Culturally grounded strategies for suicide and alcohol risk prevention delivered by rural Alaska Native communities: A dynamic wait-listed design evaluation of the Qungasvik intervention.

We examined the effectiveness of the Qungasvik (Tools for Life) intervention in enhancing protective factors as a universal suicide and alcohol prevention strategy for young people ages 12-18 living in highly affected rural Alaska Native communities. Four communities were assigned to immediate intervention or to a dynamic wait list. Outcomes were analyzed for 239 young people at four time points over two years of community intervention. Outcomes assessed two ultimate variable protective factors buffering suicide and alcohol risk, and three intermediate variable protective factors at the individual, family, and community level. Dose dependent intervention effects were associated with growth in ultimate but not intermediate variables. This evaluation of the Qungasvik intervention provides support for the effectiveness of its Indigenous strategies for suicide and alcohol misuse prevention in this rural Alaska Native setting. Though findings did not provide support for a theory of change where growth in ultimate variables is occasioned through effects on intermediate variables, research designs focused on young people who enter intervention at lower levels of preexisting protection hold promise for better understanding of intervention change processes. The Qungasvik intervention is responsive to an acute public health need for effective rural Alaska Native suicide and alcohol risk prevention strategies.

Race and Depressive Symptoms are Associated with the Prevalence of Adolescent Suicide Attempts in Hawai'i, Youth Risk Behavior Survey 2015-2017.

Suicide is death caused by injuring oneself with the intent to die. According to the 2017 National Vital Statistics report, suicide was the second leading cause of death for adolescents 10-24 years old, accounting for 19.2% of deaths in that age group. Aggregated 2015-2017 Hawai'i Youth Risk Behavior Survey (YRBS) data from 12 120 respondents were analyzed. Multivariate logistic regression modeling for complex survey procedure was created using predicted marginals to estimate crude and adjusted prevalence ratios for suicide attempts. After adjusting for race, depressive symptoms, bullying, illicit drug use, alcohol use, and self-harm, youth who experienced bullying (adjusted prevalence ratio=1.75; 95% confidence interval: 1.44-2.12), used illicit drugs (1.89; 1.54-2.31), those with one-time self-harm (2.87; 2.04-4.04), or repeated self-harm (5.31; 4.28-6.60) were more likely to have suicide attempts. Race by depressive symptoms interaction was significant (P <.01), demonstrating the heterogeneity of the stratum-specific measures of association. When depressive symptoms were present, youth who are Native Hawaiian (2.64; 1.68-4.15), Japanese (2.39; 1.44-3.95), other Pacific Islander (2.04; 1.29-3.21), Filipino (1.77; 1.21-2.59), and those who do not describe as only one race/ethnicity (1.74; 1.16-2.62) were more likely to have suicide attempts compared to White. When depressive symptoms were not present, other Pacific Islanders (4.05; 1.69-9.67), Hispanics/Latinos (3.37; 1.10-10.30), Native Hawaiians (3.03; 1.23-7.45), and other race groups (2.03; 1.03-4.00) were more likely to have suicide attempts compared to White. These results demonstrated the importance of screening for depressive symptoms and other risk factors to prevent suicide attempts in adolescents.

Emergency Room Visits with a Non-Traumatic Dental-Related Diagnosis in Hawaii, 2016-2020.

The purpose of this study was to characterize the frequencies and patterns of emergency room (ER) visits with a non-traumatic dental-related diagnosis among adults (≥21 years old) in Hawaii, United States. This descriptive cross-sectional study used state-level inpatient and outpatient data recorded in Hawaii from 2016 to 2020. We identified dental-related ER visits using the diagnosis codes for non-traumatic dental-related conditions and summarized the frequency, rates, and cumulative total charges of the ER visits. The results show that approximately 30 thousand ER visits between 2016 and 2020 had a dental-related diagnosis. Sixty-seven percent of them had it as a principal diagnosis, amounting to USD 38.7 million total charges over the five years. A high proportion of these visits was found among those aged 21−44 years old (62%), Medicaid beneficiaries (49%), and Native Hawaiians/Part Native Hawaiians (26%). Compared to the proportions of ER visits with a secondary diagnosis, these groups had a higher proportion of ER visits with a principal diagnosis (ps < 0.001). A higher visit rate was found for those aged 21−44 years old and from less-populated counties. These results suggest that oral health disparities in age, socioeconomic status, and race/ethnicity exist in Hawaii. Our findings could provide insight in developing a framework to reduce oral health disparities, particularly among Medicaid beneficiaries and Native Hawaiians. Dental coverage with effective education in multiple dimensions is necessary to reduce non-traumatic dental-related ER visits.

