Feasibility of a community intervention for the prevention of suicide and alcohol abuse with Yup'ik Alaska Native youth: the Elluam Tungiinun and Yupiucimta Asvairtuumallerkaa studies

Place-based strengths and vulnerabilities for mental wellness among rural minority older adults: an intervention development study protocol

INTRODUCTION

Severe inequities in depression and its diagnosis and treatment among rural-dwelling, racial-minority and ethnic-minority older adults compared with their urban white counterparts result in cognitive impairment, comorbidities and increased mortality, presenting a growing public health concern as the United States (US) population ages. These inequities are often attributable to social and environmental factors, including economic insecurity, histories of trauma, gaps in transportation and safety-net services, and disparities in access to policy-making processes rooted in colonialism. This constellation of factors renders racial-minority and ethnic-minority older adults 'structurally vulnerable' to mental ill health. Fewer data exist on protective factors associated with social and environmental contexts, such as social support, community attachment and a meaningful sense of place. Scholarship on the social determinants of health widely recognises the importance of such place-based factors. However, little research has examined how they shape disparities in depression and treatment specifically, limiting the development of practical approaches addressing these factors and their effects on mental well-being for rural minority populations.

METHODS AND ANALYSIS

This community-driven mixed-method study uses quantitative surveys, qualitative interviews and ecological network research with 125 rural American Indian and Latinx older adults in New Mexico and 28 professional and non-professional social supporters to elucidate how place-based vulnerabilities and protective factors shape experiences of depression among older adults. Data will serve as the foundation of a community-driven plan for a multisystem intervention focused on the place-based causes of disparities in depression. Intervention Mapping will guide the intervention development process.

ETHICS AND DISSEMINATION

This study has been reviewed and approved by the University of New Mexico Health Sciences Center Institutional Review Board. All participants will provide informed consent. Study results will be disseminated within the community of study through community meetings and presentations, as well as broadly via peer-reviewed journals, conference presentations and social media.

American Indian and Alaska Native violence prevention efforts: a systematic review, 1980 to 2018

BACKGROUND

Violence is a serious public health concern disproportionately experienced by American Indian and Alaska Native (AIAN) people. While the burden and impact of violence may be explained by the presence of risk factors among this group, AIAN communities benefit from unique protective factors and universal strategies which may be tailored with tribal adaptations. We sought to identify and explore violence prevention strategies specific to AIAN populations.

METHODS

A review was conducted to systematically identify violence prevention programs, policies, and practices implemented in AIAN communities. We searched nine electronic databases and relevant gray literature released between January 1980 and June 2018. We included intervention-focused records targeting at least one violence topic area (child abuse/neglect, elder abuse, intimate partner violence, sexual violence, youth violence, and suicide) in a majority (> 50%) AIAN population.

RESULTS

A total of 5220 non-duplicate records were screened, yielding 318 full-text records. After applying exclusion criteria, 57 records describing 60 program, policy, or practice implementations of 43 unique interventions were identified. All six violence types were represented, although more than half (58%; n = 25/43) focused on suicide prevention. Among suicide prevention programs, the most common strategies were identifying and supporting people at risk (80%; n = 20), teaching coping and problem-solving skills (56%; n = 14), and promoting connectedness (48%; n = 12). Two-thirds of the implementations (67%; n = 40/60) were in fully (100%) AIAN communities. Programs were implemented across many settings, though schools were the most common (35%, n = 21/60) setting. Of the 60 total implementations, a majority (80%; n = 48) were new approaches developed by and for AIAN communities, while the remainder were AIAN adaptations of programs previously created for non-AIAN populations. Most implementations (60%; n = 36/60) provided some evaluation data although less than half (45%; n = 27/60) reported evaluation results.

CONCLUSIONS

This review identified many violence prevention strategies specific to AIAN populations. While programs developed in one tribe may not be completely generalizable to others, shared tribal risk and protective factors suggest programs could be successful across diverse communities. Findings indicate there is a need to develop and evaluate violence prevention programs, policies and practices for AIAN populations.

Knowing Who You Are (Becoming): Effects of a university-based elder-led cultural identity program on Alaska Native students' identity development, cultural strengths, sense of community, and behavioral health

