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.

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.

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.

Developmental Trajectories of Personal and Collective Self-Concept Among American Indian Adolescents

Developmental trajectories of personal and collective self-concept were examined among American Indian adolescents. Personal self-concept (self-esteem) and collective self-concept (American Indian identity, Euro-American identity, community-mindedness) were assessed 6 times over 3 years in 4 cohorts of adolescents from 3 American Indian cultural groups (N=1,252). An accelerated longitudinal design was used to estimate developmental trajectories from 14 to 19 years; parallel-process and covariate models were used to examine variation in trajectories. Both personal and collective self-concepts were generally positive and showed small gains; they were moderately related to one another and differentially related to cultural group, gender, and perceived social support. The findings highlight the complexity of self-concept for American Indian youth and the significance of both personal and collective identity.

Latent class analysis of substance use: comparison of two American Indian reservation populations and a national sample

OBJECTIVE

Our goal was to carefully examine disparities in substance use between two American Indian reservation communities and a national sample. We sought to identify characteristic patterns of use-both across and within samples-that could be used to inform intervention efforts aimed at reducing disparities.

METHOD

Latent class analyses were used to identify subgroups within each sample that were characterized by distinctive patterns of use of alcohol and eight drugs; the use patterns and prevalence of subgroups were then compared across samples. American Indian data were from the American Indian Service Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project (AI-SUPERPFP; N=2647), which comprised participants from two distinct cultural groups in the Southwest (SW; n=1244; 57% female) and Northern Plains (NP; n=1443; 52% female). National data were from the public use file of the 1999 National Household Survey of Drug Abuse (NHSDA; N = 39.152; 52% female).

RESULTS

Four classes of lifetime users (abstainers, primarily alcohol users, primarily alcohol and marijuana users, and polysubstance users) and three classes of past-year users (abstainers, primarily alcohol users, and alcohol and drug users) were identified in each sample (SW, NP, NHSDA). Despite consistency in classes of users found across these samples, there were notable sample differences in class prevalence. The modal class for lifetime use, for example, was primarily alcohol users in the SW and NHSDA, and primarily alcohol and marijuana use in the NP. The concordance of lifetime and past-year use classes also varied across the three samples, and examination of past-year abstainers in conjunction with lifetime-use class suggested potentially important differences in the stability of substance-use patterns over time.

CONCLUSIONS

Our findings highlight the utility of latent class techniques for understanding substance use, comparing substance use across populations and identifying key points of intervention, prevention, and treatment within different communities.

Help seeking for substance use problems in two American Indian reservation populations

OBJECTIVES

This study examined the extent and types of help seeking (biomedical, traditional, and 12-step groups) for substance use problems in two American Indian reservation populations by using data from the American Indian Service Utilization, Psychiatric Epidemiology, Risk, and Protective Factors Project (AI-SUPERPFP). This study also sought to understand the correlates of such help seeking, including measures of need, demographic characteristics, spirituality, and ethnic identity.

METHODS

AI-SUPERPFP, completed between 1997 and 2000, was a cross-sectional probability sample survey. Altogether 2,825 tribal members, aged 18 to 54 years, representing two tribal groups living on or near their home reservations, were randomly sampled from the tribal rolls. Response rates averaged 75.3 percent. The primary outcome measure was help seeking in the past year for substance use problems, which was further divided into help seeking from biomedical services, traditional healing sources, and 12-step programs.

RESULTS

Help-seeking rates were high, with 13 percent of the population and 38 percent of those with diagnoses of substance use disorders in the past year having sought services for alcohol or drug problems in the preceding 12 months. Correlates of help seeking included variables related to need for services (substance use disorders, tobacco use, and mental and physical health problems), marital status, and spirituality. Slightly more than half of service users sought help from formal biomedical providers; use of traditional healing and 12-step programs was also common. Need and spirituality variables best differentiated among the users of the three modalities.