Disaster Preparedness Among Women With a Recent Live Birth in Hawaii - Results From the Pregnancy Risk Assessment Monitoring System (PRAMS), 2016.

OBJECTIVE: The aim of this study was to examine emergency preparedness behaviors among women with a recent live birth in Hawaii. METHODS: Using the 2016 Hawaii Pregnancy Risk Assessment Monitoring System, we estimated weighted prevalence of 8 preparedness behaviors. RESULTS: Among 1010 respondents (weighted response rate, 56.3%), 79.3% reported at least 1 preparedness behavior, and 11.2% performed all 8 behaviors. The prevalence of women with a recent live birth in Hawaii reporting preparedness behaviors includes: 63.0% (95% CI: 58.7-67.1%) having enough supplies at home for at least 7 days, 41.3% (95% CI: 37.1-45.6%) having an evacuation plan for their child(ren), 38.7% (95% CI: 34.5-43.0%) having methods to keep in touch, 37.8% (95% CI: 33.7-42.1%) having an emergency meeting place, 36.6% (95% CI: 32.6-40.9%) having an evacuation plan to leave home, 34.9% (95% CI: 30.9-39.2%) having emergency supplies to take with them if they have to leave quickly, 31.8% (95% CI: 27.9-36.0%) having copies of important documents, and 31.6% (95% CI: 27.7-35.8%) having practiced what to do during a disaster. CONCLUSIONS: One in 10 women practiced all 8 behaviors, indicating more awareness efforts are needed among this population in Hawaii. The impact of preparedness interventions implemented in Hawaii can be tracked with this question over time.

Strengths-Based Assessment for Suicide Prevention: Reasons for Life as a Protective Factor From Yup'ik Alaska Native Youth Suicide.

Suicide is the second leading cause of death among American Indian and Alaska Native youth, and within the Alaska Native youth subpopulation, the leading cause of death. In response to this public health crisis, American Indian and Alaska Native communities have created strategies to protect their young people by building resilience using localized Indigenous well-being frameworks and cultural strengths. These approaches to suicide prevention emphasize promotion of protective factors over risk reduction. A measure of culturally based protective factors from suicide risk has potential to assess outcomes from these strengths-based, culturally grounded suicide prevention efforts, and can potentially address several substantive concerns regarding direct assessment of suicide risk. We report on the Reasons for Life (RFL) scale, a measure of protective factors from suicide, testing psychometric properties including internal structure with 302 rural Alaska Native Yup'ik youth. Confirmatory factor analyses revealed the RFL is best described through three distinct first-order factors organized under one higher second-order factor. Item response theory analyses identified 11 satisfactorily functioning items. The RFL correlates with other measures of more general protective factors. Implications of these findings are described, including generalizability to other American Indian and Alaska Native, other Indigenous, and other culturally distinct suicide disparities groups.

Prevalence and Risk Factors for Self-Reported Postpartum Depression Symptoms (SRPDS) in Hawai'i, 2012-2015.

