based intervention followed by tailored text messaging for 6 months. Interviews were recorded, transcribed, and coded using thematic analysis principles. RESULTS: Participants strongly endorsed using technology to deliver an alcohol intervention, citing the interactivity and personal tailoring available in the proposed software. Education about the effects of post-surgical drinking and learning new coping strategies for social situations were the two most salient themes to emerge from questions about intervention content. Throughout the interviews, participants strongly highlighted the importance of measuring patient readiness to change alcohol use and matching intervention content to such motivation levels. Respondents felt that text messages could extend what they had learned, but also requested additional non-alcohol content (e.g., recipes, exercise tips). Most participants agreed that an online forum consisting of peers and professionals with whom they could ask questions and interact would be useful. CONCLUSION: Web- and text message-based interventions may be an acceptable approach to prevent alcohol use post-bariatric surgery.

Ground-up approach to understanding the impacts of historical trauma in one reserve-dwelling first nations community.

OBJECTIVE: First Nations peoples experience disproportionate health inequities compared to most non-Indigenous populations. Historical trauma is one factor that has received growing attention in relation to health inequities among First Nations populations. The goal of the present study was to improve understanding of the specific forms, impacts, and mechanisms of transmission of events that lead to historical trauma and the historical trauma response in First Nations peoples. METHOD: Five focus groups were conducted among adult members of one First Nations community in Canada (N = 34; 70.4% female). RESULTS: Conventional content analysis revealed the numerous forms that historical trauma take in this First Nations community; individual-, familial-, community-, and societal-level impacts of historical trauma; and ways in which historical trauma has been transmitted in this community. Loss of culture, alcohol use, and parenting were major themes identified across these domains. CONCLUSIONS: Findings provide important information on the experience of historical trauma in one First Nations community, highlighting the roles of loss of culture; alcohol use; and parenting in the forms, impacts, and transmission of historical trauma. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Patient perceptions regarding alcohol use after bariatric surgery.

INTRODUCTION: Patients who have undergone bariatric surgery are at increased risk of an alcohol use disorder. Though patients understand this risk, the majority engage in post-surgical alcohol use. This suggests that education alone is not sufficient to reduce post-surgical drinking. To prevent development of post-surgical alcohol use disorders, we need better understanding of the reasons patients use alcohol following surgery. The purpose of this study was to identify factors associated with post-surgical alcohol use. METHOD: Patients (N = 20) who were 1-3 years post-bariatric surgery and were consuming alcohol at least twice monthly participated in a 60-min interview. Participants responded about their knowledge regarding risk of post-surgical alcohol use and reasons why patients may start drinking. Deductive and inductive coding were completed by two independent raters. RESULTS: Although nearly all participants were aware of the risks associated with post-surgical alcohol use, most believed that lifelong abstinence from alcohol was unrealistic. Common reasons identified for using alcohol after bariatric surgery included social gatherings, resuming pre-surgical use, and addiction transfer. Inductive coding identified three themes: participants consumed alcohol in different ways compared to prior to surgery; the effect of alcohol was substantially stronger than pre-surgery; and beliefs about why patients develop problematic alcohol use following surgery. CONCLUSION: Patients consume alcohol after bariatric surgery for a variety of reasons and they do not believe recommending abstinence is useful. Understanding patient perceptions can inform interventions to minimize alcohol use after bariatric surgery. Modifications to traditional alcohol relapse prevention strategies may provide a more robust solution to decreasing negative outcomes experienced by individuals undergoing bariatric surgery.

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.

Virtual Research with Urban Native Young Women: Cautionary Tales in the Time of a Pandemic.

BACKGROUND: Community-based participatory research is a particularly powerful approach to research with American Indian and Alaska Native (AIAN) communities who have been subject to a history of mistreatment and unethical research. In person meetings, discussion, and engagement with tribal members and the community have become an essential component of community-based participatory research in AIAN communities. With the advent of the coronavirus disease 2019 pandemic, AIAN communities have moved to close or sharply curtail in-person activities, precluding in-person research methods. Current best practices for research with AIAN communities assumes in-person engagement; little guidance exists on engaging AIAN communities in research using virtual technologies. Our study, Native Women, Young, Strong, Empowered Changing High-risk alcohOl use and Increasing Contraception Effectiveness Study (Native WYSE CHOICES), was intentionally designed before the pandemic to be virtual, including recruitment, enrollment, intervention, and assessment with urban AIAN young women. OBJECTIVES: We present our perspectives on virtual research with AIAN communities, including the critical role of our advisory partners to inform the virtual intervention design and recruitment methods in the formative stages of our project. METHODS: Experiential reflection among research team and community partners. CONCLUSIONS: Virtual technologies, such as videoconferencing, social media, and mobile health apps, offer many tools to reach communities, especially in a pandemic. The virtualization of research with AIAN communities requires a significant investment in time, resources and planning to mitigate disadvantages; it cannot fully replace in-person-based community-based participatory research approaches, but may offer many strengths and unique advantages for research, especially in a pandemic.

