Higher glucose and insulin responses to a mixed meal are associated with increased risk of diabetic retinopathy in Indigenous Americans

PURPOSE

Prior research has focused on glucose/insulin responses to meal challenges to create personalized diets to improve health, though it is unclear if these responses predict chronic diseases. We aimed to identify glucose and insulin responses to a mixed meal tolerance test (MMTT) that predict the development of diabetic retinopathy (DR) and compare the predictive abilities with the oral glucose tolerance test (OGTT).

METHODS

Indigenous American adults without diabetes (n = 168) underwent a 4-h MMTT, body composition assessment, and a 3-h OGTT at baseline. During follow-up (median 13.4 years), DR was diagnosed by direct ophthalmoscopy (n = 28) after onset of type 2 diabetes. Total and incremental area under the curve (AUC and iAUC) were calculated from glucose/insulin responses after the MMTT and OGTT.

RESULTS

In separate Cox proportional hazards models adjusted for age, sex, and body fat (%), MMTT glucose AUCs (180-min and 240-min) and iAUC (180-min) predicted DR (HR 1.50, 95% CI 1.06, 2.12; HR 1.50, 95% CI 1.05, 2.14; HR 1.58, 95% CI 1.01, 2.46). The predictive abilities were better than the fasting OGTT glucose (p < 0.01) but similar to the 120-min OGTT glucose (p = 0.53). MMTT insulin AUCs (180-min and 240-min) and iAUC (180-min) also predicted DR (HR 1.65, 95% CI 1.09, 2.51; HR 1.58, 95% CI 1.00, 2.35; HR 1.53 95% CI 1.06, 2.22) while insulin AUC and iAUC from the OGTT did not (p > 0.05).

CONCLUSIONS

Higher MMTT glucose and insulin responses predicted DR and were comparable to the OGTT, supporting the use of a meal challenge for precision nutrition.

TRIAL REGISTRATIONS

Clinical Trial Registry: ClinicalTrials.gov identifier: NCT00340132, NCT00339482.

Integrating Community-Engagement and a Multiphase Optimization Strategy Framework: Adapting Substance Use Prevention for American Indian Families

Initiation of substance use often occurs earlier among American Indian (AI) youth than among other youth in the USA, bringing increased risk for a variety of poor health and developmental outcomes. Effective prevention strategies are needed, but the evidence base remains thin for this population. Research makes clear that prevention strategies need to be culturally coherent; programs with an evidence base in one population cannot be assumed to be effective in another. However, guidance on effective adaptation is lacking. This paper reports on cultural adaptation of an evidence-based program utilizing the multiphase optimization strategy (MOST) framework embedded within a community-engaged process to evaluate intervention components. The Strengthening Families Program for Parents and Youth 10-14 was adapted to become the Thiwáhe Gluwáš'akapi Program for American Indian youth and families. Three program components were evaluated for their effectiveness with regard to outcomes (youth substance use, theoretical mediators of program effects on substance use, and program attendance) in a sample of 98 families (122 youth and 137 adults). Consistent with the MOST framework, the value of components was also evaluated with regard to efficiency, economy, and scalability. Expanding on the MOST framework for cultural adaptation, we also considered the results of the MOST findings regarding the acceptability of each component from the perspectives of community members and participants. The promise of a strategic component-based approach to adapting evidence-based interventions is discussed, including the benefits of engaging community to ensure relevance and considering both cultural and scientific rationale for each component to enhance impact.

Self-Efficacy About Sexual Risk/Protective Behaviors: Intervention Impact Trajectories Among American Indian Youth

For adolescents, normative development encompasses learning to negotiate challenges of sexual situations; of special importance are skills to prevent early pregnancy, HIV, and other sexually transmitted diseases. Disparities in sexual risk among American Indian youth point to the importance of intervening to attenuate this risk. This study explored the impact of Circle of Life (COL), an HIV prevention intervention based on social cognitive theory, on trajectories of self-efficacy (refusing sex, avoiding sexual situations) among 635 students from 13 middle schools on one American Indian reservation. COL countered a normative decline of refusal self-efficacy among girls receiving the intervention by age 13, while girls participating at age 14 or older, girls in the comparison group, and all boys showed continuing declines.