In part due to cultural loss and identity disruption over many generations from colonial and neocolonial forces, significant emotional/behavioral health disparities exist among Alaska Native (AN) people. Such forces are apparent in higher education, where many AN students feel othered and are more likely to withdraw without a degree than their nonnative counterparts. A strong cultural identity has been found to buffer psychosocial difficulties. The AN Cultural Identity Project (CIP) was developed from the best available scientific literature, local data from AN students, and traditional wisdom from Elders to support cultural identity development. This 8-week Elder-led program incorporated storytelling, experiential learning, connection, exploration, and sharing of identity and cultural strengths to help students remain grounded in their cultures across settings in the hopes of improving emotional/behavioral health outcomes. Through a stepped-wedge design randomized controlled trial, we examined the impact of CIP on cultural identity, cultural strengths, sense of community, and emotional/behavioral health across two cohorts of 44 AN students who ranged in age from 18 to 54 years. On average, students attended 75% of the program. The program had positive impacts on students' cultural identity development, endorsement of cultural strengths, sense of community with AN people at the university, and overall emotional/behavioral health. While gains in some outcomes were sustained over time, others were not, suggesting the potential benefits of a lengthened program. As the first program of its kind directed at AN university students of diverse cultural groups in urban settings, CIP shows promise for supporting emotional/behavioral health through cultural identity development. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Culturally grounded strategies for suicide and alcohol risk prevention delivered by rural Alaska Native communities: A dynamic wait-listed design evaluation of the Qungasvik intervention

We examined the effectiveness of the Qungasvik (Tools for Life) intervention in enhancing protective factors as a universal suicide and alcohol prevention strategy for young people ages 12-18 living in highly affected rural Alaska Native communities. Four communities were assigned to immediate intervention or to a dynamic wait list. Outcomes were analyzed for 239 young people at four time points over two years of community intervention. Outcomes assessed two ultimate variable protective factors buffering suicide and alcohol risk, and three intermediate variable protective factors at the individual, family, and community level. Dose dependent intervention effects were associated with growth in ultimate but not intermediate variables. This evaluation of the Qungasvik intervention provides support for the effectiveness of its Indigenous strategies for suicide and alcohol misuse prevention in this rural Alaska Native setting. Though findings did not provide support for a theory of change where growth in ultimate variables is occasioned through effects on intermediate variables, research designs focused on young people who enter intervention at lower levels of preexisting protection hold promise for better understanding of intervention change processes. The Qungasvik intervention is responsive to an acute public health need for effective rural Alaska Native suicide and alcohol risk prevention strategies.

Centering Indigenous knowledge in suicide prevention: a critical scoping review

BACKGROUND

Indigenous peoples of Canada, United States, Australia, and New Zealand experience disproportionately high rates of suicide as a result of the collective and shared trauma experienced with colonization and ongoing marginalization. Dominant, Western approaches to suicide prevention-typically involving individual-level efforts for behavioural change via mental health professional intervention-by themselves have largely failed at addressing suicide in Indigenous populations, possibly due to cultural misalignment with Indigenous paradigms. Consequently, many Indigenous communities, organizations and governments have been undertaking more cultural and community-based approaches to suicide prevention. To provide a foundation for future research and inform prevention efforts in this context, this critical scoping review summarizes how Indigenous approaches have been integrated in suicide prevention initiatives targeting Indigenous populations.

METHODS

A systematic search guided by a community-based participatory research (CBPR) approach was conducted in twelve electronic bibliographic databases for academic literature and six databases for grey literature to identify relevant articles. the reference lists of articles that were selected via the search strategy were hand-searched in order to include any further articles that may have been missed. Articles were screened and assessed for eligibility. From eligible articles, data including authors, year of publication, type of publication, objectives of the study, country, target population, type of suicide prevention strategy, description of suicide prevention strategy, and main outcomes of the study were extracted. A thematic analysis approach guided by Métis knowledge and practices was also applied to synthesize and summarize the findings.

RESULTS

Fifty-six academic articles and 16 articles from the grey literature were examined. Four overarching and intersecting thematic areas emerged out of analysis of the academic and grey literature: (1) engaging culture and strengthening connectedness; (2) integrating Indigenous knowledge; (3) Indigenous self-determination; and (4) employing decolonial approaches.

CONCLUSIONS

Findings demonstrate how centering Indigenous knowledge and approaches within suicide prevention positively contribute to suicide-related outcomes. Initiatives built upon comprehensive community engagement processes and which incorporate Indigenous culture, knowledge, and decolonizing methods have been shown to have substantial impact on suicide-related outcomes at the individual- and community-level. Indigenous approaches to suicide prevention are diverse, drawing on local culture, knowledge, need and priorities.

An interview-based evaluation of an Indigenous traditional spirituality program at an urban American Indian health clinic

American Indians suffer from disproportionately high rates of mental health problems. Professional therapies may not meet the specific mental health needs of American Indians, owing to cultural mismatch and long histories of political disempowerment. Instead, Indigenous traditional spiritual practices are often promoted as alternative sources of health and help in these communities. In response to a community needs assessment, we developed a 12-week traditional spirituality curriculum in partnership with the urban American Indian health clinic in Detroit. Centered on the sweat lodge ceremony, the program was pilot tested with 10 community members. Semi-structured interviews were conducted with nine participants following the program. Based on our analyses, all participants endorsed responses within two overarching themes: impact on personal well-being, and suggestions for improvement reflecting their desire for an ongoing program. Participant responses about the program's impact comprised four themes: (1) improved psychological and spiritual well-being, (2) community benefit, (3) increase in cultural knowledge, and (4) a desire for further learning and sharing. Participant responses about their desire for an ongoing program also comprised four themes: (1) drop-in classes may be more practical as regular attendance was difficult for some, (2) future classes should include more areas of knowledge, (3) the program could be expanded to include more knowledge-holders and perspectives, and (4) the program should include a progression of classes to accommodate more diversity. Overall, participants reported benefit from participation in Indigenous spiritual practices; however, the program can be improved by further adapting the curriculum to the sometimes-challenging lives of its participants.