Community Awareness of Outreach Efforts to Reduce Underage Drinking on California Indian Reservations.

We report an evaluation of a combined individual- and community-level treatment and prevention effort to reduce underage drinking by American Indian (AI) youths on rural California Indian reservations. The interventions included: brief motivational interviewing and psychoeducation for Tribal youths, restricting alcohol sales to minors in alcohol sales outlets, and community mobilization and awareness activities. Surveys were collected from 120 adults and 74 teens to evaluate the awareness and effectiveness of the interventions. A high proportion of adult (93%) and youth (96%) respondents endorsed being aware of one or more of the intervention activities, and 88% of adults and 71% of youth felt the program impacted the community in a positive way. Eighty-four percent of adults and 63% of youth agreed that as a result of the activities that they decided to take action to reduce teen drinking in their community. Being aware of more of the intervention activities significantly increased the odds of taking action to change drinking behaviors. This study documents that a significant proportion of the community was aware of the intervention efforts and that awareness caused them to take action to reduce underage drinking. Such efforts may benefit other AI/AN communities seeking to reduce underage drinking.

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.

Correlates of Alcohol-Related Treatment Among American Indians and Alaska Natives with Lifetime Alcohol Use Disorder.

BACKGROUND: To describe sociodemographic and selected psychiatric disorder patterns and estimate correlates of seeking alcohol treatment among American Indians and Alaska Natives (AIAN) and non-Hispanic Whites (NHW) with lifetime alcohol use disorder (AUD). METHODS: Data come from the 2012 to 2013 U.S. National Epidemiologic Survey on Alcohol and Related Conditions-III. We retrospectively identified participants who completed information on lifetime AUD, race/ethnicity, and seeking alcohol treatment or help for AUD. We used a generalized linear model with a log link and Poisson distribution to estimate prevalence ratios (PRs) among adults with DSM-5 lifetime AUD. We included the following correlates: race/ethnicity, sex, age, personal annual income, marital status, education, urban/rural status, U.S. region, any illegal drug use disorder, nicotine use disorder, and select mood-, anxiety-, personality-, and trauma-related disorders. RESULTS: Among AIAN, the prevalence of lifetime AUD was 46.6%. Among AIAN with lifetime AUD, 33.8% sought alcohol-related treatment. Among individuals with lifetime AUD, AIAN were associated with greater alcohol-related treatment-seeking compared to NHW (adjusted PR = 1.41 [95% CI 1.26 to 1.58]). Among AIAN with AUD, being male and age 35 to 64 were statistically significant correlates of seeking treatment or help for AUD. CONCLUSIONS: A relatively higher proportion of AIAN than NHW with AUDs sought alcohol treatment. Among individuals with lifetime AUD, significant demographic and psychiatric disorder correlates of treatment are present, showing that certain groups are less likely to seek treatment or help for alcohol-related issues. Among AIAN with AUD, these correlates may reflect distinct patterns of seeking alcohol-related treatment, which can inform more effective treatment promotion efforts with this population.

Sleep disturbances after deployment: National Guard soldiers' experiences and strategies.

Sleep deprivation and sleep disturbance are pervasive among military personnel during and after combat deployment. However, occupational and other constraints often influence military workers to decline behavioral health services and prescription pharmaceutical sleep aids. This article, drawing on ethnographic interviews with National Guard veterans of combat deployment, demonstrates that soldiers with sleep disturbance frequently manage symptoms without medical supervision and by using ad hoc methods including alcohol use. Findings suggest the potential significance of further research into the sleep management practices of military populations, who face both high risk for sleep disturbance and occupational and cultural constraints in effectively managing these serious health concerns.

Prevention of Underage Drinking on California Indian Reservations Using Individual- and Community-Level Approaches.