Longitudinal Patterns of Stages of Change for Exercise and Lifestyle Intervention Outcomes: An Application of Latent Class Analysis with Distal Outcomes

Stages of change measure an individual's readiness to alter a health behavior. This study examined the latent longitudinal patterns of stages of change (SoC) for regular exercise over time among individuals participating in a lifestyle intervention project. It also investigated the association between the longitudinal patterns of SoC and intervention outcomes using a new statistical method to assess the relationship between latent class membership and distal outcomes. We analyzed data from the Special Diabetes Program for Indians Diabetes Prevention Program, a lifestyle intervention program to prevent diabetes among American Indians and Alaska Natives. Latent class analysis (LCA) was conducted to identify the longitudinal patterns of SoC for regular exercise reported at three time points. LCA with distal outcomes was performed to investigate the associations between latent class membership and behavioral changes after the intervention. The parameters and standard errors of the LCA with distal outcomes models were estimated using an improved three-step approach. Three latent classes were identified: Pre-action, Transition, and Maintenance classes. The Transition class, where stage progression occurred, had the greatest improvements in physical activity and weight outcomes at both time points post-baseline among female participants. It also had the largest improvements in weight outcomes among male participants. Furthermore, the Pre-action class had more attenuation in the improvements they had achieved initially than the other two classes. These findings suggest the potential importance of motivating participants to modify their readiness for behavioral change in future lifestyle interventions.

Effectiveness of Circle of Life, an HIV-preventive intervention for American Indian middle school youths: a group randomized trial in a Northern Plains tribe

OBJECTIVES

We assessed the effectiveness of Circle of Life (COL), an HIV-preventive intervention developed specifically for American Indian and Alaska Native (AI/AN) middle school youths.

METHODS

By partnering with a tribal community, we conducted a longitudinal wait-listed group randomized trial with 635 seventh and eighth graders in 13 schools of a Northern Plains tribe. We surveyed participants at baseline, 3 months, and 12 months from 2006 to 2007.

RESULTS

COL was found to increase HIV knowledge in the short term, but had no effect on sexual activity compared with those who did not receive it. However, COL was found to be effective for delaying the onset of sexual activity, with the greatest reduction in risk occurring for those receiving COL at early ages.

CONCLUSIONS

Community partnership was key to successful project design, implementation, and analysis. The project confirmed the importance of the timing of interventions in early adolescence. COL may be a key resource for reducing sexual risk among AI/AN youths.

Trajectories of substance use among young American Indian adolescents: patterns and predictors

Substance use often begins earlier among American Indians compared to the rest of the United States, a troubling reality that puts Native youth at risk for escalating and problematic use. We need to understand more fully patterns of emergent substance use among young American Indian adolescents, risk factors associated with escalating use trajectories, and protective factors that can be parlayed into robust prevention strategies. We used growth mixture modeling with longitudinal data from middle-school students on a Northern Plains reservation (Wave 1 N = 381, M age at baseline = 12.77, 45.6% female) to identify subgroups exhibiting different trajectories of cigarette, alcohol, and marijuana use. We explored how both risk (e.g., exposure to stressful events, deviant peers) and protective (e.g., positive parent-child relationships, cultural identity) factors were related to these trajectories. For all substances, most youth showed trajectories characterized by low rates of substance use (nonuser classes), but many also showed patterns characterized by high and/or escalating use. Across substances, exposure to stress, early puberty, and deviant peer relationships were associated with the more problematic patterns, while strong relationships with parents and prosocial peers were associated with nonuser classes. Our measures of emergent cultural identity were generally unrelated to substance use trajectory classes among these young adolescents. The findings point to the importance of early substance use prevention programs for American Indian youth that attenuate the impact of exposure to stressful events, redirect peer relationships, and foster positive parent influences. They also point to the need to explore more fully how cultural influences can be captured.

Toddler socioemotional behavior in a northern plains Indian tribe: associations with maternal psychosocial well-being

