Research with American Indian and Alaska Native populations: Measurement matters

Research is an important tool in addressing myriad American Indian and Alaska Native (AIAN) health disparities; however, tensions exist between common empirical measurement approaches that facilitate cross-cultural comparisons and measurement specificity that may be more valid locally and/or culturally appropriate. The tremendous diversity of AIAN communities, small population sizes of distinct AIAN cultural groups, and varying cultural contexts and worldviews should influence measurement decisions in health research. We provide a framework for guiding measurement in collaboration with AIAN communities using examples from substance abuse research for illustration. Our goal is to build upon ongoing efforts to advance measurement validity for AIAN research by engaging community–researcher partnerships and critical thinking in the selection, adaptation, creation, and implementation of measures.     

Mobilizing communities to reduce substance abuse in Indian country

The impact of substance abuse is notable on Indian reservations in the United States and in the border communities surrounding them. One Indian country community, McKinley County, New Mexico, developed and implemented a series of alcohol policy and programmatic reforms beginning in 1989 which have reduced the impact of substance abuse on this community. Learning from the McKinley County experience, Fremont County in Wyoming, home of the Wind River Indian Reservation, has implemented similar reforms. This article introduces the substance abuse reduction efforts and delineates specific innovations implemented in these communities. The influence that these two communities have had on changes in substance abuse policy and programming statewide in New Mexico and Wyoming is also reviewed.     

American Indian youth substance abuse: community-driven interventions

Substance abuse among American Indians has a long history that dates back to the colonial era. American Indian youth today continue to have one of the highest substance abuse rates when compared with other groups. Researchers have implemented American Indian youth substance abuse interventions that previously have worked in the general population, but studies have found that they are generally unprepared and poorly designed for American Indian populations. The lack of inclusion of American Indian populations in the interventional studies, poor understanding of American Indian diversity and cultures, and lack of consideration for the unique historical and sociopolitical context of each tribe were cited as reasons the interventions failed. It has been suggested that historical trauma plays a considerable role in American Indian youth substance abuse; however, much of this theoretical framework has yet to be rigorously tested. Contemporary trauma appears to contribute significantly more to American Indian youth substance abuse. The data on American Indian substance abuse are limited, but what is currently available appears to show a vast heterogeneity in the level of substance abuse among American Indian youth that varies across different American Indian tribes and geographical distribution. In summary, this article seeks to describe the special relationship American Indian tribes have with the federal government, review historical and contemporary trauma, review American Indian youth substance abuse and interventions today, and finally describe a unique intervention strategy that tribes in the Pacific Northwest are implementing in order to combat American Indian youth substance abuse.     

Evidence-based practices, attitudes, and beliefs in substance abuse treatment programs serving American Indians and Alaska Natives: a qualitative study

Substance abuse disproportionately impacts American Indian/Alaska Native (AI/AN) communities in the United States. For the increasing numbers of AI/AN individuals who enter and receive treatment for their alcohol or other drug problem it is imperative that the service they receive be effective. This study used qualitative methodology to examine attitudes toward evidence-based practices, also known as evidence-based treatments (EBTs) in minority-serving substance abuse treatment programs in the San Francisco Bay area. Twenty-two interviews were conducted in the study, of which seven were with program directors and substance abuse counselors at two urban AI/AN focused sites. These clinics were more likely than other minority-focused programs to have experience with research and knowledge about adapting EBTs. Only in the AI/AN specific sites did an issue arise concerning visibility, that is, undercounting AI/AN people in national and state databases. Similar to other minority-focused programs, these clinics described mistrust, fear of exploitation from the research community, and negative attitudes towards EBTs. The underutilization of EBTs in substance abuse programs is prevalent and detrimental to the health of patients who would benefit from their use. Future research should explore how to use this research involvement and experience with adaptation to increase the adoption of EBTs in AI/AN serving clinics.     

Cultural investment: providing opportunities to reduce risky behavior among gay American Indian males

Many gay American Indian (GAI) men feel alienated from their tribal, ceremonial and social communities because of homophobia and heterosexism. As a result, they often turn to their local gay community for social participation and sex opportunities. It is no secret that a significant aspect of some gay communities is socializing in local bars and clubs. The gay bar scene makes healthy living difficult for Native American gay men. This is especially the case for those who are in alcohol or drug recovery. In response, gay Native men's support groups are attempting to make available a cultural alternative to the double bind of alienation from one's Native community and exposure to substance abuse by providing alcohol and substance free opportunities for ceremonial and social involvement. The hope is that the men will go to bars less frequently and instead turn to Native cultural activities in men's groups for social, spiritual and emotional support. The logic of this approach assumes that individuals who are culturally invested in a community will gain a level of self and social acceptance, making them less likely to abuse substances and put themselves at risk for HIV infection. The information presented in this article comes from over six years of ethnographic research among GAI men concerning self and social acceptance, HIV/AIDS and American Indian GLBT identity.     