CONCLUSIONS

Help seeking for alcohol and drug problems was common in these communities, with traditional healing and 12-step resources as essential components of the local service ecologies.

Different factor loadings for SF36: The Strong Heart Study and the National Survey of Functional Health Status

BACKGROUND

To increase our understanding of the psychometric characteristics and factor structure of the SF36 in older American Indian populations.

METHODS

Between 1993 and 1995, SF36 data were collected from 3,488 Phase II participants of the Strong Heart Study (SHS) between the ages of 48 and 81. Comparison data were provided by an age- and gender-matched sample (n = 695) from the National Survey of Functional Health Status (NSFHS) conducted in 1989 and 1990.

RESULTS

Generally, the basic psychometric analyses showed that the SF36 performed adequately in these older American Indians. Exploratory factor analyses indicated that a one-factor model best fit the data for both older groups. On the other hand, confirmatory factor analyses showed that a two-factor model with correlated factors provided a superior fit to the data than a one-factor model. An assumption of equivalent factor loadings for the SHS and NSFHS groups was untenable.

CONCLUSION

These analyses demonstrate that use of summary scores assuming a differentiated physical/mental functioning structure is likely improper in at least some populations. The SF36 provides an important opportunity to understand cultural differences in the conceptualization and measurement of health-related quality of life.

The development of alcohol use and outcome expectancies among American Indian young adults: a growth mixture model

Adolescence is an important developmental period for understanding alcohol use. American Indian youth are a group for whom various preventive interventions focusing on alcohol use have been implemented but have not necessarily been widely successful, highlighting the need to further refine our approaches. In the work reported here, we followed 464 14- to 18-year-old American Indian youth annually for seven years. We examined the development of alcohol use and positive alcohol outcome expectancies in parallel, using growth mixture modeling to identify classes with different trajectories of alcohol use and expectancies. We found five classes; the largest (n = 198) was made up of youth who experienced increases in both alcohol use and positive outcome expectancies. Initial levels of outcome expectancies were related to subsequent changes in alcohol use, while the reverse was not true, suggesting that interventions focusing on outcome expectancies are appropriate for a substantial number of youth. However, class heterogeneity in the relationships between the two processes pointed out that changes in expectancies may not always precede changes in alcohol use. Thus, intervention design implications are discussed for the class structures.

Prevalence of mental disorders and utilization of mental health services in two American Indian reservation populations: mental health disparities in a national context

OBJECTIVE

The American Indian Service Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project (AI-SUPERPFP) provided estimates of the prevalence of DSM-III-R disorders and utilization of services for help with those disorders in American Indian populations. Completed between 1997 and 1999, the AI-SUPERPFP was designed to allow comparison of findings with the results of the baseline National Comorbidity Survey (NCS), conducted in 1990-1992, which reflected the general United States population.

METHOD

A total of 3,084 tribal members (1,446 in a Southwest tribe and 1,638 in a Northern Plains tribe) age 15-54 years living on or near their home reservations were interviewed with an adaptation of the University of Michigan Composite International Diagnostic Interview. The lifetime and 12-month prevalences of nine DSM-III-R disorders were estimated, and patterns of help-seeking for symptoms of mental disorders were examined.

RESULTS

The most common lifetime diagnoses in the American Indian populations were alcohol dependence, posttraumatic stress disorder (PTSD), and major depressive episode. Compared with NCS results, lifetime PTSD rates were higher in all American Indian samples, lifetime alcohol dependence rates were higher for all but Southwest women, and lifetime major depressive episode rates were lower for Northern Plains men and women. Fewer disparities for 12-month rates emerged. After differences in demographic variables were accounted for, both American Indian samples were at heightened risk for PTSD and alcohol dependence but at lower risk for major depressive episode, compared with the NCS sample. American Indian men were more likely than those in NCS to seek help for substance use problems from specialty providers; American Indian women were less likely to talk to nonspecialty providers about emotional problems. Help-seeking from traditional healers was common in both American Indian populations and was especially common in the Southwest.