Postpartum depression (PPD) affects an estimated 10% to 20% of women in the United States, but little is known about the risk factors for PPD in Hawai'i. This study sought to identify PPD risk factors and examine whether disparities exist in Hawai'i. Aggregated 2012-2015 Hawai'i Pregnancy Risk Assessment Monitoring System (PRAMS) data from 5572 women with a recent live birth were analyzed. Two questions on the PRAMS survey about mood and interest in activities were used to create a brief measure of Self-Reported Postpartum Depression Symptoms (SRPDS). Multivariate generalized logit analysis was conducted to identify risk factors associated with SRPDS or possible SRPDS, adjusting for maternal race and age, intimate partner violence (IPV), prenatal anxiety, prenatal depression, illicit drug use before pregnancy, and stressful life events (SLEs). About 10.0% of women surveyed had SRPDS and 27.7% had possible SRPDS. SRPDS was more common among Native Hawaiians (adjusted odds ratios=1.77; 95% confidence interval: 1.17-2.70), Filipinos (2.16; 1.33-3.50), Japanese (2.88; 1.67-4.98), and other Pacific Islanders (OPI; 3.22; 1.78-5.82), when compared to white. Women aged 20-29 years (0.39; 0.24-0.65) and 30-52 years (0.41; 0.24-0.69) were less likely to have SRPDS than those 19 years and younger. SRPDS was highest among women who experienced IPV (2.65; 1.37-5.13), prenatal anxiety (2.10; 1.28-3.42), prenatal depression (2.78; 1.47-5.25), or used illicit drugs before pregnancy (1.97; 1.21-3.20). There was an upward trend in SRPDS based on the number of SLEs. Possible SRPDS had similar but smaller effects, suggesting the importance of clinical screening and appropriate follow-up for these high-risk groups.

Multi-Level Cultural Intervention for the Prevention of Suicide and Alcohol Use Risk with Alaska Native Youth: a Nonrandomized Comparison of Treatment Intensity.

Suicide and alcohol use disorders are primary determinants of health disparity among Alaska Native people in contrast to the US general population. Qungasvik, a Yup'ik word for toolbox, is a strengths-based, multi-level, community/cultural intervention for rural Yup'ik youth ages 12-18. The intervention uses "culture as intervention" to promote reasons for life and sobriety in young people using local expertise, high levels of community direction, and community based staff. The intervention is grounded in local practices and adaptive to local cultural differences distinctive to rural Yup'ik communities. The current study compares the effectiveness of high-intensity intervention in one community (treatment), operationalized as a high number of intervention activities, or modules, implemented and attended by youth, contrasted to a lower intensity intervention in a second community (comparison) that implemented fewer modules. A Yup'ik Indigenous theory of change developed through previous qualitative and quantitative work guides intervention. In the model, direct intervention effects on proximal or intermediate variables constituting protective factors at the individual, family, community, and peer influences levels lead to later change on the ultimate prevention outcome variables of Reasons for Life protective from suicide risk and Reflective Processes about alcohol use consequences protective from alcohol risk. Mixed effects regression models contrasted treatment and comparison arms, and identified significant intervention effects on Reasons for Life (d = 0.27, p < .05) but not Reflective Processes.

Maybe Small Is Too Small a Term: Introduction to Advancing Small Sample Prevention Science.

Prevention research addressing health disparities often involves work with small population groups experiencing such disparities. The goals of this special section are to (1) address the question of what constitutes a small sample; (2) identify some of the key research design and analytic issues that arise in prevention research with small samples; (3) develop applied, problem-oriented, and methodologically innovative solutions to these design and analytic issues; and (4) evaluate the potential role of these innovative solutions in describing phenomena, testing theory, and evaluating interventions in prevention research. Through these efforts, we hope to promote broader application of these methodological innovations. We also seek whenever possible, to explore their implications in more general problems that appear in research with small samples but concern all areas of prevention research. This special section includes two sections. The first section aims to provide input for researchers at the design phase, while the second focuses on analysis. Each article describes an innovative solution to one or more challenges posed by the analysis of small samples, with special emphasis on testing for intervention effects in prevention research. A concluding article summarizes some of their broader implications, along with conclusions regarding future directions in research with small samples in prevention science. Finally, a commentary provides the perspective of the federal agencies that sponsored the conference that gave rise to this special section.

Why Small is Too Small a Term: Prevention Science for Health Disparities, Culturally Distinct Groups, and Community-Level Intervention.