OBJECTIVES: To evaluate combined individual- and community-level interventions to reduce underage drinking by American Indian/Alaska Native (AI/AN) youths on rural California Indian reservations. METHODS: Individual-level interventions included brief motivational interviewing and psychoeducation for Tribal youths. Community-level interventions included community mobilization and awareness activities, as well as restricting alcohol sales to minors. To test effects, we compared 7 waves of California Healthy Kids Survey data (2002-2015) for 9th- and 11th-grade AI/AN and non-AI/AN students in intervention area schools with California AI/AN students outside the intervention area (n = 617, n = 33 469, and n = 976, respectively). RESULTS: Pre- to postintervention mean past 30-day drinking frequency declined among current drinkers in the intervention group (8.4-6.3 days) relative to comparison groups. Similarly, heavy episodic drinking frequency among current drinkers declined in the intervention group (7.0-4.8 days) versus the comparison groups. CONCLUSIONS: This study documented significant, sustained past 30-day drinking or heavy episodic drinking frequency reductions among AI/AN 9th- and 11th-grade current drinkers in rural California Indian reservation communities exposed to multilevel interventions. Public Health Implications. Multilevel community-partnered interventions can effectively reduce underage alcohol use in this population.

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.

Developing a tailored substance use intervention for youth exiting foster care.

Youth who are aging out of the foster care system face significant barriers to accessing substance use treatment. Mobile interventions have shown efficacy for several mental and physical health issues and may be helpful in overcoming barriers facing foster youth with substance use problems. A program (iHeLP) for substance use reduction was developed that used a computerized screening and brief intervention (SBI) followed by six months of dynamically-tailored text messages. The program was shown to focus groups of youth (N = 24) ages 18-19 who recently left foster care and had moderate to severe substance use risk. Focus group feedback was used to modify iHeLP prior to delivery in an open trial (N = 16). Both study phases included assessments of feasibility and acceptability; the open trial also included assessments of substance use outcomes at 3 and 6 months. Focus groups indicated a high level of acceptability for the proposed intervention components. Of those screened for the open trial, 43% were eligible and 74% of those eligible enrolled, indicating good feasibility. Retention through the final follow-up was 59%, and drop out was associated with involvement in the criminal justice system. Participant ratings for liking, ease of working with, interest in and respectfulness of the SBI were high. Satisfaction ratings for the texting component were also high. A computerized brief screening intervention for substance use risk reduction together with tailored text messaging is both feasible and highly acceptable among youth who have recently aged-out of foster care.

Spatial Epidemiology of Alcohol- and Drug-Related Health Problems Among Northern Plains American Indians: Nebraska and South Dakota, 2007 to 2012.

BACKGROUND: Despite high abstinence rates, American Indians experience elevated rates of many alcohol and other drug problems. American Indians also predominantly reside in poor and rural areas, which may explain some observed health disparities. We investigated whether geographic areas including reservations or large American Indian populations exhibited greater incidence of alcohol- and drug-related hospitalizations. METHODS: We obtained inpatient hospitalization records for 2 Northern Plain states (Nebraska and South Dakota) for the years 2007 to 2012. We constructed zip code counts for 10 categories of hospitalization with diagnoses or injury causation commonly associated with alcohol or drug use. We related these to community sociodemographic characteristics using Bayesian Poisson space-time regression models and examined associations with and without controls for whether each zip code was located within an American Indian reservation. RESULTS: Controlling for other demographic and economic characteristics, zip codes with greater percentage of American Indians exhibited greater incidence for all 10 substance abuse-related health outcomes (9 of 10 well supported); zip code areas within American Indian reservations had greater incidence of self-inflicted injury and drug dependence and abuse, and reduced incidence of alcohol cirrhosis and prescription opioid poisoning. However, the analyses generally demonstrated no well-supported differences in incidence associated with local residence percentages of American Indian versus African American. CONCLUSIONS: In our analyses, ethnicity or heredity alone did not account for alcohol- and drug-related hospitalizations among Native populations. Aspects of social, economic, and political dimensions of Native lives must be considered in the etiology of alcohol- and drug-related problems for rural-dwelling indigenous peoples.

A Pilot Randomized Controlled Trial of a Technology-Based Substance Use Intervention for Youth Exiting Foster Care.

