Unsettling Settler Colonialism in Research: Strategies Centering Native American Experience and Expertise in Responding to Substance Misuse and Co-occurring Sexual Risk-Taking, Alcohol-Exposed Pregnancy, and Suicide Prevention Among Young People

Native American (NA) populations in the USA (i.e., those native to the USA which include Alaska Natives, American Indians, and Native Hawaiians) have confronted unique historical, sociopolitical, and environmental stressors born of settler colonialism. Contexts with persistent social and economic disadvantage are critical determinants of substance misuse and co-occurring sexual risk-taking and suicide outcomes, as well as alcohol exposed pregnancy among NA young people (i.e., adolescents and young adults). Despite intergenerational transmission of resistance and resiliencies, NA young people face continued disparities in substance misuse and co-occurring outcomes when compared to other racial and ethnic groups in the USA. The failure in progress to address these inequities is the result of a complex set of factors; many of which are structural and rooted in settler colonialism. One of these structural factors includes barriers evident in health equity research intended to guide solutions to address these disparities yet involving maintenance of a research status quo that has proven ineffective to developing these solutions. Explicitly or implicitly biased values, perspectives, and practices are deeply rooted in current research design, methodology, analysis, and dissemination and implementation efforts. This status quo has been supported, intentionally and unintentionally, by researchers and research institutions with limited experience or knowledge in the historical, social, and cultural contexts of NA communities. We present a conceptual framework illustrating the impact of settler colonialism on current research methods and opportunities to unsettle its influence. Moreover, our framework illustrates opportunities to resist settler colonialism in research. We then focus on case examples of studies from the Intervention Research to Improve Native American Health program, funded by the NIH, that impact substance use and co-occurring health conditions among NA young people.

A virtual randomized controlled trial of an alcohol-exposed pregnancy prevention mobile app with urban American Indian and Alaska Native young women: Native WYSE CHOICES rationale, design, and methods

BACKGROUND

Fetal Alcohol Spectrum Disorders (FASD) result in lifelong disability and are a leading cause of preventable birth defects in the US, including for American Indian and Alaska Natives (AIANs). Prevention of alcohol exposed pregnancies (AEPs), which can cause FASD, is typically aimed at adult women who are risky drinkers and have unprotected sex. Among AIANs, AEP prevention research has been primarily conducted in reservation communities, even though over 70% of AIANs live in urban areas. Culturally appropriate AEP prevention for urban AIAN young women, regardless of current drinking or sexual behaviors, may maximize the potential for primary prevention at the beginning of the reproductive years for this underserved population.

METHODS

We developed a virtual randomized controlled trial (RCT) - fully implemented through technology - to evaluate Native WYSE CHOICES, a culturally tailored mobile app, with urban AIAN young women ages 16-20 nationally. While virtual RCTs are not new, this is the first engaging a solely urban AIAN population, historically excluded from research. Participants are recruited on a rolling basis through the project social media community, organizational partnerships, and in-person events. Eligible participants complete a baseline survey and are randomized to either the app's intervention or comparison arm - each of which provide about 3 h of content. Follow-up data are collected at 1-, 6-, and 12-months post-baseline.

RESULTS

Our study offers a template for building trust and extending reach to this underserved population while also providing important lessons and insights on advances in virtual or hybrid research approaches.

A culturally tailored intervention to reduce risk of alcohol-exposed pregnancies in American Indian communities: Rationale, design, and methods

INTRODUCTION

Prenatal exposure to alcohol can cause lifelong physical and cognitive challenges in the form of fetal alcohol syndrome and other fetal alcohol spectrum disorders (FASDs). The prevention of prenatal alcohol exposure is thus a public health priority - and one that should account for the particular needs of subpopulations, including in American Indian/Alaska Native (AI/AN) communities. Prior to conception, alcohol-exposed pregnancy prevention is accomplished by encouraging the reduction or elimination of risky alcohol use and/or promoting effective contraceptive use among risky drinkers who could become pregnant. The current study builds on promising findings about the impact of the Centers for Disease Control and Prevention CHOICES intervention with AI/AN communities by implementing a randomized control trial of Native CHOICES, a cultural adaptation of CHOICES, with AI/AN women in a rural reservation community.

METHODS

AI/AN women aged 18-44 who are at-risk for an alcohol-exposed pregnancy are being recruited. Participants are randomized in 1:1 proportion to the intervention and a services-as-usual, waitlist control condition. The Native CHOICES intervention consists of 2 motivational interviewing (MI) sessions, an elective contraception counseling session, and electronic messaging to boost the effects of MI. Data are collected at baseline and at 6 weeks, 3 months, and 6 months post-baseline. Those assigned to the control group are eligible to enroll in Native CHOICES following the completion of the 6 months post-baseline data collection. In addition to testing intervention effectiveness, the study is designed to yield a comprehensive economic evaluation, which will provide important information regarding the financial feasibility and sustainability of Native CHOICES for healthcare systems serving AI/ANs.