Implications of the Advancing Small Sample Prevention Science Special Section are discussed. Efficiency and precision are inadequately considered in many current prevention-science methodological approaches. As a result, design and analytic practices pose difficulties for the study of contextual factors in prevention, which often involve small samples. Four primary conclusions can be drawn from the Special Section. First, contemporary statistical and measurement approaches provide a number of underutilized opportunities to maximize power. These strategies maximize efficiencies by optimizing design and resource allocation parameters, allowing for the detection of effects with small samples. Second, several alternative research designs provide both rigor and further optimize efficiencies through more complete use of available information, allowing study of important questions in prevention science for which only small samples may be accessible. Third, mixed methods hold promise for enhancing the utility of qualitative data in studies with small samples. Finally, Bayesian analytic approaches, through their use of prior information, allow for even greater efficiencies in work with small samples, and through their introduction in the routines of mainstream software packages, hold particular promise as an emergent methodology in prevention research.

Research Designs for Intervention Research with Small Samples II: Stepped Wedge and Interrupted Time-Series Designs.

The stepped wedge design (SWD) and the interrupted time-series design (ITSD) are two alternative research designs that maximize efficiency and statistical power with small samples when contrasted to the operating characteristics of conventional randomized controlled trials (RCT). This paper provides an overview and introduction to previous work with these designs and compares and contrasts them with the dynamic wait-list design (DWLD) and the regression point displacement design (RPDD), which were presented in a previous article (Wyman, Henry, Knoblauch, and Brown, Prevention Science. 2015) in this special section. The SWD and the DWLD are similar in that both are intervention implementation roll-out designs. We discuss similarities and differences between the SWD and DWLD in their historical origin and application, along with differences in the statistical modeling of each design. Next, we describe the main design characteristics of the ITSD, along with some of its strengths and limitations. We provide a critical comparative review of strengths and weaknesses in application of the ITSD, SWD, DWLD, and RPDD as small sample alternatives to application of the RCT, concluding with a discussion of the types of contextual factors that influence selection of an optimal research design by prevention researchers working with small samples.

Increasing the Sensitivity of Measures to Change.

Little attention is paid in prevention research to the ability of measures to accurately assess change, termed "responsiveness" or "sensitivity to change." This paper reviews definitions and measures of responsiveness, and suggests five strategies for increasing sensitivity to change, with central focus on prevention research with small samples: (a) improving understandability and cultural validity, (b) assuring that the measure covers the full range of the latent construct being measured, (c) eliminating redundant items, (d) maximizing sensitivity of the device used to collect responses; and (e) asking directly about change. Examples of the application of each strategy are provided. The discussion focuses on using the issues as a checklist for improving measures and the implications of sensitivity to change for prevention research with small samples.

Feasibility of a community intervention for the prevention of suicide and alcohol abuse with Yup'ik Alaska Native youth: the Elluam Tungiinun and Yupiucimta Asvairtuumallerkaa studies.

The Elluam Tungiinun and Yupiucimta Asvairtuumallerkaa studies evaluated the feasibility of a community intervention to prevent suicide and alcohol abuse among rural Yup'ik Alaska Native youth in two remote communities. The intervention originated in an Indigenous model of protection, and its development used a community based participatory research process. Feasibility assessment aimed to assess the extent to which (1) the intervention could be implemented in rural Alaska Native communities, and (2) the intervention was capable of producing measurable effects. Scales maximally sensitive to change were derived from earlier measurement work, and the study contrasted implementation process and outcomes across the two communities. In one community, medium dose response effects (d = .30-.50), with dose defined as number of intervention activities attended, were observed in the growth of intermediate protective factors and ultimate variables. In the other community, medium dose effects were observed for one intermediate protective factor variable, and small dose effects were observed in ultimate variables. Differences across communities in resources supporting intervention explain these contrasting outcomes. Results suggest implementation in these rural Alaska settings is feasible when sufficient resources are available to sustain high levels of local commitment. In such cases, measureable effects are sufficient to warrant a prevention trial.

A protective factors model for alcohol abuse and suicide prevention among Alaska Native youth.