Youth exiting foster care represent a unique, at-risk population in that they receive supportive health services while under the umbrella of the foster care system, but access to care can drop precipitously upon release from foster custody. Traditional means of substance use treatment may not meet the needs of this vulnerable population. Mobile interventions, however, have demonstrated high acceptability and efficacy across a range of mental and physical health issues. The specific advantages to mobile interventions dovetail well with the barriers faced by youth exiting foster care. This study describes the feasibility, acceptability, and initial efficacy of iHeLP, a computer- and mobile phone-based intervention based in Motivational Interviewing for reducing substance use among youth exiting foster care (n = 33). Participants were randomly assigned to either iHeLP or a contact control, each of which lasted six months. Feasibility was evaluated through eligibility and enrollment rates at baseline, and retention and intervention reach rates 3, 6, 9, and 12 months later. Acceptability was measured through a 5-item satisfaction measure and exit interviews. The two groups were then compared on a monthly measure of substance use. Study enrollment, retention, response rate, engagement, and satisfaction were all very good. Participants receiving iHeLP reported higher percent days abstinent than the control group, with effect sizes ranging from 0.32 to 0.62. Technology-based interventions such as iHeLP may be attractive to this population and support efforts towards reductions in substance use.

Feeling Heard and Not Judged: Perspectives on Substance Use Services Among Youth Formerly in Foster Care.

Youth in foster care have limited access to substance use services for a variety of reasons. Attempts to unpack this health disparity have focused on foster care systems, administrators, providers, and foster parents. This study seeks to understand the perspectives of youth themselves, with the hope of understanding their experiences with and preferences for such services. Analyses of focus groups with youth who had recently left foster care suggested concrete and perceptual facilitators/barriers to treatment. Concrete facilitators/barriers included the need for expanding social support, access to multiple service options, and tailored intervention approaches. Perceptual concerns revolved around understanding each individual's readiness to change, feeling judged by authority figures, and desiring help from people with lived experience. Participants also described novel intervention ideas, including a focus on technology-based approaches. By relying on youth voices, we can improve upon the current state of substance use interventions within foster care.

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.

A pilot randomized trial of Motivational Interviewing compared to Psycho-Education for reducing and preventing underage drinking in American Indian adolescents.

Underage drinking is an important public health issue for American Indian and Alaska Native (AI/AN) adolescents, as it is for U. S. teens of all ethnicities. One of the demonstrated risk factors for the development of alcohol use disorders in AI/AN is early age of initiation of drinking. To address this issue a randomized trial to assess the efficacy of Motivational Interviewing (MI) compared to Psycho-Education (PE) to reduce and prevent underage drinking in AI/AN youth was developed and implemented. Sixty-nine youth received MI or PE and 87% were assessed at follow-up. For teens who were already drinking, participating in the intervention (MI or PE) was associated, at follow-up, with lower quantity×frequency (q×f) of drinking (p=0.011), fewer maximum drinks per drinking occasion (p=0.004), and fewer problem behaviors (p=0.009). The MI intervention resulted in male drinkers reporting a lower q×f of drinking (p=0.048) and female drinkers reporting less depression (p=0.011). In teens who had not started drinking prior to the intervention, 17% had initiated drinking at follow-up. As a group they reported increased quantity×frequency of drinking (p=0.008) and maximum drinks (p=0.047), but no change in problem behaviors. These results suggest that intervening against underage drinking using either MI or PE in AI/AN youth can result in reduced drinking, prevention of initiation of drinking, and other positive behavioral outcomes. Brief interventions that enhance motivation to change as well as Psycho-Education may provide a successful approach to reducing the potential morbidity of underage drinking in this high-risk group.

Developing a Tailored Texting Preventive Intervention: A Card Sort Methodology.

PURPOSE: Intervention content written by adults for youth can result in miscommunication due to generational and cultural differences. Inviting at-risk youth to participate in the creation of intervention material can augment acceptability for their peers. METHODS: To improve intervention messaging, the present study examines the utility of a card sort technique when creating cellular phone text messages to be used in a preventive substance use intervention. During focus groups with 24 youth who are exiting the foster care system - a population with distinct cultural attributes - participants were asked to rate stage of change-specific health messages rooted in Motivational Interviewing and the Transtheoretical Model. RESULTS: Participants unanimously favored content that encouraged autonomy and choice. Statements that invited a "look to the future" were also rated favorably. Messages that referenced the past were not rated well, as were suggestions for professional assistance. Finally, encouragement to receive social support for change was met with ambivalence. While some participants regarded support as helpful, many others felt a severe lack of support in their lives, possibly prompting further substance use. CONCLUSIONS: Youth exiting foster care constitute a unique population whose voice is paramount in the development of interventions. The content present in traditional approaches to substance use prevention (e.g., increasing social support) may not apply to this group of vulnerable youth. The card sort technique has strong potential to evoke youth-specific intervention content that is more readily understood and accepted by target audiences.