M.C. Sarche, C.D. Croy, C. Big Crow, C. Mitchell, and P. Spicer (2009) provided first-ever information relating the socioemotional development of American Indian toddlers to the immediate context of their mothers' lives. The current study sought to replicate and build on their earlier work by examining the impact of additional maternal risk factors, identified in previous research with non-American Indian populations, on the development of American Indian toddlers: maternal depression, negative social influences, and mother's feelings of isolation. At 27 months, American Indian mothers (N = 110) completed the Parent Demographic Questionnaire, which measured maternal psychosocial characteristics (e.g., depressed affect, social support, drug and alcohol use, isolation) and demographics. Mothers also completed the Infant-Toddler Social Emotional Assessment (A.S. Carter & M.J. Briggs-Gowan, 2006) and the Parent-Child Dysfunctional Interaction subscale of the Parenting Stress Index (R.R. Abidin, 1995, 1997). Some results replicated the original study, but others did not. Reports of a dysfunctional mother-child relationship related to externalizing and internalizing problems, replicating the earlier study. This study also found associations between a dysfunctional mother-child relationship and socioemotional competence as well as dysregulation. The previous finding of a relationship between American Indian identity and socioemotional competence was supported. Adding the effects of maternal depressed affect and isolation significantly increased prediction of toddler behavior problems.

Lifetime prevalence of posttraumatic stress disorder in two American Indian reservation populations

Posttraumatic stress disorder (PTSD) has been found to be more common among American Indian populations than among other Americans. A complex diagnosis, the assessment methods for PTSD have varied across epidemiological studies, especially in terms of the trauma criteria. Here, we examined data from the American Indian Service Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project (AI-SUPERPFP) to estimate the lifetime prevalence of PTSD in two culturally distinct American Indian reservation communities, using two formulas for calculating PTSD prevalence. The AI-SUPERPFP was a cross-sectional probability sample survey conducted between 1997 and 2000. Southwest (n = 1,446) and Northern Plains (n = 1,638) tribal members living on or near their reservations, aged 15-57 years at time of interview, were randomly sampled from tribal rolls. PTSD estimates were derived based on both the single worst and 3 worst traumas. Prevalence estimates varied by ascertainment method: single worst trauma (lifetime: 5.9% to 14.8%) versus 3 worst traumas (lifetime, 8.9% to 19.5%). Use of the 3-worst-event approach increased prevalence by 28.3% over the single-event method. PTSD was prevalent in these tribal communities. These results also serve to underscore the need to better understand the implications for PTSD prevalence with the current focus on a single worst event.

Impact of targeted health promotion on cardiovascular knowledge among American Indians and Alaska Natives

The National Heart, Lung, and Blood Institute developed the Honoring the Gift of Heart Health (HGHH) curriculum to promote cardiovascular knowledge and heart-healthy lifestyles among American Indians and Alaska Natives (AI/ANs). Using data from a small randomized trial designed to reduce diabetes and cardiovascular disease (CVD) risk among overweight/obese AI/ANs, we evaluated the impact of an adapted HGHH curriculum on cardiovascular knowledge. We also assessed whether the curriculum was effective across levels of health literacy (defined as the 'capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions'). We examined change in knowledge from baseline to 3 months for two groups: HGHH (N = 89) and control (N = 50). Compared with controls, HGHH participants showed significant improvement in heart attack knowledge and marginally significant improvement in stroke and general CVD knowledge. HGHH participants attending ≥1 class showed significantly greater improvement than controls on all three measures. Although HGHH participants with inadequate health literacy had worse heart attack and stroke knowledge at baseline and 3 months than did participants with adequate skills, the degree of improvement in knowledge did not differ by health literacy level. HGHH appears to improve cardiovascular knowledge among AI/ANs across health literacy levels.

Epidemiology and etiology of substance use among American Indians and Alaska Natives: risk, protection, and implications for prevention

BACKGROUND

The epidemiology and etiology of substance use and disorder in American Indian and Alaska Native (AI/AN) communities have received increasing attention over the past 25 years and accumulating evidence provides important insights into substance use patterns in these populations.

OBJECTIVES AND METHODS

We provide a descriptive sketch of the AI/AN population in the United States today, present a brief review of the literature on the epidemiology and etiology of substance use within these populations, and discuss key implications of this literature for prevention efforts.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Patterns of alcohol use and abuse in AI/AN populations are complex and vary across cultural groups, but alcohol clearly impacts both physical health and mental health within these communities. Tobacco use - and associated health consequences - is typically higher in these populations than among other US groups, although significant variation across Native communities is apparent here as with alcohol. Evidence regarding drug use and disorder is less extensive and thus less conclusive, but evidence demonstrates higher rates of use as well. Etiological explanations for substance use and disorder cut across individual characteristics (e.g., genetics) or experiences (e.g., exposure to trauma), to social contexts (e.g., family disruption), and to cultural factors (e.g., historical trauma). Protective factors likely cut across these multiple levels as well and deserve more focused attention for informing prevention efforts. The development of effective prevention strategies, built through collaboration between researchers and Native communities, drawing from the wisdom of both, is a high priority.