Factors That Influence Substance Use Among American Indian/Alaskan Native Youth: A Systematic Mixed Studies Review

BACKGROUND

The American Indian/Alaskan Native (AI/AN) mortality rate from illicit drug use was 22.7%, double that of the general population between 2007 and 2009. Fifteen percent of AI/AN youth reported receiving treatment for substance use compared with 10% of non-AI/AN peers.

OBJECTIVE

The purpose was to explore the factors that influence substance use among AI/AN youth.

METHOD

We performed a systematic review using a results-based convergent synthesis design. Eight electronic databases were searched for articles published between 2014 and 2019 using the search terms "Native American youth," "Native American adolescent," "Native Youth," "substance use," "substance misuse," and "substance abuse." The Mixed Methods Appraisal Tool was used to appraise the studies.

RESULTS

Forty-seven studies met the inclusion criteria (44 quantitative, one qualitative, and two mixed-methods studies). The results were organized using the ecological systems model and included evaluation of both protective and risk factors related to AI/AN youth substance use. Three system levels were found to influence substance use: individual, micro- and macrosystems. The individual systems-level coping mechanisms played a key role in whether AI/AN youth initiated substance use. Family, school, and peer factors influence the microsystem level. At the macrosystem level, community environmental factors were influential.

CONCLUSION

The major factor linking all the systems was the influence of a connected relationship with a prosocial adult who instilled future aspirations and a positive cultural identity. Findings of this systematic mixed studies review will assist in intervention development for AI/AN youth to prevent substance misuse.

Protective Factors as a Unifying Framework for Strength-Based Intervention and Culturally Responsive American Indian and Alaska Native Suicide Prevention

The ongoing challenge of American Indian and Alaska Native (AIAN) youth suicide is a public health crisis of relatively recent historical origin inadequately addressed by contemporary prevention science. A promising development in AIAN suicide prevention highlights the role of protective factors. A protective factor framework adopts a social ecological perspective and community-level intervention paradigm. Emphasis on protection highlights strength-based AIAN cultural strategies in prevention of youth suicide. Attention to multiple intersecting levels incorporates strategies promoting community as well as individual resilience processes, seeking to influence larger contexts as well as individuals within them. This approach expands the scope of suicide prevention strategies beyond the individual level and tertiary prevention strategies. Interventions that focus on mechanisms of protection offer a rigorous, replicable, and complementary prevention science alternative to risk reduction approaches. This selected review critically examines recent AIAN protective factor suicide prevention science. One aim is to clarify key concepts including protection, resilience, and cultural continuity. A broader aim is to describe the evolution of this promising new framework for conducting primary research about AIAN suicide, and for designing and testing more effective intervention. Recommendations emphasize focus on mechanisms, multilevel interactions, more precise use of theory and terms, implications for new intervention development, alertness to unanticipated impacts, and culture as fundamental in a protective factors framework for AIAN suicide prevention. A protective factor framework holds significant potential for advancing AIAN suicide prevention and for work with other culturally distinct suicide disparity groups, with broad implications for other areas of prevention science.

Suicide justice: Adopting Indigenous feminist methods in settler suicidology

White settler colonies around the world have long reported disproportionately high rates of Indigenous suicides, a consequence of the continuing violence of imperialism. This article posits a need for interdisciplinary approaches to address this crisis and therefore turns to humanist methods developed in Indigenous and feminist scholarship. I analyze texts from U.S. psychologist Edwin Shneidman to rearticulate their relationship to what I call settler suicidology. I then evoke literary critic Eve K. Sedgwick's reparative reading method to reimagine suicide prevention as suicide justice, reading the novel There There by Tommy Orange (Cheyenne and Arapaho) to advocate for distributive justice as a new approach to Indigenous suicide crises. My term suicide justice names increasing accountability between settler suicide workers and the communities they seek to serve.