Substance abuse treatment and HIV services: Massachusetts' policies and programs

States and communities use many strategies and policies to facilitate the integration of HIV and AIDS services with alcoholism and drug abuse treatment and prevention programs. Massachusetts' policy initiatives that promoted collaboration between substance abuse programs and AIDS services are outlined. The review begins with an overview of the HIV epidemic in Massachusetts and reflects on the initial challenges of building system capacity so that HIV and substance abuse services could become more closely integrated. The discussion summarizes specific policy strategies implemented to encourage system development and to develop program and staff skills for working with men and women with HIV/AIDS and at risk of infection. The initiatives included integration of alcoholism and drug abuse treatment programs, expansion of Medicaid reimbursement for substance abuse treatment, training and skills development for counselors, and coordinated service development and advocacy for substance abuse and AIDS/HIV services.     

The prospects of a harm reduction approach among indigenous people in Canada

A harm reduction approach to alcohol and substance abuse is becoming increasingly popular as an alternative to prohibitionist and abstentionist policies. It is seen as particularly valuable for some high-risk populations, such as injection drug users and street youth. A strong argument can be made that Aboriginal communities in Ontario, Canada, and probably across the country, are appropriate environments for a harm reduction approach. Aboriginal people are at extremely elevated risk for accident, illness and death. At the same time, alcohol use is a predominant factor in many of these outcomes, and elevates many of the risks associated with Aboriginal life. Isolated, remote reserve communities in northern Ontario present additional risks of extremely poor living conditions and extreme weather conditions. Prohibition and abstinence are currently the main approaches to alcohol and substance abuse in many of these communities, while the role of alcohol in morbidity, mortality and other social problems remains high. There are positive indications that the feasibility of harm reduction strategies could be broached in some communities. It is concluded that the obstacles are significant but a community-by-community approach is a strong feature of harm reduction, and may increase its prospects for piloting strategies in individual communities.     

Symptom endorsement of alcohol and other substance abuse and dependence criteria among American-Indian adolescents in residential substance abuse treatment

OBJECTIVE: This study addresses the prevalence of DSM-IV substance abuse and dependence and the endorsement of specific symptoms of these disorders among American Indian adolescents admitted to a residential substance abuse treatment program. METHOD: We interviewed 89 American Indian adolescents using the Composite International Diagnostic Interview-Substance Abuse Module (CIDI-SAM). RESULTS: The most frequent diagnoses included marijuana dependence (51.7%), followed by alcohol abuse and dependence (33.7% each) and marijuana abuse (32.6%). Among the three substances with the highest prevalence of any use disorder (alcohol, marijuana and stimulants), the most frequently endorsed abuse criterion was Impaired Role Obligations. The two most frequently endorsed dependence criteria were Use Despite Substance-Related Psychological/Physical Problems and Unsuccessful Attempts to Quit/Cut down on substance use. CONCLUSIONS: These American Indian adolescents presented to a residential substance abuse treatment program with serious, highly complex substance use disorders that represent substantial challenges to effective treatment.     

American Indian adolescents in substance abuse treatment: diagnostic status

The goal of this study was to describe the prevalence of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) psychiatric disorders among a sample of American Indian (AI) adolescents in residential substance abuse treatment. Data on 89 AI adolescents admitted to a tribally operated residential substance abuse treatment program were collected. Participants reported using a mean of 5.26 substances; 20% percent met DSM-IV criteria for four or more substance use disorders. Marijuana abuse/dependence was the most common substance use disorder (84.3%). Eighty-two percent met criteria for at least one DSM-IV nonsubstance use disorder, the most common of which was conduct disorder (74.2%). These results suggest strong diagnostic parallels between these AI adolescents and their non-AI counterparts who have participated in similar studies, including the considerable diagnostic complexity that was common among the participants in this study. These diagnostic patterns suggest that emerging practices for treating substance-abusing adolescents that have been developed for use with non-AI adolescents warrant consideration for use with AI youths.     