Sensation-seeking predicts initiation of daily smoking behavior among American Indian high school students

PURPOSE

American Indian (AI) youth have a high risk of smoking initiation. Sensation-seeking, defined as the tendency to seek novel and thrilling experiences, has been associated with smoking initiation in other groups but has never been examined in AI youth.

METHODS

Data were from the Voices of Indian Teens Project (VOICES), a longitudinal study of AI youth from seven high schools in four AI communities in the western United States. Participants completed annual surveys in school over a three-year period. Our sample comprised 764 students who were non-smokers at baseline. Smoking initiation was defined as endorsement of daily smoking after baseline. We used binary logistic regression to evaluate the association of baseline sensation-seeking with odds of daily smoking initiation, stratified by gender.

RESULTS

Participants were 353 males and 411 females aged 13 to 21years at baseline. After adjusting for covariates, baseline sensation-seeking correlated with smoking initiation differently in males and females. Sensation-seeking did not predict daily smoking in males. Among females, however, higher sensation-seeking scores at baseline predicted daily smoking in both the unadjusted (odds ratio=1.4; 95% CI=1.1-1.8; p=0.005) and covariate-adjusted (odds ratio=1.3; 95% CI=1.0-1.6; p=0.04) models.

CONCLUSION

Gender-specific prevention programs may be warranted in addressing different risk-factor profiles in this high-risk population.

Patterns of substance use initiation among young adolescents in a Northern Plains American Indian tribe

BACKGROUND

Substantial evidence documents problematic substance use in Northern Plains American Indian communities. Studies suggest that disparities can be traced to disproportionate rates of early substance use, but most evidence comes from the retrospective reports of adults or older adolescents.

OBJECTIVE

To use a prospective longitudinal design to examine substance use initiation patterns as they emerge among young American Indian adolescents.

METHODS

Four waves of data were collected across three consecutive school years from middle school students on a Northern Plains reservation (N = 450). Discrete-time survival analyses were used to estimate risks of initiation of cigarettes, alcohol, and marijuana from age 10 to 13.

RESULTS

Risk for cigarette initiation was relatively high at age 10 and stable until age 13. Marijuana risk was low at age 10 but increased sharply by age 12. Alcohol initiation lagged, not surpassing risk for cigarette initiation until age 13 and remaining below risk for marijuana initiation throughout middle school. Hazards for girls trended higher than those for boys across all substances, but differences did not reach significance.

CONCLUSION

Initiation patterns among these American Indian adolescents differed from patterns reported in other US groups, particularly with respect to deviation from the sequence characterized the initiation of marijuana before alcohol that is predicted by the gateway theory.

SCIENTIFIC SIGNIFICANCE

Findings suggest that prevention efforts with youth in this community should begin early with a primary focus on marijuana use. They also suggest the importance of examining sequences of substance initiation among youth in other American Indian communities.

Mechanisms underlying the relationship between health literacy and glycemic control in American Indians and Alaska Natives

OBJECTIVE

Research suggests that health literacy (HL) is associated with clinical outcomes. Few studies, however, have examined the mechanisms accounting for this relationship. To understand why HL is related to outcomes, we tested a theoretical framework proposing that diabetes-related knowledge and behavior mediate (explain) the relationship between HL and glycemic control (i.e., A1c).

METHODS

Analyses used baseline data from the Special Diabetes Program for Indians Healthy Heart Project (N=2594), an intervention to reduce cardiovascular risk among American Indians/Alaska Natives (AI/ANs) with diabetes. Three nested structural equation models tested the theoretical framework.

RESULTS

Model 1 demonstrated that participants with stronger HL skills had better glycemic control. Model 2 tested whether diabetes-related behaviors accounted for this relationship. Self-monitoring of blood glucose significantly mediated the HL-A1c relationship. Model 3 examined the role of diabetes knowledge, showing that it mediated the relationship between HL and dietary behavior. When knowledge was included, behavior was no longer a significant mediator, suggesting that knowledge was the main driver of the relationship between HL with A1c.

CONCLUSION

Interventions to improve knowledge may be particularly important in enhancing outcomes among AI/ANs with diabetes.