Time-Space Distanciation as a Decolonizing Framework for Psychology

Coloniality describes the way in which racialized conceptions of being, personhood, and morality inherent in colonial regimes are maintained long after the formal end of colonial enterprises. Central to coloniality has been the material and psychological colonization of space and time, largely by Western and industrialized nations. We propose the importance of understanding the coloniality of time and space through a historically grounded framework called time-space distanciation (TSD). This framework posits that via the global spread of capitalism through colonization, psychological understandings of time and space have been separated from one another, such that they are now normatively treated as distinct entities, each with their own abstract and quantifiable value. We discuss the construct and its centrality to coloniality, as well as the ways in which contemporary psychology has been complicit in proliferating the coloniality of psychologies of time and space. Finally, we discuss ways to employ the decolonial strategies of denaturalization, indigenization, and accompaniment in the context of future research on the psychology of time and space. TSD contributes to decolonial efforts by combatting the reification of hegemonic psychological constructs, showing how these constructs arise as a function of historical changes in understanding, experience, and use of time and space.

The Validity of the Short Inventory of Problems and Drinking Intensity among Urban American Indian Adults

BACKGROUND

American Indian (AI) adults have both high prevalence rates of alcohol abstinence and alcohol use disorders compared to non-Hispanic White adults. We investigated the applicability and validity of the Short Inventory of Problems (SIP) among AI urban adults and the moderating effect of biological sex.

METHODS

AI adults from three Alcoholics Anonymous samples (n = 124) provided baseline, 3-, 6- and 9-month data. Measures included Form 90 and the SIP, which includes 5 domains of alcohol-related negative consequences including interpersonal, intrapersonal, physical, impulse control and social. Drinking frequency and intensity were assessed by percent days abstinent (PDA) and drinks per drinking day (DPDD).

RESULTS

Cronbach alphas of the SIP were similar between urban AI adults and the mainstream treatment-seeking population reported in the SIP manual. DPDD was a significant and positive predictor of all five SIP scales collected 9-months later. Higher PDA was significantly and negatively associated with later consequences, and all 5 SIP scales. Moderation tests indicated that the association between consequences and drinking intensity was stronger for AI females with fewer drinking days resulting in significantly fewer consequences for AI males relative to AI females.

CONCLUSIONS

Findings highlight the acceptability of SIP as a measure to assess drinking related consequences among AI urban adults, with clinical implications related to alcohol use and sex. Further research is warranted to examine differential drinking related outcomes among AI men and women in addition to adaptations of the SIP that more fully capture the range of negative drinking consequences.

Alaska Native genomic research: perspectives from Alaska Native leaders, federal staff, and biomedical researchers

Meaningful engagement of Alaska Native (AN) tribes and tribal health organizations is essential in the conduct of socially responsible and ethical research. As genomics becomes increasingly important to advancements in medicine, there is a risk that populations not meaningfully included in genomic research will not benefit from the outcomes of that research. AN people have historically been underrepresented in biomedical research; AN underrepresentation in genomics research is compounded by mistrust based on past abuses, concerns about privacy and data ownership, and cultural considerations specific to this type of research. Working together, the National Human Genome Research Institute and two Alaska Native health organizations, Southcentral Foundation and the Alaska Native Health Board, cosponsored a workshop in July 2018 to engage key stakeholders in discussion, strengthen relationships, and facilitate partnership and consideration of participation of AN people in community-driven biomedical and genomic research. AN priorities related to translation of genomics research to health and health care, return of genomic results, design of research studies, and data sharing were discussed. This report summarizes the perspectives that emerged from the dialogue and offers considerations for effective and socially responsible genomic research partnerships with AN communities.

Global systematic review of the effects of suicide prevention interventions in Indigenous peoples

OBJECTIVE

Suicide rates are often higher in Indigenous than in non-Indigenous peoples. This systematic review assessed the effects of suicide prevention interventions on suicide-related outcomes in Indigenous populations worldwide.

METHODS

We searched CINAHL, Embase, PubMed, PsycINFO, ProQuest Dissertations & Theses and Web of Science from database inception to April 2020. Eligible were English language, empirical and peer-reviewed studies presenting original data assessing the primary outcomes of suicides and suicide attempts and secondary outcomes of suicidal ideation, intentional self-harm, suicide or intentional self-harm risk, composite measures of suicidality or reasons for life in experimental and quasi-experimental interventions with Indigenous populations worldwide. We assessed the risk of bias with the Cochrane Risk of Bias Tool and the Risk of Bias Assessment for Non-randomised Studies.

FINDINGS

We included 24 studies from Australia, Canada, New Zealand and the USA, comprising 14 before-after studies, 4 randomised controlled trials (RCTs), 3 non-randomised controlled trials, 2 interrupted time-series designs and 1 cohort study. Suicides decreased in four and suicide attempts in six before-after studies. No studies had a low risk of bias. There was insufficient evidence to confirm the effectiveness of any one suicide prevention intervention due to shortage of studies, risk of bias, and population and intervention heterogeneity. Review limitations include language bias, no grey literature search and data availability bias.

CONCLUSION

For the primary outcomes of suicides and suicide attempts, the limited available evidence supports multilevel, multicomponent interventions. However, there are limited RCTs and controlled studies.