A pilot study of motivation and treatment completion among American Indian adolescents in substance abuse treatment

This study assessed intrinsic and extrinsic motivation toward treatment among American Indian adolescents 13-18 years old admitted to a residential substance abuse treatment program and the relationship of these measures to treatment completion. Participants completed a questionnaire regarding motivation towards treatment and a diagnostic interview. Participant treatment records were also reviewed. Being an older adolescent (16-18 years old), having higher scores on a scale measuring treatment readiness and endorsing a single question regarding concern about legal problems were all associated with treatment completion. The relationship of an additional scale measuring desire for help with substance use problems was mediated by the measure of treatment readiness. This pilot study is the first to assess the relationship of motivation toward substance abuse treatment completion among American Indian adolescents and provides preliminary evidence of the applicability of these concepts to this treatment population. These concepts and their related therapeutic approaches warrant further study in this population.     

Counseling substance abuse clients infected with human immunodeficiency virus

Some of the barriers to effective dual treatment of substance abuse and AIDS-related diagnoses have been detailed in this article, and some practical strategies to improve the response of treatment providers in caring for this difficult population of patients have been offered. While there are many problems associated with the dual diagnosis of substance abuse and AIDS, health care providers and substance abuse treatment professionals can intervene effectively by first recognizing how their own values and anxieties impact on treatment approaches. Next, they can accept substance abuse as a problem that can be treated and the diagnosis of AIDS as one issue of many that needs to be addressed. Finally, they can stay informed about community resources to help them make accurate assessments and to develop effective treatment strategies.     

HIV/AIDS and Native Americans: the health departments' response

For some time, state health department HIV/AIDS programs have worked with communities of color to address their unmet needs. Because of the need for a holistic approach to the multiple issues impacting these communities, efforts to address HIV/AIDS in Native American communities are often integrated into programs addressing related issues, such as substance abuse, mental health and other STDs. Building upon a recent report from the National Alliance of State and Territorial AIDS Directors (NASTAD), this article will review the numerous challenges state and local health departments face in supporting HIV/AIDS-focused health and human services in Native American communities and how some health departments have worked with Native American communities to respond to these challenges. A series of recommendations and next steps for health departments seeking to improve services in Native American communities will be offered.     

Growing Our Own: Building a Native Research Team

Abstract

In 2006, American Indian/Alaska Natives (AI/AN) made up less than 1% of the science, engineering and health doctorates in the U.S. Early introduction of AI/AN students to research and continued opportunities are necessary to develop successful AI/AN researchers who can better serve their communities. This team was developed to form a cohort of American Indian students, staff and faculty interested in research and becoming researchers. Since implementation, the program grew from one student to over 20 AI students ranging from freshmen just entering college to doctoral students working to complete their dissertations. This article highlights the team growth, increasing structure, student needs and the faculty and staff involved. It further addresses the support and educational aspects of growing an ongoing, multidisciplinary research team committed to ethical research in Native communities. The team addresses substance use prevalence, the relationship of substance abuse to other mental health diagnoses, and treatment issues. The team includes weekly team meetings, a Blackboard site on the Internet that is populated with resources and focused on sharing materials and information, a weekly journal club discussion of research articles, and collaborative discussions on each project and the barriers and challenges that need to be addressed to move forward.     

Growing our own: building a native research team

In 2006, American Indian/Alaska Natives (AI/AN) made up less than 1% of the science, engineering and health doctorates in the U.S. Early introduction of AI/AN students to research and continued opportunities are necessary to develop successful AI/AN researchers who can better serve their communities. This team was developed to form a cohort of American Indian students, staff and faculty interested in research and becoming researchers. Since implementation, the program grew from one student to over 20 AI students ranging from freshmen just entering college to doctoral students working to complete their dissertations. This article highlights the team growth, increasing structure, student needs and the faculty and staff involved. It further addresses the support and educational aspects of growing an ongoing, multidisciplinary research team committed to ethical research in Native communities. The team addresses substance use prevalence, the relationship of substance abuse to other mental health diagnoses, and treatment issues. The team includes weekly team meetings, a Blackboard site on the Internet that is populated with resources and focused on sharing materials and information, a weekly journal club discussion of research articles, and collaborative discussions on each project and the barriers and challenges that need to be addressed to move forward.     