PRACTICE IMPLICATIONS

Strategies known to enhance patient comprehension may enable low-literate patients to develop needed diabetes knowledge.

Circle of Life HIV/AIDS-prevention intervention for American Indian and Alaska Native youth

This article describes the objectives, theoretical bases, development process, and evaluation efforts to-date for the Circle of Life (COL) curricula, HIV/AIDS prevention interventions designed for American Indian and Alaska Native (AI/AN) youth. The curricula are based on Indigenous models of learning and behavior encompassing concepts of Western theories of health behavior change. The curricula underwent extensive national and community review. Subsequent advances include the development of a computer-based version of the intervention.

Trajectories of cognitive development among American Indian young children

Children who begin kindergarten with stronger skills learn faster than do those who enter with lower skills. Minority children tend to enter kindergarten already at a disadvantage, and the gap widens across time. However, little is known about cognitive development among American Indian young children. In this study, 110 American Indian infants from one Northern Plains reservation community were assessed four times between ages 6 months and 36 months, with the Mullen Scales of Early Learning. At 6 months of age, scores were near the national norms; a drop occurred between 6 months and 15 months. Scores then tended to level off below the norms through 36 months. In each domain, we observed a crucial decline over the 1st year of life and relatively little change in the 2nd and 3rd years of life, highlighting the importance of developing culturally syntonic interventions to facilitate cognitive development during the 1st year of life.

The utility of the Kessler Screening Scale for Psychological Distress (K6) in two American Indian communities

The Kessler Screening Scale for Psychological Distress (K6; Kessler et al., 2002) has been used widely as a screener for mental health problems and as a measure of severity of impact of mental health problems. However, the applicability and utility of this measure for assessments within American Indian communities has not been explored. Data were drawn from a large-scale epidemiological study conducted in cooperation with 2 American Indian populations. Participants (N = 3,084) were 15-54 years of age and living on or near their home reservations; each completed an interview that included a version of the Composite International Diagnostic Interview (Robins, Wing, Wittchen, & Helzer, 1988) and the K6. A measure of both physical- and mental-health-related quality of life-the Medical Outcome Study's Short Form-36 (Ware & Sherbourne, 1992)-was used to examine the importance of the K6 over and above psychiatric diagnoses. The K6 was shown to be an appropriate screening and severity measure for mood disorders in these 2 samples. It also predicted health-related quality of life over and above that predicted by diagnoses alone. Inclusion of a measure such as the K6 as a complement to more traditional dichotomous diagnoses in both research and clinical practice is recommended.

Childhood exposure to adversity and risk of substance-use disorder in two American Indian populations: the meditational role of early substance-use initiation

OBJECTIVE

We examined the relationship of childhood exposure to adversity and risk of substance-use disorder in two culturally distinct American Indian reservation communities, exploring both the role of early initiation of substance use in mediating this relationship and variation in risk across types of adversity exposure.

METHOD

The American Indian Service Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project provided data from 2,927 American Indians on the occurrence and age at onset of adversities, substance use, and substance-use-disorder symptoms.

RESULTS

The risk of substance-use disorder associated with early adversity was explained partially by early initiation of substance use. Three types of adversity (major childhood events, traumas, and witnessed violence) were associated with early onset of substance use and increased risk of substance-use disorder. Gender and tribe were also related to variation in both early substance use and substance-use disorder.

CONCLUSIONS

Early exposure to adverse events was associated with early substance use and the subsequent development of substance-use disorders among American Indians. public health initiatives targeting substance use and substance-use disorders in American Indian communities should include efforts to help children in these communities cope with adversities they encounter.

Religiosity and Spiritual Engagement in Two American Indian Populations

Social scientific investigation into the religiospiritual characteristics of American Indians rarely includes analysis of quantitative data. After reviewing information from ethnographic and autobiographical sources, we present analyses of data from a large, population-based sample of two tribes (n = 3,084). We examine salience of belief in three traditions: aboriginal, Christian, and Native American Church. We then investigate patterns in sociodemographic subgroups, determining the significant correlates of salience with other variables controlled. Finally, we examine frequency with which respondents assign high salience to only one tradition (exclusivity) or multiple traditions (nonexclusivity), again investigating subgroup variations. This first detailed, statistical portrait of American Indian religious and spiritual lives links work on tribal ethnic identity to theoretical work on America's "religious marketplace." Results may also inform social/behavioral interventions that incorporate religiospiritual elements.

