Prevention of alcohol misuse: a review of health promotion efforts among American Indians

Pre-pregnancy and Prenatal Alcohol use Among American Indian and Alaska Native and Non-Hispanic White Women: Findings from PRAMS in Five States

INTRODUCTION

Estimates of prenatal alcohol use among American Indian and Alaska Native (AI/AN) women are limited. This study sought to characterize pre-pregnancy and prenatal alcohol use among AI/AN women in the Pregnancy Risk Assessment Monitoring System (PRAMS) dataset, evaluate variation in alcohol use by state and rural/urban residence, and evaluate associations between potential risk factors and prenatal alcohol use among AI/AN and non-Hispanic white (NHW) women.

METHODS

We pooled PRAMS data from five states (Alaska, New Mexico, Oklahoma, South Dakota and Washington) from 2015 to 2017. We estimated the prevalence of pre-pregnancy and pregnancy risk factors, and alcohol use by race and examined alcohol use by state and rural/urban residence among AI/AN women. We conducted bivariate and multivariable logistic regression modelling to estimate the association between each risk factor of interest and the odds of prenatal alcohol use for AI/AN and NHW women.

RESULTS

AI/AN women were less likely to report pre-pregnancy alcohol use compared to NHW women (56% vs. 76%, p < 0.0001). Among women who reported drinking pre-pregnancy, AI/AN women were more likely than NHW women to report drinking 1 or more drinks during pregnancy (4.3% vs. 2.4, p = 0.0049). For AI/AN women, older age and experiencing homelessness (aOR = 2.76; 95% CI 1.16-6.55) increased odds of prenatal alcohol use. For NHW women, having a college education (aOR = 4.06; 95% CI 1.19-13.88) and urban residence (aOR = 1.88; 95% CI 1.40-2.53) increased odds of prenatal alcohol use.

CONCLUSIONS

Factors associated with prenatal alcohol use differ between AI/AN women and NHW women, suggesting the need for tailored interventions.

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.

Substance Use Prevention Programs for Indigenous Adolescents in the United States of America, Canada, Australia and New Zealand: Protocol for a Systematic Review

BACKGROUND

Indigenous adolescents are at a higher risk of experiencing harms related to substance use compared with their non-Indigenous counterparts as a consequence of earlier onset and higher rates of substance use. Early onset of substance use has been identified as a risk factor for future substance use problems and other health, social, and family outcomes. Therefore, prevention of substance use among adolescents has been identified as a key area to improve health of Indigenous Peoples. Evidence exists for the effectiveness of prevention approaches for adolescents in mainstream populations and, most recently, for the use of computer- and Internet-delivered interventions to overcome barriers to implementation. However, there is currently no conclusive evidence about the effectiveness of these approaches for Indigenous adolescents.

OBJECTIVE

The purpose of this review is to synthesize the international evidence regarding the effectiveness of substance use prevention programs for Indigenous adolescents in the United States, Canada, Australia, and New Zealand.

METHODS

A total of 8 peer-reviewed databases and 20 gray literature databases will be searched, using search terms in line with the aims of this review and based on previous relevant reviews of substance use prevention. Studies will be included if they evaluate a substance use prevention program with Indigenous adolescents (aged 10 to 19 years) as the primary participant group and are published between January 1, 1990 and August 31, 2017.

RESULTS

A narrative synthesis will be provided about the effectiveness of the programs, the type of program (whether culture-based, adapted, or unadapted), delivery of the program (computer- and Internet-delivered or traditional), and the setting in which the programs are delivered (community, school, family, clinical, or a combination).

CONCLUSIONS

The study will identify core elements of effective substance use prevention programs among Indigenous adolescents and appraise the methodological quality of the studies. This review will provide researchers, policy makers, and program developers with evidence about the potential use of prevention approaches for Indigenous adolescents.

Similarities and Differences Across Cultures: Questions to Inform a Third Generation for Health Promotion Research

The increasing diversity of American communities raises an important question about the efficiency, appropriateness, and feasibility of tailoring messages and intervention strategies to target groups identified by race and ethnicity. To explore this issue, This article distinguishes race and ethnicity from culture and then discusses four questions: (1) What is the meaning of culture in health promotion? (2) What is the role of culture in understanding health behavior? (3) What is the role of culture in the design of interventions? and (4) What do the relationships of culture to behavior and to intervention mean for cultural tailoring? Based on this analysis, the authors suggest that effective health promotion will tailor interventions by culture as necessary but reach across cultures when possible and appropriate. A framework is presented to assess the need for cultural tailoring, and a new generation of health promotion research is proposed to facilitate cross-cultural comparisons.