Program use of effective drug abuse treatment practices for juvenile offenders

This study examined the extent to which organizational context predicted use of consensus-based elements of effective substance abuse treatment practices with juvenile offenders. Participants were either directors of substance abuse treatment programs located in residential facilities (institutional sample) or directors of community-based treatment agencies providing services to adolescents in their home communities (community sample). The two settings differed significantly in the number and types of effective practices they were using. Community programs were more likely to have staff qualified to deliver substance abuse treatment, involve families in treatment, and assess their treatment outcomes. In contrast, institutional programs were more likely to provide comprehensive services. Resources dedicated to training, internal support for new programming, and network connectedness with non-criminal-justice facilities were associated with greater use of effective practices. These findings highlight the importance of establishing corrections-community partnerships designed to promote continuity of care for juvenile offenders.     

Harm reduction and alternative development in the Golden Triangle

The authors of this Digest are anthropologists from Macquarie University, Sydney Australia. At the invitation of the German aid agency GTZ, they have been monitoring opium use and the impact of drug rehabilitation in Muang Sing Laos over the past 3 years. Their role is to provide analyses of how development projects alter the social make-up of their target communities and contribute to ways in which substance use/abuse is understood, practiced and controlled or reconfigured. In their consideration of development projects they take the perspective that harm reduction can and should include pre-emptive concern with factors that promote damaging drug use in the first place and furthermore, that these factors are at times the products of the distinct drug reduction strategies themselves. SIMON LENTONEditor, Harm Reduction Digest     

The moderating role of substance abusers’ personal attributes in predicting relapse and partner persuasiveness

In relationships where one partner is dependent on substances, the non-dependent, or “functional” partners use a variety of strategies to stop the abuse and prevent relapse. Inconclusive research results on the effectiveness of these strategies can be partially explained by the failure to consider personal characteristics of the substance abusers that may make them more or less receptive to their partners’ attempts at assisting them in their sobriety. This work explores the substance abusers’ anger, over-controlled hostility, and ego-strength as moderating factors influencing both the types and amounts of persuasive strategies used by the significant other. The sample was composed of 67 married or cohabitating couples with one functional and one substance-abusing partner (as assessed by the chemical use, abuse, and dependence (CUAD) scale). Participants’ personality variables were tested using the Minnesota Multiphasic Personality Inventory (MMPI), followed by videotaped interviews where they were independently asked about their own and their partner's behavior. Contrary to predictions, as the abusers’ anger and ego-strength increased so did their partners’ use of punishment and the consistency of the substance-abusing behavior. Finally, as the abusers’ ego-strength increased and over-controlled hostility decreased the partner presented more reinforcement of the substance abuse. These findings encourage a systems approach to the treatment of substance abuse, and provide insight into appropriate and effective strategies used by the functional partner in this system.     

Substance Abuse and American Indians: Prevalence and Susceptibility

The use of alcohol and other substances by American Indians has received considerable popular attention over the years. Empirical studies of prevalence for all types of substance abuse, however, have generally been few and limited in scope. In this paper prevalence studies among Indians are reviewed and analyzed by comparison with each other and national studies. In addition, issues important to the research of Indian alcohol and drug abuse are discussed. Finally a specific scheme of susceptibility is proposed which may eplain the patterns of variation in both tribal and individual substance abuse.     

Indigenous communities and evidence building

Indigenous populations in the U.S. and Pacific Islands are underrepresented in mental health and substance abuse research, are underserved, and have limited access to mainstream providers. Often, they receive care that is low quality and culturally inappropriate, resulting in compromised service outcomes. The First Nations Behavioral Health Association (U.S.) and the Pacific Substance Abuse and Mental Health Collaborating Council (Pacific Jurisdictions), have developed a Compendium of Best Practices for American Indian/Alaska Native and Pacific Island Populations. The private and public sector's increasing reliance on evidence-based practices (EBP) leaves many Indigenous communities at a disadvantage. For example, funding sources may require the use of EBP without awareness of its cultural usefulness to the local Indigenous population. Indigenous communities are then faced with having to select an EBP that is rooted in non-native social and cultural contexts with no known effectiveness in an Indigenous community. The field of cultural competence has tried to influence mainstream research, and the escalating requirement of EBP use. These efforts have given rise to the practice-based evidence (PBE) and the community-defined evidence (CDE) fields. All of these efforts, ranging from evidence-based practice to community-defined evidence, have a shared goal: practice improvement.