Planning for a group-randomized trial with American Indian youth.

PURPOSE: To describe lessons learned working with tribal communities in the Northern Plains to plan and implement a group randomized trial of multimedia Circle of Life (mCOL), a sexual risk reduction program designed for American Indian (AI) youth. METHODS: Project records including emails, travel reports, and meeting minutes were reviewed and synthesized to describe participatory development of the project. RESULTS: Several challenges were identified including: discussing sexual health interventions for preteens with communities; developing a culturally appropriate research design; managing costs of conducting research in remote and culturally distinct tribal communities; and building research infrastructure of partner organizations. Opportunities for strengthening research partnerships included transparency, openness to bi-directional learning, planning for change, flexibility, and strategic use of technology. CONCLUSIONS: Findings suggest that meaningful AI community participation in research trials is achievable and a critical step towards generating evidence for interventions in settings where they are most needed. Substantial investments in time, resources, and relationship-building are necessary.

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.

Challenges in operationalizing the DSM-IV clinical significance criterion.

BACKGROUND: An explicit clinical significance (CS) criterion was added to many DSM-IV diagnoses in an attempt to more closely approximate the clinical diagnostic process and reduce the proportion of false positives in epidemiological studies. The American Indian Service Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project (AI-SUPERPFP) offered a unique opportunity to examine the success of this effort. OBJECTIVE: To determine the impact of distress, impairment, and help-seeking reported in a lay structured interview on concordance with a clinical reappraisal. Further, to test the efficacy of 5 operationalizations of CS on the concordance and prevalence of DSM-IV lifetime disorders. DESIGN: Completed between 1997 and 2000, a cross-sectional probability sample survey with clinical reappraisal of approximately 10% of participants. SETTING: General community. PARTICIPANTS: A population-based sample of 3084 members of 2 American Indian tribal groups, who were between the ages of 15 and 54 years and resided on or near their home reservations, were randomly sampled from the tribal rolls and participated in structured psychiatric interviews. Clinical reappraisals were conducted with approximately 10% of the lay-interview participants. The response rate for the lay interview was 75%, and for the clinical reappraisal it was 72%. MAIN OUTCOMES MEASURES: The AI-SUPERPFP Composite International Diagnostic Interview (CIDI), a culturally adapted version of the CIDI, University of Michigan version. Adapted to assess DSM-IV diagnoses, questions assessing the CS criterion were inserted in all diagnostic modules. The Structured Clinical Interview for DSM-III-R (SCID) was used in the clinical reappraisal. RESULTS: Most participants who qualified as having AI-SUPERPFP CIDI lifetime disorders reported at least moderate levels of distress or impairment. Evidence of increased concordance between the CIDI and the SCID was lacking when more restrictive operationalizations of CS were used; indeed, the CIDI was very likely to underdiagnose disorders compared with the SCID (false negatives). Concomitantly, the CS operationalizations affected prevalence rates dramatically. CONCLUSION: The CS criterion, at least as operationalized to date, demonstrates little effectiveness in increasing the validity of diagnoses using lay-administered structured interviews.