This study provides an empirical test of a culturally grounded theoretical model for prevention of alcohol abuse and suicide risk with Alaska Native youth, using a promising set of culturally appropriate measures for the study of the process of change and outcome. This model is derived from qualitative work that generated an heuristic model of protective factors from alcohol (Allen et al. in J Prev Interv Commun 32:41-59, 2006; Mohatt et al. in Am J Commun Psychol 33:263-273, 2004a; Harm Reduct 1, 2004b). Participants included 413 rural Alaska Native youth ages 12-18 who assisted in testing a predictive model of Reasons for Life and Reflective Processes about alcohol abuse consequences as co-occurring outcomes. Specific individual, family, peer, and community level protective factor variables predicted these outcomes. Results suggest prominent roles for these predictor variables as intermediate prevention strategy target variables in a theoretical model for a multilevel intervention. The model guides understanding of underlying change processes in an intervention to increase the ultimate outcome variables of Reasons for Life and Reflective Processes regarding the consequences of alcohol abuse.

The brief family relationship scale: a brief measure of the relationship dimension in family functioning.

The Relationship dimension of the Family Environment Scale, which consists of the Cohesion, Expressiveness, and Conflict subscales, measures a person's perception of the quality of his or her family relationship functioning. This study investigates an adaptation of the Relationship dimension of the Family Environment Scale for Alaska Native youth. The authors tested the adapted measure, the Brief Family Relationship Scale, for psychometric properties and internal structure with 284 12- to 18-year-old predominately Yup'ik Eskimo Alaska Native adolescents from rural, remote communities. This non-Western cultural group is hypothesized to display higher levels of collectivism traditionally organized around an extended kinship family structure. Results demonstrate a subset of the adapted items function satisfactorily, a three-response alternative format provided meaningful information, and the subscale's underlying structure is best described through three distinct first-order factors, organized under one higher order factor. Convergent and discriminant validity of the Brief Family Relationship Scale was assessed through correlational analysis.

Patterns of protective factors in an intervention for the prevention of suicide and alcohol abuse with Yup'ik Alaska Native youth.

BACKGROUND: Community-based participatory research (CBPR) with American Indian and Alaska Native communities creates distinct interventions, complicating cross-setting comparisons. OBJECTIVE: The objective of this study is to develop a method for quantifying intervention exposure in CBPR interventions that differ in their forms across communities, permitting multi-site evaluation. METHODS: Attendance data from 195 youth from three Yup'ik communities were coded for the specific protective factor exposure of each youth, based on information from the intervention manual. The coded attendance data were then submitted to latent class analysis to obtain participation patterns. RESULTS: Five patterns of exposure to protective factors were obtained: Internal, External, Limits, Community/family, and Low Protection. Patterns differed significantly by community and youth age. CONCLUSION: Standardizing interventions by the functions an intervention serves (protective factors promoted) instead of their forms or components (specific activities) can assist in refining CBPR interventions and evaluating effects in culturally distinct settings.

Umyuangcaryaraq "Reflecting": multidimensional assessment of reflective processes on the consequences of alcohol use among rural Yup'ik Alaska Native youth.

BACKGROUND AND AIMS: Concerns in some settings regarding the accuracy and ethics of employing direct questions about alcohol use suggest need for alternative assessment approaches with youth. Umyuangcaryaraq is a Yup'ik Alaska Native word meaning "Reflecting." OBJECTIVES: The Reflective Processes Scale was developed as a youth measure tapping awareness and thinking over potential negative consequences of alcohol misuse as a protective factor that includes cultural elements often shared by many other Alaska Native and American Indian cultures. This study assessed multidimensional structure, item functioning, and validity. METHODS: Responses from 284 rural Alaska Native youth allowed bifactor analysis to assess structure, estimates of location and discrimination parameters, and convergent and discriminant validity. RESULTS: A bifactor model of the scale items with three content factors provided excellent fit to observed data. Item response theory analysis suggested a binary response format as optimal. Evidence of convergent and discriminant validity was established. CONCLUSION: The measure provides an assessment of reflective processes about alcohol that Alaska Native youth engage in when thinking about reasons not to drink. SCIENTIFIC SIGNIFICANCE: The concept of reflective processes has potential to extend understandings of cultural variation in mindfulness, alcohol expectancies research, and culturally mediated protective factors in Alaska Native and American Indian youth.