Measuring Bicultural Ethnic Identity among American Indian Adolescents

Based on the premise that ethnic identity provides a fruitful approach to exploring issues related to ethnicity, an empirically based strategy was used to develop a measure of ethnic identity among American Indian adolescents. Because American Indians live in two worlds, a bicultural approach was drawn on to measure the degree that respondents identified with Indian culture and with the mainstream or White culture. An exploratory factor analysis was used to examine the structure of ethnic identity among Indian adolescents and the resulting models were tested with confirmatory factor analysis. A scale for measuring bicultural ethnic identity was developed and the reliability and validity of the scale was assessed.

Alcohol Policy Issues for Indigenous People in the United States, Canada, Australia and New Zealand

This paper reviews the literature on alcohol consumption, alcohol-related problems, and national and local policy issues for indigenous people in four developed countries (United States, Canada, Australia and New Zealand). The growth of domestic self-determination and self-management policies within these countries has had an impact on the relationships between these groups and their national governments, which raises a number of questions regarding the influence of national alcohol policies on indigenous citizens. National “native” policies as well as discriminatory alcohol prohibitions have had long-standing effects, influencing indigenous responses to contemporary interventions in alcohol misuse. While national alcohol policies have had mixed impact, indigenous groups have focused on their own attempts at control, which emphasize local controls over supply; these are particularly prevalent in the far north of Canada and in Australia. Local control policies have been well evaluated in Australia, providing an evidence-based grounding for further interventions.

The Community Pulling Together: A Tribal Community–University Partnership Project to Reduce Substance Abuse and Promote Good Health in a Reservation Tribal Community

Alcohol and drug abuse are major areas of concern for many American Indian=Alaska Native communities. Research on these problems has often been less than successful, in part because many researchers are not sensitive to the culture and traditions of the tribes and communities with which they are working. They alsooften fail to incorporate tribal customs, traditions, and values into the interventions developed to deal with substance abuse. The authors describe the use of community-based participatory research and tribal participatory research approaches to develop a culturally sensitive substance abuse prevention program for Native youth. This project, The Community Pulling Together: Healing of the Canoe, is a collaboration between the Suquamish Tribe and the Alcohol and Drug Abuse Institute at the University of Washington, Seattle, Washington.

Racial/ethnic differences in alcohol-related suicide: a call for focus on unraveling paradoxes and understanding structural forces that shape alcohol-related health

A substantial proportion of injuries worldwide are attributable to alcohol consumption, and US estimates indicate that the drinking patterns of racial/ethnic groups vary considerably. The authors reviewed evidence from 19 publications regarding racial/ethnic differences in overall alcohol-attributable injury as well as percent blood alcohol content positivity for injury deaths in the United States. They found that Native Americans evidence higher rates of alcohol-attributable motor vehicle crash fatality, suicide, and falls compared with other racial/ethnic groups; conversely, Asians evidence lower rates of alcohol-attributable injury than other racial/ethnic groups. The rate of alcohol positivity and intoxication among Hispanics is disproportionately high relative to estimates of alcohol use. Black subgroups also evidence higher rates of alcohol positivity than would be expected given estimates of alcohol use, including for alcohol positivity among drivers of fatally injured black children and homicide. These findings highlight the continued need for public health focus on Native American populations with respect to alcohol consumption and injury. Further, the disparity in alcohol-attributable injury mortality among black and Hispanic groups relative to their reported rates of alcohol consumption is an overlooked area of research. The authors review potential social determinants of racial/ethnic disparities in alcohol-attributable injuries and identify directions for further research on these patterns.

Exploring Indigenous Identities of Urban American Indian Youth of the Southwest

This study examined the indigenous identities of urban American Indian youth using measures related to three theoretical dimensions of Markstrom's identity model: identification (tribal and ethnic heritage), connection (reservation ties), and involvement in traditional cultural practices and spirituality. Data came from self-administered questionnaires completed by 142 urban American Indian middle school students in a southwestern metropolitan area with the largest urban American Indian population in the United States. Using both quantitative and qualitative measures, descriptive statistics showed most youth were connected to all three dimensions of indigenous identity. Hierarchical regression analyses showed that youth with the strongest sense of American Indian ethnic identity had native fathers and were heavily involved in traditional cultural practices and spirituality. Although urban American Indians may face challenges in maintaining their tribal identities, the youth in this study appeared strongly moored to their native indigenous heritage. Implications for future research are discussed.

Critiquing fetal alcohol syndrome health communication campaigns targeted to American Indians

It is widely recognized American Indians and Alaska Natives have suffered from far worse health status than that of other Americans. Health communication campaigns directed to American Indians and Alaska Natives and their outcomes must be grounded in an understanding of the historical and ongoing marginalization and cultural dislocation of these groups. The authors draw upon the specific case of health communication campaigns to reduce cases of fetal alcohol syndrome among American Indians and Alaska Natives. Counteracting stereotyping of American Indians and alcohol consumption by mainstream American popular culture and mediated discourses, coverage of fetal alcohol syndrome in the media is assessed. The study analyzes 429 American Indian news articles from 1990 to 2010. Mainstream American and American Indian media should cover health concerns such as fetal alcohol syndrome more extensively. Researchers, health communication campaign developers, health policy makers, and mainstream media must be knowledgeable about American Indian and Alaskan Native identity, cultures, and history, and diversity across Nations. Last, and most important, health communication strategists and health policy makers must welcome American Indians and Alaska Natives to take leadership roles in communicating culture- and Nation-specific health campaign strategies to eliminate health disparities.