CONCLUSIONS

The results suggest that these American Indian populations had comparable, and in some cases greater, mental health service needs, compared with the general population of the United States.

Prevalence of major depressive episode in two American Indian reservation populations: unexpected findings with a structured interview

OBJECTIVE

American Indian populations have often been considered to be at greater risk for major depressive episode than are other groups in the United States. The American Indian Service Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project (AI-SUPERPFP), completed between 1997 and 1999, was designed to allow comparisons with the baseline National Comorbidity Survey (NCS), conducted in 1990-1992. The prevalence of lifetime and 12-month DSM-III-R major depressive episode was compared between the AI-SUPERPFP and NCS samples.

METHOD

A total of 3,084 tribal members (1,446 in a Southwest tribe [73.7% of eligible participants] and 1,638 in a Northern Plains tribe [76.8% of eligible participants]) age 15-54 years living on or near their home reservations were interviewed. An adaptation of the University of Michigan Composite International Diagnostic Interview and the NCS algorithm for diagnosis were used to estimate the prevalence of lifetime and 12-month major depressive episode in these groups.

RESULTS

The prevalence estimates for lifetime and 12-month major depressive episode were substantially lower in the American Indian samples, compared to the NCS sample. Detailed analyses indicated differential endorsement of lifetime symptoms between the American Indian groups and the NCS participants. Furthermore, American Indians were substantially less likely than NCS participants to indicate that depressive symptoms had co-occurred during an episode lasting at least 2 weeks. The lifetime prevalence estimates based on the NCS algorithm ranged from 3.8% to 7.9% for men and women in the two tribes. The analogous rates based on an adapted AI-SUPERPFP algorithm ranged from 7.2% and 14.3%. Few tribe, age, and gender differences were found.

CONCLUSIONS

The findings underscore the need for careful examination of diagnostic instruments cross-culturally. Adaptation of the NCS algorithm for diagnosis appears necessary for estimation of the prevalence of major depressive episode in the American Indian populations included in this study. In striving to better reflect the clinical diagnostic process in epidemiological and services research, careful consideration of the resulting complexity becomes increasingly critical.

Prevalence of DSM-IV disorders and attendant help-seeking in 2 American Indian reservation populations

BACKGROUND

The American Indian Service Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project (AI-SUPERPFP) estimated the mental health burden and associated help-seeking in select American Indian reservation communities.

OBJECTIVE

To determine the lifetime and 12-month prevalence of common DSM-IV disorders, their demographic correlates, and patterns of help-seeking in 2 culturally distinct American Indian reservation communities in the Southwest and Northern Plains.

DESIGN

Completed between 1997 and 2000, a cross-sectional probability sample survey.

SETTING

General community.

PARTICIPANTS

Three thousand eighty-four (Southwest = 1446 and Northern Plains = 1638) members, aged 15-54 years, of 2 tribal groups living on or near their home reservations were randomly sampled from the tribal rolls. Response rates were 73.7% and 76.8% for the Southwest and Northern Plains tribes, respectively.Main Outcomes Measures The AI-SUPERPFP Composite International Diagnostic Interview, a culturally adapted version of the University of Michigan version of the Composite International Diagnostic Interview, to assess DSM-IV diagnoses and help-seeking.

RESULTS

Overall lifetime prevalence of AI-SUPERPFP DSM-IV disorders ranged from 35.7% for Southwest women to near 50% for both groups of men. Alcohol abuse and dependence were the most common disorders for men, with posttraumatic stress disorder most prevalent for women. Many of those with lifetime alcohol problems or posttraumatic stress disorder no longer met criteria for 12-month diagnoses. Significant levels of comorbidity were found between those with depressive and/or anxiety and substance disorders. Demographic correlates other than tribe, sex, and age were generally unrelated to disorder status. A majority of participants with lifetime disorders had sought help from mental health professionals, other medical personnel, or culturally traditional sources.