Maternal correlates of 2-year-old American Indian children's social-emotional development in a Northern Plains tribe

The developmental experiences of very young American Indian children today are not well documented in the current literature. The present study sought to explore the social-emotional development of American Indian toddlers living on a Northern Plains reservation, as a function of maternal variables. Mothers completed self-report questionnaires about their experiences and their children's development. Observer ratings of children's development also were conducted. Maternal stress, substance use/abuse, perceptions of stress in the mother-child relationship, social support, and American Indian cultural identity were significantly related to children's social-emotional development. This study is the first to explore these relationships in a Northern Plains American Indian sample of young children and their mothers. Results suggest possible points of intervention for improving the developmental outcomes of very young American Indian children.

Young Adult Migration from a Northern Plains Indian Reservation: Who Stays and Who Leaves

We evaluated how ambitions, community ties, monetary sufficiency, employment, and alcohol consumption related to whether young American Indian adults had moved from their Northern Plains reservation. Of 518 Northern Plains reservation residents in 1993, we located 472 in 2003-2005 and found that 89 lived more than a four-hour drive from the reservation. Coding the 472 as to whether they had stayed on/near the reservation or moved away, we ran logistic regressions on data they reported in 1996 to determine which demographic and attitudinal variables were associated with having moved. We found ambitions and goals were more associated with moving away than were ties to the community, which in turn were more related than monetary and personal characteristics that promote independence and prosperity. The more importance they placed on getting a good education or carrying on the tribe's traditions, the more likely they were to have moved away. We found too that the odds of moving away decreased with greater alcohol consumption. Tribal council members and college administrators therefore may wish to promote policies that increase opportunities for young adults to achieve higher education goals while remaining on reservation to carry on tribal traditions. Benefits may also come from encouraging and assisting reservation members studying off-reservation to return after completing their education. These findings would argue too for greater investment in alcohol services for reservation-dwelling populations.

A longitudinal study of self-esteem, cultural identity, and academic success among American Indian adolescents

Latent growth curve modeling was used to estimate developmental trajectories of self-esteem and cultural identity among American Indian high school students and to explore the relationships of these trajectories to personal resources, problem behaviors, and academic performance at the end of high school. The sample included 1,611 participants from the Voices of Indian Teens project, a 3-year longitudinal study of adolescents from 3 diverse American Indian cultural groups in the western United States. Trajectories of self-esteem were clearly related to academic achievement; cultural identity, in contrast, was largely unrelated, with no direct effects and only very small indirect effects. The relationships between self-esteem and success were mediated by personal resources and problem behaviors.

Alcohol use among American Indian high school youths from adolescence and young adulthood: a latent Markov model

OBJECTIVE

We explored patterns of alcohol use among American Indian youths as well as concurrent predictors and developmental outcomes 6 years later.

METHOD

This study used six semi-annual waves of data collected across 3 years from 861 American Indian youths, ages 14-20 initially, from two western tribes. Using a latent Markov model, we examined patterns of change in latent states of adolescent alcohol use in the past 6 months, combining these states of alcohol use into three latent statuses that described patterns of change across the 3 years: abstainers, inconsistent drinkers, and consistent drinkers. We then explored how the latent statuses differed, both initially and in young adulthood (ages 20-26).

RESULTS

Both alcohol use and nonuse were quite stable across time, although we also found evidence of change. Despite some rather troubling drinking patterns as teens, especially among consistent drinkers, most of the youths had achieved important tasks of young adulthood. But patterns of use during adolescence were related to greater levels of substance use in young adulthood.

CONCLUSIONS

Latent Markov modeling provided a useful categorization of alcohol use that more finely differentiated those youths who would otherwise have been considered inconsistent drinkers. Findings also suggest that broad-based interventions during adolescence may not be the most important ones; instead, programs targeting later alcohol and other drug use may be a more strategic use of often limited resources.

Preoperative Onyx embolization of aggressive vertebral hemangiomas

We report the first use of Onyx in the embolization of spinal tumors in 2 cases of aggressive vertebral hemangioma. In both cases, Onyx embolization provided effective preoperative tumor devascularization after the initial prolonged particulate embolization with Embospheres made little overall impact. Onyx enables a more rapid and visible embolization than particles and is less technically demanding than traditional liquid embolic agents, such as n-butyl cyanoacrylate.

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.