Instruments for Measuring the Resilience of Indigenous Adolescents: An Exploratory Review

Introduction: Resilience is enabled by internal, individual assets as well as the resources available in a person's environment to support healthy development. For Indigenous people, these resources and assets can include those which enhance cultural resilience. Measurement instruments which capture these core resilience constructs are needed, yet there is a lack of evidence about which instruments are most appropriate and valid for use with Indigenous adolescents. The current study reviews instruments which have been used to measure the resilience of Indigenous adolescents in Canada, Australia, New Zealand, and the United States (the CANZUS nations). The aim is to provide guidance for the future use of instruments to measure resilience among Indigenous adolescents and provide recommendations for research to strengthen evidence in this area.

Method: Instruments were identified through a systematic search of resilience intervention and indicator studies targeting Indigenous youth from CANZUS nations. The studies were analyzed for information on the constructs of resilience measured in the instruments, their use with the targeted groups, and their psychometric properties. A second search was conducted to fill in any gaps in information. Instruments were included if they measured at least one construct of resilience reflecting individual assets, environmental resources, and/or cultural resilience.

Results: A total of 20 instruments were identified that measured constructs of resilience and had been administered to Indigenous adolescents in the CANZUS nations. Instruments which measured both individual assets and environmental resources (n = 7), or only environmental resources (n = 6) were most common. Several instruments (n = 5) also measured constructs of cultural resilience, and two instruments included items addressing all three constructs of individual assets, environmental resources, and cultural resilience. The majority of the reviewed studies tested the reliability (75%) and content or face validity (80%) of instruments with the target population.

Conclusion: There are several validated instruments available to appropriately measure constructs of resilience with Indigenous adolescents from CANZUS nations. Further work is needed on developing a consistent framework of resilience constructs to guide research efforts. Future instrument development and testing ought to focus on measures which include elements of all three core constructs critical to Indigenous adolescent resilience.

The qasgiq model as an indigenous intervention: Using the cultural logic of contexts to build protective factors for Alaska Native suicide and alcohol misuse prevention

OBJECTIVES

The foundational role culture and Indigenous knowledge (IK) occupy within community intervention in American Indian and Alaska Native (AIAN) communities is explored. To do this, we define community or complex interventions, then critically examine ways culture is translated into health interventions addressing AIAN disparities in existing programs and research initiatives. We then describe an Indigenous intervention based in the cultural logic of its contexts, as developed by Alaska Native communities. Yup'ik coauthors and knowledge keepers provided their critical and theoretical perspectives and understandings to the overall narrative, constructing from their IK system an argument that culture is prevention.

CONCLUSIONS

The intervention, the Qungasvik (phonetic: koo ngaz vik; "tools for life") intervention, is organized and delivered through a Yup'ik Alaska Native process the communities term qasgiq (phonetic: kuz gik; "communal house"). We describe a theory of change framework built around the qasgiq model and explore ways this Indigenous intervention mobilizes aspects of traditional Yup'ik cultural logic to deliver strengths-based interventions for Yup'ik youth. This framework encompasses both an IK theory-driven intervention implementation schema and an IK approach to knowledge production. This intervention and its framework provide a set of recommendations to guide researchers and Indigenous communities who seek to create Indigenously informed and locally sustainable strategies for the promotion of health and well-being. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Validation and Factor Analysis of the Child and Youth Resilience Measure for Indigenous Australian Boarding School Students

Introduction: Resilience is a strengths-based construct that is useful for understanding differences in health and wellbeing among youth. There are a range of validated survey instruments available to measure resilience for Aboriginal and Torres Strait Islander (hereafter respectfully Indigenous¹) youth. However, standard international instruments should only be used if they have been subjected to a rigorous cross-cultural adaptation process and psychometric evaluation in the target population to ensure their validity. The aim of the study was to validate an adapted Child and Youth Resilience Measure (CYRM-28) within a sample of Indigenous Australian boarding school students.

Method: The CYRM-28, augmented with an additional 11 site specific items was administered to a purposive sample of Australian Indigenous boarding school students (n = 233) as part of the broader T4S survey instrument that captures demographic information and measures resilience, psychological distress and risk, and service usage. Confirmatory factor analysis was undertaken to verify the relationship between the observed variables with the theoretical constructs of the CYRM-28 and previous findings on the factor structure. Cronbach alpha was also calculated to assess the internal consistency of the CYRM-28 within this sample.

Results: Survey data were not a good fit for any previously identified models of the CYRM-28, although the inclusion of a site-specific variable improved the overall fit statistics. Two separate scales were confirmed that capture the sources and expressions of resilience for Indigenous Australian boarding school students. This structure is different to previous findings in relation to the CYRM-28, but consistent with conceptualizations of resilience as a dynamic process.