CONCLUSIONS

Alcohol disorders and posttraumatic stress disorder were more common in these American Indian populations than in other populations using comparable methods. Substantial comorbidity between depressive and/or anxiety and substance disorders suggests the need for greater coordination of treatment for comorbid disorders.

Identifying diverse HIV risk groups among American Indian young adults: the utility of cluster analysis

We demonstrate the utility of cluster analysis for identifying diverse HIV risk groups found in a community-based sample. Within a group of 706 American Indian young adults, we used cluster analysis to identify four profiles of HIV risk/protection. The High Efficacy/Low Risk cluster had high levels of knowledge/education, self-efficacy, and outcome expectations about HIV protection, with low levels of risk behaviors. Low Efficacy/Low Risk had low levels of HIV knowledge/education, self-efficacy, and outcome expectations, but high levels of perceived risk for HIV with low levels of HIV risk behaviors. Low Efficacy/Moderate Risk was similar to the previous group, but its members had moderately higher levels of several risk behaviors and higher condom use. Low Efficacy/High Risk had high rates of several high-risk behaviors such as exchanging sex for money or injection drug use. Validation analyses highlighted differences that can be useful for the development of preventive interventions.

Challenges in Operationalizing the DSM-IV ClinicalSignificance 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.

Stress, trauma, and risky sexual behaviour among American Indians in young adulthood

This paper examines the relationship of risky sexual behaviour to stress and trauma-often the mediators of the content and structure of everyday life-among young American Indians. School, work, social life, and home life bring about demands and stresses for youth; choices young people make may depend on the quantity and content of those demands. Traumatic events or highly distressing situations may shatter fragile (or even resilient) systems of external and internal support from which youth may draw. American Indians live in some of the most impoverished areas of the country, where everyday life includes a heavy burden of stress and trauma. Using data from a representative sample of youth from a Northern Plains tribe, bivariate and adjusted ordered logit models are used to show that stress and trauma do play a role in the sexual decision-making of young people, especially young women. For example, young women who have experienced a trauma have a 20% probability of having had multiple casual partners in the prior year compared to 9% for those who have not experiences a trauma. Types and levels of stress and trauma also make a difference by gender.

The Prevalence of DSM-III-R Alcohol Dependence in Two American Indian Populations

BACKGROUND

Evidence suggests that American Indian (AI) populations may be at increased risk for problems with alcohol, but a lack of community-based research using diagnostic criteria has constrained our ability to draw inferences about the extent of severe alcohol problems, such as dependence, in AI populations.

METHODS

This article draws on data collected by the American Indian Service Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project (AI-SUPERPFP), which involved interviews with 3084 AI people living on or near their reservations. The AI-SUPERPFP sample was drawn from two culturally distinct tribes, which were designated with geographical descriptions: Northern Plains (NP) and Southwest (SW). Comparisons with data collected by the National Comorbidity Survey (NCS) were explored by using shared measures to situate the findings from AI-SUPERPFP in a national context.

RESULTS

Lifetime rates of DSM-III-R alcohol dependence for men in both AI-SUPERPFP samples were 50% higher than those found in the NCS. Rates of lifetime alcohol dependence for women varied by sample, however; NP women had twice the rate of women in the NCS, but SW women had rates quite similar to those of NCS women. Patterns for 12-month alcohol dependence in AI-SUPERPFP were generally more similar to those found in NCS.

CONCLUSIONS

The rates of DSM-III-R alcohol dependence found in AI-SUPERPFP were generally higher than US averages and justify continued attention and concern to alcohol problems in AI communities, but they are not nearly as high as those in other reports in the literature that rely on less stringent sampling methods. Furthermore, significant sociocultural influences on the correlates of alcohol dependence in AI communities are evident in these data, underscoring the need to appreciate the complex and varying influences on the patterning of alcohol problems in the diverse cultural contexts of the US.