Preferred drug resistance strategies of urban American Indian youth of the southwest

This study explored the drug resistance strategies that urban American Indian adolescents consider the best and worst ways to respond to offers of alcohol, cigarettes, and marijuana. Focus group data were collected from 11 female and 9 male American Indian adolescents attending urban middle schools in the southwest. The youth were presented with hypothetical substance offer scenarios and alternative ways of responding, based on real-life narratives of similar youth. They were asked to choose a preferred strategy, one that would work every time, and a rejected strategy, one they would never use. Using eco-developmental theory, patterns in the preferred and rejected strategies were analyzed to identify culturally specific and socially competent ways of resisting substance offers. The youth preferred strategies that included passive, non-verbal strategies like pretending to use the substance, as well as assertive strategies like destroying the substance. The strategies they rejected were mostly socially non-competent ones like accepting the substance or responding angrily. Patterns of preferred and rejected strategies varied depending on whether the offer came from a family member or non-relative. These patterns have suggestive implications for designing more effective prevention programs for the growing yet underserved urban American Indian youth population.

"Alcohol is something that been with us like a common cold": community perceptions of American Indian drinking

This study examined tribal members' perspectives on alcohol, risk factors, consequences, and community responses. Focus groups were conducted with five American Indian tribes between 1997 and 2001. Participants were knowledgeable of the cultural lives of their reservation communities. Although there was agreement regarding the pervasiveness of heavy drinking, participants reported different opinions about the meaning of alcohol and appropriate intervention strategies. Three dilemmas were identified, suggesting that community ambivalence may serve as a barrier to reducing problem drinking. Implications, limitations, and future research directions are discussed. The study was funded by the National Institute on Alcohol Abuse and Alcoholism.

American Indian/Alaska Native alcohol-related incarceration and treatment

American Indian/Alaska Natives have high rates of alcohol-related arrests and are overrepresented in justice systems. To understand the relationship between alcohol dependence, treatment, and alcohol-related incarceration, this study queried American Indian/Alaska Natives currently in remission from alcohol dependence. Participants reported receiving 0 to 43 treatment experiences. Moreover, participants had a significantly greater number of alcohol-related incarcerations than all other treatments combined. These findings underline the importance of making alcohol treatment available within criminal justice settings.

Native Americans and alcohol: past, present, and future

Native Americans have higher rates of alcohol use, frequency of use, and increased rates of fetal alcohol syndrome, compared with other ethnic groups (J. Hisnanick, 1992; P. A. May, 1996; J. M. Wallace et al., 2003). High prevalence rates of alcohol misuse among Native Americans must be understood in light of their unique history, which has resulted in trauma and exposure to many risk factors for problem alcohol use. Many risk factors have been identified in the general population; however, only some of these risk factors have been examined among Native American populations. The unique history and world view of Native Americans mean that, often, risk factors operate differently from the way they do in other populations. The authors discuss interventions and promising treatments.

Aboriginal community alcohol harm reduction policy (ACAHRP) project: a vision for the future

Four First Nation communities in Ontario, Canada, formulated alcohol management policies between 1992 and 1994. An alcohol management policy is a local control option to manage alcohol use in recreation and leisure areas. Survey results indicate that decreases in alcohol use-related problems related to intoxication, nuisance behaviors, criminal activity, liquor license violations, and personal harm were perceived to have occurred. Furthermore, having policy regulations in place did not have an adverse effect on facility rentals. Band administrators and facility staff in each community felt the policy had had a positive effect on events at which alcohol was sold or served.

Organization and financing of alcohol and substance abuse programs for American Indians and Alaska Natives

OBJECTIVES

Although American Indians and Alaska Natives have high rates of substance abuse, few data about treatment services for this population are available. We used national data from 1997-2002 to describe recent trends in organizational and financial arrangements.

METHODS

Using data from the Indian Health Service (IHS), the Substance Abuse and Mental Health Services Administration, the National Institute on Alcohol Abuse and Alcoholism, the Henry J. Kaiser Family Foundation, and the Census Bureau, we estimated the number of American Indians served by substance abuse treatment programs that apparently are unaffiliated with either the IHS or tribal governments. We compared expected and observed IHS expenditures.