Conclusions: The findings are useful in guiding the future use of the CYRM-28 instrument, explorations of Indigenous youth resilience, and for services working with Indigenous youth in out of home care situations. They highlight contextual differences in the measurement of resilience and the importance of validating standard instruments that have been subjected to rigorous cross-cultural adaptation processes. The two scales offer practical guidance to human services working with Indigenous youth on strategies to build and monitor resilience in Indigenous Australian youth and contribute to the emergent understanding of their resilience.

Advancing Scientific Methods in Community and Cultural Context to Promote Health Equity: Lessons From Intervention Outcomes Research With American Indian and Alaska Native Communities

Evidence-based interventions hold promise for reducing gaps in health equity across diverse populations, but evidence about effectiveness within these populations lags behind the mainstream, often leaving opportunities to fulfill this promise unrealized. Mismatch between standard intervention outcomes research methods and the cultural and community contexts of populations at greatest risk presents additional challenges in designing and implementing rigorous studies; these challenges too often impede efforts to generate needed evidence. We draw on experiences with American Indian and Alaska Native (AIAN) communities to illustrate how consideration of culture and context can constructively shape intervention research and improve the quality of evidence produced. Case examples from a partnership with one AI community highlight opportunities for increasing alignment in intervention development, research design, and study implementation to maximize both validity and feasibility. We suggest that responsively tailoring intervention outcome research to cultural and community contexts is fundamental to supporting health equity.

Multi-Level Cultural Intervention for the Prevention of Suicide and Alcohol Use Risk with Alaska Native Youth: a Nonrandomized Comparison of Treatment Intensity

Suicide and alcohol use disorders are primary determinants of health disparity among Alaska Native people in contrast to the US general population. Qungasvik, a Yup'ik word for toolbox, is a strengths-based, multi-level, community/cultural intervention for rural Yup'ik youth ages 12-18. The intervention uses "culture as intervention" to promote reasons for life and sobriety in young people using local expertise, high levels of community direction, and community based staff. The intervention is grounded in local practices and adaptive to local cultural differences distinctive to rural Yup'ik communities. The current study compares the effectiveness of high-intensity intervention in one community (treatment), operationalized as a high number of intervention activities, or modules, implemented and attended by youth, contrasted to a lower intensity intervention in a second community (comparison) that implemented fewer modules. A Yup'ik Indigenous theory of change developed through previous qualitative and quantitative work guides intervention. In the model, direct intervention effects on proximal or intermediate variables constituting protective factors at the individual, family, community, and peer influences levels lead to later change on the ultimate prevention outcome variables of Reasons for Life protective from suicide risk and Reflective Processes about alcohol use consequences protective from alcohol risk. Mixed effects regression models contrasted treatment and comparison arms, and identified significant intervention effects on Reasons for Life (d = 0.27, p < .05) but not Reflective Processes.

The prevalence of patient engagement in published trials: a systematic review

PLAIN ENGLISH SUMMARY

With the growing movement to engage patients in research, questions are being asked about who is engaging patients and how they are being engaged. Internationally, research groups are supporting and funding patient-oriented research studies that engage patients in the identification of research priorities and the design, conduct and uptake of research. As we move forward, we need to know what meaningful patient engagement looks like, how it benefits research and clinical practice, and what are the barriers to patient engagement?We conducted a review of the published literature looking for trials that report engaging patients in the research. We included both randomized controlled trials and non-randomized comparative trials. We looked at these trials for important study characteristics, including how patients were engaged, to better understand the practices used in trials. Importantly, we also discuss the number of trials reporting patient engagement practices relative to all published trials. We found that very few trials report any patient engagement activities even though it is widely supported by many major funding organizations. The findings of our work will advance patient-oriented research by showing how patients can be engaged and by stressing that patient engagement practices need to be better reported.

BACKGROUND

Patient-Oriented Research (POR) is research informed by patients and is centred on what is of importance to them. A fundamental component of POR is that patients are included as an integral part of the research process from conception to dissemination and implementation, and by extension, across the research continuum from basic research to pragmatic trials [J Comp Eff Res 2012, 1:181-94, JAMA 2012, 307:1587-8]. Since POR's inception, questions have been raised as to how best to achieve this goal.We conducted a systematic review of randomized controlled trials and non-randomized comparative trials that report engaging patients in their research. Our main goal was to describe the characteristics of published trials engaging patients in research, and to identify the extent of patient engagement activities reported in these trials.

METHODS

The MEDLINE®, EMBASE®, Cinahl, PsycINFO, Cochrane Methodology Registry, and Pubmed were searched from May 2011 to June 16th, 2016. Title, abstract and full text screening of all reports were conducted independently by two reviewers. Data were extracted from included trials by one reviewer and verified by a second. All trials that report patient engagement for the purposes of research were included.