Cultural specificity and comparison in psychiatric epidemiology: walking the tightrope in American Indian research

Increasingly, the mental health needs of populations are measured using large-sample surveys with standardized measures and methods. Such efforts, however, rarely include sufficient number of smaller, culturally defined populations to draw defensible conclusions about their needs. Furthermore, without some adaptation, the standardized methods and measures may yield invalid results in such populations. Using a recently completed psychiatric epidemiology and services study with American Indian populations as a case example, this paper outlines issues facing epidemiologists working in such culturally diverse contexts. The issues discussed include the following: (1) persuading the scientific community and potential sponsors that work with distinct or culturally defined populations is important; (2) framing research questions and activities to meet the needs of communities; (3) defining a population of inference; (4) balancing the needs for comparability and cultural specificity; (5) maximizing scientific validity in light of the challenges in sample acquisition; and (6) developing and implementing data collection methods that uphold scientific standards but are also realistic given the context. The authors draw on their experiences--most recently in the American Indian Service Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project (AI-SUPERPFP)--to illustrate these issues and suggest ways to address each. A goal of this paper is to challenge those invested in conducting culturally valid epidemiologic work in such populations to better articulate the nature of these efforts.

Aboriginal social organization, contemporary experience and American Indian adolescent alcohol use

OBJECTIVE

Anthropologists with an interest in American Indian alcohol use have long held that how native people drink has been conditioned by aspects of the social organization of their societies prior to the disruptive influences of European colonialism. Our goal in this article was to explicitly test the importance of these factors in four contemporary American Indian cultural groups.

METHOD

Using data on adolescent alcohol use drawn from the first full wave of the longitudinal Voices of Indian Teens Project (N = 1,651, 51% female), we tested whether patterns of quantity-frequency of alcohol use and the negative consequences of alcohol use predicted by social organzational variables were found among contemporary adolescents and, subsequently, whether these differences persisted when other, more proximal, variables were included.

RESULTS

Cultural differences appeared to account for a small percentage of the variance in both quantity-frequency of alcohol use and negative consequences in the initial steps of our analyses, but the pattern in these data was not consistent with the predictions of existing theories regarding aboriginal social organization. Moreover, these cultural differences were no longer significant in the final step of our analyses, suggesting that the cultural differences that did exist were better explained by other factors, at least among these adolescents.

CONCLUSIONS

Although these analyses did not indicate that culture was irrelevant in understanding adolescent alcohol use in American Indian communities, classic formulations of these effects were of limited utility in understanding the experiences of contemporary American Indian adolescents.

Drug use among two American Indian populations: prevalence of lifetime use and DSM-IV substance use disorders

American Indians (AIs) have often reported higher rates of drug use than have other racial/ethnic groups. However, the majority of these studies have focused on drug use among high school adolescents, with little attention to pathological use such as drug abuse or dependence. This study is among the first to report lifetime drug use and disorder (abuse/dependence) information from community samples of two culture groups of AI people-one in the Southwest (SW), one in the Northern Plains (NP)-ranging in age from 15 to 57 years old. Analyses were conducted within four groups: SW men, SW women, NP men, and NP women. Across the four groups, lifetime use rates for marijuana (36.9-57.5%), cocaine (4.3-21.5%), and inhalants (3.6-17.0%) were the highest drug use rates; heroin (0.5-2.1%), the lowest. Lifetime drug disorder rates were highest for marijuana (4.5-14.1%), cocaine (1.1-2.3%), and stimulants (0.7-1.7%). Lifetime polydrug use disorder rates from 1.2 to 4.5%. Women generally had lower prevalence rates than did men in their culture group. The SW women generally had the lowest rates of use and disorder. Lifetime use and disorder rates among the youngest group were often not different from rates of the older groups. Overall, 40-60% had never used any drugs; 85-95% had not developed any drug disorder. Despite widespread concern and rhetoric about drug problems among AIs, many who had used various drugs either were using them without serious consequences or had quit use altogether.