RESULTS

Half of the American Indians and Alaska Natives treated for substance abuse were served by programs (chiefly in urban areas) apparently unaffiliated with the IHS or tribal governments. IHS substance abuse expenditures were roughly what we expected. Medicaid participation by tribal programs was not universal.

CONCLUSIONS

Many Native people with substance abuse problems are served by programs unaffiliated with the IHS. Medicaid may be key to expanding needed resources.

American Indians and suicide: a neglected area of research

Suicide is a major public health problem for American Indians in the United States. Published studies indicate that American Indians experience the highest rate of suicide of all ethnic groups in the United States. This article synthesizes the epidemiology and risk factors associated with suicide among American Indians, barriers to research, prevention, mental-health services, and recommendations for research and practice. The authors' recommendations arise from the current literature as well as interviews with practitioners and academics in the field of suicide prevention. The authors present significant substantive and methodological issues that inform research on suicide in American Indian communities, as well as existing contemporary interventions. Overall, socioeconomic characteristics, substance abuse, barriers to mental health services and acculturation play a role in the occurrence of suicide in American Indian communities. These findings suggest suicide is an important public health problem that needs to be addressed for American Indians.

Preventing fetal alcohol spectrum disorder in Aboriginal communities: a methods development project

The authors describe their three-year project working collaboratively with Aboriginal communities to prevent fetal alcohol spectrum disorder.

Prevention of adolescent alcohol problems in special populations

Research on the prevention of alcohol abuse in America has only recently begun to consider the needs of special populations. This chapter will consider alcohol prevention as a function of four major special population divisions: gender, ethnicity, region (population density), and socioeconomic status. Specific ethnic groups examined will include Hispanics, African-Americans, Asian-Americans, and Native Americans. In general, there is some support for the utility of current alcohol prevention approaches on special populations. Much population-specific work completed to date has not been rigorously designed or evaluated, though it appears likely that partnering with population gatekeepers and showing cultural respect and sensitivity to the population, and providing material that is relevant to the population's adaptation to their environment are essential.

Preventing Substance Abuse in American Indian and Alaska Native Youth: Promising Strategies for Healthier Communities

Substance abuse has had profoundly devastating effects on the health and well-being of American Indians and Alaska Natives. A wide variety of intervention methods has been used to prevent or stem the development of alcohol and drug problems in Indian youth, but there is little empirical research evaluating these efforts. This article is an overview of the published literature on substance use prevention among Indian adolescents, providing background epidemiological information, a review of programs developed specifically for Indian adolescents, and recommendations for the most promising prevention strategies currently in practice.

Tribal participatory research: mechanisms of a collaborative model

Although much social science research has been conducted within American Indian and Alaska Native (AIAN) communities, relatively little research has been conducted by or for those communities. We describe an approach that facilitates the active involvement of AIAN communities in the research process, from conceptualizing the issues to be investigated to developing a research design, and from collecting, analyzing, and interpreting the data to disseminating the results. The Tribal Participatory Research (TPR) approach is consistent with recent developments in psychology that emphasize the inclusion of community members and the social construction of knowledge. We describe the foundations of the approach and present specific mechanisms that can be employed in collaborations between researchers and AIAN communities. We conclude with a discussion of the implications of the use of TPR regarding project timelines and budgets, interpretation of the data, and ultimately the relationships between tribes and researchers.

What works in prevention. Principles of effective prevention programs

The high prevalence of drug abuse, delinquency, youth violence, and other youth problems creates a need to identify and disseminate effective prevention strategies. General principles gleaned from effective interventions may help prevention practitioners select, modify, or create more effective programs. Using a review-of-reviews approach across 4 areas (substance abuse, risky sexual behavior, school failure, and juvenile delinquency and violence), the authors identified 9 characteristics that were consistently associated with effective prevention programs: Programs were comprehensive, included varied teaching methods, provided sufficient dosage, were theory driven, provided opportunities for positive relationships, were appropriately timed, were socioculturally relevant, included outcome evaluation, and involved well-trained staff. This synthesis can inform the planning and implementation of problem-specific prevention interventions, provide a rationale for multi-problem prevention programs, and serve as a basis for further research.

Similarities and Differences across Cultures: Questions to Inform a Third Generation for Health Promotion Research

The increasing diversity of American communities raises an important question about the efficiency, appropriateness, and feasibility of tailoring messages and intervention strategies to target groups identified by race and ethnicity. To explore this issue, this article distinguishes race and ethnicity from culture and then discusses four questions: (1) What is the meaning of culture in health promotion? (2) What is the role of culture in understanding health behavior? (3) What is the role of culture in the design of interventions? and (4) What do the relationships of culture to behavior and to intervention mean for cultural tailoring? Based on this analysis, the authors suggest that effective health promotion will tailor interventions by culture as necessary but reach across cultures when possible and appropriate. A framework is presented to assess the need for cultural tailoring, and a new generation of health promotion research is proposed to facilitate cross-cultural comparisons.