RESULTS

Of the 9490 citations retrieved, 2777 were reviewed at full text, of which 23 trials were included. Out of the 23 trials, 17 were randomized control trials, and six were non-randomized comparative trials. The majority of these trials (83%, 19/23) originated in the United States and United Kingdom. The trials engaged a range of 2-24 patients/ community representatives per study. Engagement of children and minorities occurred in 13% (3/23) and 26% (6/23) of trials; respectively. Engagement was identified in the development of the research question, the selection of study outcomes, and the dissemination and implementation of results.

CONCLUSIONS

The prevalence of patient engagement in patient-oriented interventional research is very poor with 23 trials reporting activities engaging patients. Research dedicated to determining the best practice for meaningful engagement is still needed, but adequate reporting measures also need to be defined.

Native Transformations in the Pacific Northwest: A strength-based model of protection against substance use disorder

This paper presents findings from the Native Transformations Project, an exploratory community-based participatory research study that aims to identify sources of strength and protection against substance use disorder in three tribal communities in the coastal Pacific Northwest. Preliminary results from the study describe the specific settings, acts, and behaviors that build strengths and provide protection at the family, community, individual, and spiritual levels within coastal Pacific Northwest local tribal cultures. Findings from this study give voice to stated community preferences for grassroots Native intervention programs based in local cultural knowledge, worldviews, values, and theories of change, that operate at the local level on their own terms.

Culturally-Informed Interventions for Substance Abuse Among Indigenous Youth in the United States: A Review

PURPOSE

Given the disproportionately high levels of alcohol and other drug abuse among Indigenous youth in the United States, the purpose of this systematic review was to explicate the current state of empirically-based and culturally-informed substance abuse prevention and intervention programs for Indigenous youth (ages 9-18).

METHOD

The 14 articles that met inclusion criteria for this review were analyzed both in terms of the cultural intervention itself (primary population, intervention, core tenants, focus of intervention, intervention goals, location, intervention location, and program length) and their evaluation approach.

RESULTS

Results indicate variable integration of cultural components with the majority of interventions taking place in schools and treatment facilities, targeting primarily individuals.

DISCUSSION

There is a current gap in research on culturally-informed substance abuse interventions for Indigenous youth, which this review begins to address. Promising areas of future research and interventions include bringing communities and families into treatment and prevention.

Increasing the Sensitivity of Measures to Change

Little attention is paid in prevention research to the ability of measures to accurately assess change, termed "responsiveness" or "sensitivity to change." This paper reviews definitions and measures of responsiveness, and suggests five strategies for increasing sensitivity to change, with central focus on prevention research with small samples: (a) improving understandability and cultural validity, (b) assuring that the measure covers the full range of the latent construct being measured, (c) eliminating redundant items, (d) maximizing sensitivity of the device used to collect responses; and (e) asking directly about change. Examples of the application of each strategy are provided. The discussion focuses on using the issues as a checklist for improving measures and the implications of sensitivity to change for prevention research with small samples.

Suicide Rates in Aboriginal Communities in Labrador, Canada

OBJECTIVES

To compare suicide rates in Aboriginal communities in Labrador, including Innu, Inuit, and Southern Inuit, with the general population of Newfoundland, Canada.

METHODS

In partnership with Aboriginal governments, we conducted a population-based study to understand patterns of suicide mortality in Labrador. We analyzed suicide mortality data from 1993 to 2009 from the Vital Statistics Death Database. We combined this with community-based methods, including consultations with Elders, youths, mental health and community workers, primary care clinicians, and government decision-makers.

RESULTS

The suicide rate was higher in Labrador than in Newfoundland. This trend persisted across all age groups; however, the disparity was greatest among those aged 10 to 19 years. Males accounted for the majority of deaths, although suicide rates were elevated among females in the Inuit communities. When comparing Aboriginal subregions, the Innu and Inuit communities had the highest age-standardized mortality rates of, respectively, 165.6 and 114.0 suicides per 100 000 person-years.

CONCLUSIONS

Suicide disproportionately affects Innu and Inuit populations in Labrador. Suicide rates were high among male youths and Inuit females.

Relationship of Social Network to Protective Factors in Suicide and Alcohol Use Disorder Intervention for Rural Yup'ik Alaska Native Youth

Suicide and alcohol use disorders are significant Alaska Native health disparities, yet there is limited understanding of protection and no studies of social network factors in protection in this or other populations. The Qungasvik intervention enhances protective factors from suicide and alcohol use disorders through activities grounded in Yup'ik cultural practices and values. Identification of social network factors associated with protection within the cultural context of these tight, close knit, and high density rural Yup'ik Alaska Native communities in southwest Alaska can help identify effective prevention strategies for suicide and alcohol use disorder risk. Using data from ego-centered social network and protective factors from suicide and alcohol use disorders surveys with 50 Yup'ik adolescents, we provide descriptive data on structural and network composition variables, identify key network variables that explain major proportions of the variance in a four principal component structure of these network variables, and demonstrate the utility of these key network variables as predictors of family and community protective factors from suicide and alcohol use disorder risk. Connections to adults and connections to elders, but not peer connections, emerged as predictors of family and community level protection, suggesting these network factors as important intervention targets for intervention.