Structure of HIV knowledge, attitudes, and behaviors among American Indian young adults

Although present incidence and prevalence rates are still low, dramatic increases have been noted in the percentages of American Indians (AIs) diagnosed with HIV and AIDS, perhaps indicating groups that are increasing in their risk for the infection. High rates of sexually transmitted diseases among AIs who are 20-24 years old also raise concern about the vulnerability of these young adults. In a community-based group of 706 AI young adults, knowledge about sexuality and HIV transmission was rather low; efficacy and outcome expectations were high. Levels of some risk behaviors (e.g., exchanging sex for drugs or money) were low, while others (e.g., inconsistent condom use) were considerably higher. Knowledge and attitudes were modestly related; neither was related to risk behaviors. Suggestions are made about interventions focusing on specific high-risk groups and broad-based knowledge and skill-based interventions.

Tobacco use among American Indian adolescents: protective and risk factors

PURPOSE

To determine the prevalence of, and identify protective and risk factors for, current tobacco use among American Indian adolescents.

METHODS

Data from the Voices of Indian Teens Project were used to determine the prevalence of cigarette and smokeless tobacco (ST) use among a sample of 2390 American Indian adolescents, aged 13 to 20 years. Approximately 49% of the sample were female. Data were collected in Fall 1993 among participants from 10 high schools located in five western American Indian communities. The instrument consisted of scales that assessed psychosocial beliefs, attitudes, and behaviors as well as tobacco use. Logistic regression was used to identify protective and risk factors for tobacco use. A replication subsample was used to test the final models.

RESULTS

Approximately 50% of American Indian adolescents in this sample reported some type of cigarette use, and approximately 21% reported using smokeless tobacco. Academic orientation was the only protective factor for cigarette use that replicated in both subsamples. Death/loss and other stressful life events were the risk factors for cigarette and/or ST use that replicated in both subsamples.

CONCLUSIONS

The prevalence of tobacco use was high in this sample of American Indian adolescents. Several risk and protective factors were identified, the knowledge of which may inform preventive interventions in this population.

Sequences of substance use among American Indian adolescents

OBJECTIVE

To determine whether the predominant pattern of the sequence of use of different classes of substances among a large sample of American Indian (AI) adolescents is consistent with Stage Theory [i.e., (1) alcohol, (2) marijuana, (3) other illicit drugs, and (4) cocaine].

METHOD

Data came from surveys completed by 1,562 AI high school students in 1993. Pairwise comparisons of age of first use for alcohol, marijuana, inhalants, cocaine, and other illicit drugs were examined, as were the prevalence rates of specific sequences of substance use.

RESULTS

Thirty-five percent of the AI youths who had used both alcohol and marijuana reported using alcohol first. Seventy-five percent of youths who had used three or more substances reported a sequence of first use that was inconsistent with Stage Theory. However, a general pattern of using alcohol, marijuana, and/or inhalants prior to the use of cocaine and other illicit drugs was observed. Sequences of first use varied by gender, age of first substance use, community, and number of classes of substances used.

CONCLUSIONS

To enhance the validity of Stage Theory for AI adolescents, the authors recommend its revision to include alcohol, marijuana, and inhalants as initiating substances.

Post-operative endophthalmitis: the application of hazard analysis critical control points (HACCP) to an infection control problem

Hazard analysis critical control points (HACCP) is a quality assurance system widely used in the food industry to ensure safety. We adopted the HACCP approach when conventional infection control measures had failed to solve an ongoing problem with an increased incidence of postoperative endophthalmitis, and our ophthalmology unit was threatened with permanent cessation of intraocular surgery. Although time-consuming, the result was an entirely new set of protocols for the care of patients undergoing intraocular surgery, the development of an integrated care pathway, and a comprehensive and robust audit programme, which enabled intraocular surgery to continue in a new spirit of confidence. HACCP methodology has so far been little used in healthcare, but it might be usefully applied to a variety of apparently intractable infection control problems.