Cognitions and behaviors related to risk for alcohol-exposed pregnancies among young adult women

This study assessed alcohol and sex-related cognitions and behaviors, including alcohol-related sexual expectancies, descriptive norms, and protective behavioral strategies, associated with women's risk for an alcohol-exposed pregnancy. A national sample of young adults ages 18-20 years was subset to women who were capable of pregnancy and sexually active (n = 422). The outcome was risk of alcohol-exposed pregnancy as determined by contraceptive status and heavy-episodic drinking. SAS version 9.4 was used to estimate logistic regression models. Alcohol-related sexual expectancies related to enhancement were significantly associated with increased odds of alcohol-exposed pregnancy risk. In contrast, women who reported the use of more safe sex (non-condom related) protective behavioral strategies (e.g., talk to partner about birth control use) were at decreased odds of alcohol-exposed pregnancy risk. Future interventions to reduce the risk of alcohol-exposed pregnancies should consider alcohol-related sexual expectancies and safer sex protective behavioral strategies as leverage points.

Convergence of online daily diaries and timeline followback among women at risk for alcohol exposed pregnancy

Researchers and clinicians interested in assessing drinking and unprotected sex in evaluating risk for alcohol-exposed pregnancy (AEP) have limited options. The current investigation examined the degree to which data collected from online prospectively collected daily diaries (Diaries) converged with data from interviewer-administered retrospective timeline follow back (TLFB), the standard in AEP intervention studies. 71 women (M_age=27.7, SD=6.2) at risk for AEP were recruited via online advertising and were randomly assigned to an online patient education condition or a tailored, online internet intervention to reduce AEP risk. All participants were administered both Diaries and TLFB at baseline and 6months after intervention. Key outcomes were variables of drinking rates and unprotected sex that combined to indicate risk for AEP. Zero-order and intra-class correlations (ICC) between Diaries and TLFB were strong for each outcome. Examination of ICC confidence intervals indicated that condition assignment did not have a significant impact on the degree of convergence between Diaries and TLFB. With the exception of proportion of days drinking and proportion of days with unprotected sex at baseline, none of the paired t-tests reached significance. Examination of descriptive statistics revealed that 63% of participants reported problem alcohol use and unprotected sex in both the 10-day Diaries and 90-day TLFB at baseline, with 70% agreement at post 6-month follow up. Findings indicate overall strong agreement between TLFB and Diaries in detecting alcohol use and unprotected sex in women at risk for AEP, and each method has benefits and challenges that should be weighed carefully by researchers and treatment providers.

Development and Implementation of CHOICES Group to Reduce Drinking, Improve Contraception, and Prevent Alcohol-Exposed Pregnancies in American Indian Women

Public health officials assert that prevention of alcohol-exposed pregnancies (AEP) should begin before conception, by reducing alcohol consumption in women at-risk for or planning pregnancy, and/or preventing pregnancy in women who are drinking at risky levels. One such effort is the Oglala Sioux Tribe (OST) CHOICES Program. While the OST CHOICES Program has been successfully implemented, a community-based needs assessment determined that the OST CHOICES intervention should expand and be delivered in a group setting using group motivational interviewing (MI) techniques. After extensive group MI and CHOICES group trainings, recruitment for CHOICES Group began and within a ten month period, a total of twelve groups with non-pregnant American Indian women were held for this pilot intervention. Evaluations completed by participants indicated that CHOICES Group sessions positively engaged members, had low levels of anger or tension, and had average levels of avoidance of personal responsibility. An evaluation of the CHOICES Group leaders indicated strengths in certain MI skills, although improvement is needed in some core MI and group leadership skills. This is an important expansion of a successful AEP prevention program (CHOICES), as well as a novel application of MI, and recommendations and future plans for this intervention are outlined.

Using a single binge drinking question to identify Russian women at risk for an alcohol-exposed pregnancy

INTRODUCTION

Low rates of contraception and at-risk drinking place many Russian women at risk of an alcohol-exposed pregnancy (AEP). The only realistic way to determine when women are at risk of AEP is by self-reports. A U.S. study found that a single binge-drinking question (SBD) effectively identified nearly all women whose drinking placed them at risk of AEP.

METHODS

The present study replicated the U.S.

STUDY

Participants were 689 non-pregnant Russian women of childbearing age who were at AEP risk. Their answers to SBD, "During the previous three months, how often did you have four or more drinks on one occasion", were compared with their reports of binge drinking on a 90-day Timeline Followback (TLFB) calendar.

RESULTS

The SBD identified 99% of at-risk Russian women as binge drinkers, replicating U.S.

FINDINGS

Only 8% of the women were identified at-risk using a second AEP criterion of ≥8 drinks on average per week. Although Russian women did not report heavy weekly drinking and two-thirds did not meet AUDIT criteria for problem drinking, when they did drink, 40% of the time it was binge drinking.

CONCLUSIONS

Almost all Russian women who were at risk of an AEP were identified by a single binge-drinking question. Results from this study suggest that Russian health care practitioners can use SBD to successfully screen women for AEP risk. SBD identified 99% of Russian women who were at AEP risk. Consequently, it is recommended that SBD be incorporated into routine health care screenings at OB/GYN clinic visits.