Multicultural Mastery Scale for youth: multidimensional assessment of culturally mediated coping strategies.

Self-mastery refers to problem-focused coping facilitated through personal agency. Communal mastery describes problem solving through an interwoven social network. This study investigates an adaptation of self- and communal mastery measures for youth. Given the important distinction between family and peers in the lives of youth, these adaptation efforts produced Mastery-Family and Mastery-Friends subscales, along with a Mastery-Self subscale. We tested these measures for psychometric properties and internal structure with 284 predominately Yup'ik Eskimo Alaska Native adolescents (12- to 18-year-olds) from rural, remote communities-a non-Western culturally distinct group hypothesized to display higher levels of collectivism and communal mastery. Results demonstrate a subset of items adapted for youth function satisfactorily, a 3-response alternative format provided meaningful information, and the subscale's underlying structure is best described through 3 distinct first-order factors organized under 1 higher order mastery factor.

Assessment of awareness of connectedness as a culturally-based protective factor for Alaska native youth.

Research with Native Americans has identified connectedness as a culturally based protective factor against substance abuse and suicide. Connectedness refers to the interrelated welfare of the individual, one's family, one's community, and the natural environment. We developed an 18-item quantitative assessment of awareness of connectedness and tested it with 284 Alaska Native youth. Evaluation with confirmatory factor analysis and item response theory identified a 12-item subset that functions satisfactorily in a second-order four-factor model. The proposed Awareness of Connectedness Scale (ACS) displays good convergent and discriminant validity, and correlates positively with hypothesized protective factors such as reasons for living and communal mastery. The measure has utility in the study of culture-specific protective factors and as an outcomes measure for behavioral health programs with Native American youth.

Suicide prevention as a community development process: understanding circumpolar youth suicide prevention through community level outcomes.

OBJECTIVES: Community-based models have become increasingly prominent in prevention, and have special relevance for suicide prevention in circumpolar Indigenous communities. It follows that outcomes from circumpolar suicide prevention programs might be more completely understood at the community level. We present here a methodology for analysis at this level. This paper seeks to understand a cultural prevention program for rural Yup'ik youth in Alaska targeting suicide and co-occurring alcohol abuse as a community development process through changes at the community level. STUDY DESIGN: Quasi-experimental design with assessment at pre- and post-intervention or at 4 time points. The community development process for this project began in October 2004. The first program baseline assessment began in November 2006, prior to prevention activities with youth and parents, and the post-intervention assessment concluded in March 2008. METHODS: Five key informants pre- and post-intervention completed a community readiness assessment, which is a structured procedure assessing a community's awareness of suicide as an issue and its, organizational readiness for prevention programming. Forty-three adult caregivers or sponsors of youth in the prevention program completed an assessment of behaviours that contributed to community protective factors from youth suicide and alcohol abuse at 4 time points before, during and after the intervention. The 54 youth who participated in the prevention program completed an assessment of community protective factors, also at 4 time points before, during and after the intervention. The community protective factors from suicide that were assessed included safety, enforcement of alcohol prohibitions, role models, support and opportunities for youth. RESULTS: Community readiness for the prevention efforts increased to new developmental stages of readiness post-intervention, and a trend in the data suggested community protective factors increased in the amount of protective behaviours performed by adults (slope estimate = 0.0162, 95% CI--0.0028-0.0351, d=.55) and in the perceptions of youth (slope estimate=0.0148, 95% CI--0.0004-0.0291, d=.45), in a dose response relationship to the number of prevention program sessions attended by adults and youth. CONCLUSIONS: Using data from a feasibility study, this paper demonstrates the feasibility and potential utility of methodological approaches that use community-level variables beyond individual level outcomes in circumpolar suicide prevention research.