Creating Qungasvik (a Yup'ik intervention "toolbox"): case examples from a community-developed and culturally-driven intervention

This paper describes the development of a Yup'ik Alaska Native approach to suicide and alcohol abuse prevention that resulted in the creation of the Qungasvik, a toolbox promoting reasons for life and sobriety among youth. The Qungasvik is made up of thirty-six modules that function as cultural scripts for creating experiences in Yup'ik communities that build strengths and protection against suicide and alcohol abuse. The Qungasvik manual represents the results of a community based participatory research intervention development process grounded in culture and local process, and nurtured through a syncretic blending of Indigenous and Western theories and practices. This paper will provide a description of the collaborative steps taken at the community-level to develop the intervention modules. This process involved university researchers and community members coming together and drawing from multiple sources of data and knowledge to inform the development of prevention activities addressing youth suicide and alcohol abuse. We will present case examples describing the development of three keystone modules; Qasgiq (The Men's House), Yup'ik Kinship Terms, and Surviving Your Feelings. These modules each are representative of the process that the community co-researcher team took to develop and implement protective experiences that: (1) create supportive community, (2) strengthen families, and (3) give individuals tools to be healthy and strong.

A protective factors model for alcohol abuse and suicide prevention among Alaska Native youth

This study provides an empirical test of a culturally grounded theoretical model for prevention of alcohol abuse and suicide risk with Alaska Native youth, using a promising set of culturally appropriate measures for the study of the process of change and outcome. This model is derived from qualitative work that generated an heuristic model of protective factors from alcohol (Allen et al. in J Prev Interv Commun 32:41-59, 2006; Mohatt et al. in Am J Commun Psychol 33:263-273, 2004a; Harm Reduct 1, 2004b). Participants included 413 rural Alaska Native youth ages 12-18 who assisted in testing a predictive model of Reasons for Life and Reflective Processes about alcohol abuse consequences as co-occurring outcomes. Specific individual, family, peer, and community level protective factor variables predicted these outcomes. Results suggest prominent roles for these predictor variables as intermediate prevention strategy target variables in a theoretical model for a multilevel intervention. The model guides understanding of underlying change processes in an intervention to increase the ultimate outcome variables of Reasons for Life and Reflective Processes regarding the consequences of alcohol abuse.

People awakening: collaborative research to develop cultural strategies for prevention in community intervention

The consequences of alcohol use disorder (AUD) and suicide create immense health disparities among Alaska Native people. The People Awakening project is a long-term collaboration between Alaska Native (AN) communities and university researchers seeking to foster health equity through development of positive solutions to these disparities. These efforts initiated a research relationship that identified individual, family, and community protective factors from AUD and suicide. AN co-researchers next expressed interest in translating these findings into intervention. This led to development of a strengths-based community intervention that is the focus of the special issue. The intervention builds these protective factors to prevent AUD and suicide risk within AN youth, and their families and communities. This review provides a critical examination of existing literature and a brief history of work leading to the intervention research. These work efforts portray a shared commitment of university researchers and community members to function as co-researchers, and to conduct research in accord with local Yup'ik cultural values. This imperative allowed the team to navigate several tensions we locate in a convergence of historical and contemporary ecological contextual factors inherent in AN tribal communities with countervailing constraints imposed by Western science.

Introduction to ecological description of a community intervention: building prevention through collaborative field based research

This special issue of the American Journal of Community Psychology is the result of a 18-year partnership with Alaska Native communities using collaborative field based research methods. Its goal is to provide a case study fulfilling the spirit of ecological inquiry, offering a detailed and nuanced description of a community intervention. The articles describe the nature of our work, including some of our successes, as well as challenges, dilemmas, and even disappointments we experienced along the way. Our primary aim was to develop and assess the feasibility of a complex, multi-level intervention to increase protective factors hypothesized to reduce suicide and alcohol abuse among rural Yup'ik Alaska Native youth ages 12-18. The articles that follow include descriptions of the cultural context, relevant literature and project history, our methods of community engagement in measurement development strategies, an empirical test of the prevention model that guided the intervention, the development and implementation of the intervention, a feasibility and impact assessment, and an evaluation of community engagement. A final article summarizes what is generalizable from the work in field based intervention research with rural and culturally distinct populations, and future prospects for decolonizing community intervention research methods. These papers raise important issues, including (1) need for deep, contextual ecological descriptions, (2) reconceptualization of time in the research relationship, (3) distinctions between populations and communities, and (4) the conflict between values of communities and intervention science.