Prevalence of mental disorders and utilization of mental health services in two American Indian reservation populations: mental health disparities in a national context

Social zeitgeber and sleep loss as risk factors for suicide in American Indian adolescents

American Indians / Alaska Natives (AI/AN) bear a high burden of suicide, the reasons for which are not completely understood, and rates can vary by tribal group and location. This article aims to identify circumstances reported by a community group of American Indian adolescent participants to be associated with their depression and/or suicide. American Indian adolescents (n  =  360) were recruited from contiguous reservations and were assessed with a semi-structured diagnostic interview. Twenty percent of the adolescents reported suicidal thoughts (ideation, plans), an additional 8% reported a history of suicide attempts, and three deaths due to suicide were reported. Suicidal behaviors and major depressive disorder (MDD) co-occurred and were more common among female adolescents. The distressing events that adolescents most often reported were: death in the family, family disruption, peer relationship problems, and school problems. All of these events were significantly associated with suicidal behaviors, however those with suicidal acts were more likely to report death in the family. Those with MDD but no suicidal behaviors were more likely to report disruptions in the family. Disruptions in falling asleep were also associated with suicidal behaviors and having experienced a death in the family. Disruptions in important relationships, particularly through death or divorce, may be interpreted as a loss or disruption in "social zeitgebers" that may in turn disturb biological rhythms, such as sleep, thus potentially increase the risk for MDD and/or suicide. Prevention programs aimed at ameliorating the impact of disruptions in important relationships may potentially reduce suicidal behaviors in AI/AN adolescents.

Tribal Reservation Adolescent Connections Study: A study protocol using mixed methods for examining social networks and associated outcomes among American Indian youth on a Northern Plains reservation

BACKGROUND

Rich cultural and traditional practices make interpersonal relationships vital for American Indian (AI) youth. Social relations and multigenerational networks (i.e., peer, family, kinship, and community) remain a salient fixture of AI culture, survival and thriving in reservation communities. Research in other populations has demonstrated how social networks impact youth risk and resilience, but data are lacking on AI adolescent networks. Intergenerational trauma from settler colonialism leads some AI youth to early initiation of substance use and subsequent substance misuse, along with disproportionately high risk for suicide and vulnerability to witnessing and experiencing violence. Using network data to develop prevention strategies among this population is a promising new avenue of research. In this study protocol paper, we describe the rationale and methodology of an exploratory study to be conducted with American Indian 9th and 10th graders at three schools on a Northern Plains reservation.

METHODS

This mixed methods study will collect quantitative social network surveys (N = 300) and qualitative interviews (n = 30). The study will examine the extent to which existing social network theories and data metrics adequately characterize AI youth networks or how they may need to be expanded for this population. Associations of network characteristics with risk and protective factors for substance use, exposure to violence, and suicide will also be examined.

DISCUSSION

This innovative methodological approach holds promise for informing the development of effective preventive approaches to address co-occurring risks for substance use, violence and suicide among AI adolescents. Understanding processes that impact social networks among AI adolescents can promote culturally resonant social relationships that may support better outcomes for youth.

Genetic factors associated with suicidal behaviors and alcohol use disorders in an American Indian population

American Indians (AI) demonstrate the highest rates of both suicidal behaviors (SB) and alcohol use disorders (AUD) among all ethnic groups in the US. Rates of suicide and AUD vary substantially between tribal groups and across different geographical regions, underscoring a need to delineate more specific risk and resilience factors. Using data from over 740 AI living within eight contiguous reservations, we assessed genetic risk factors for SB by investigating: (1) possible genetic overlap with AUD, and (2) impacts of rare and low-frequency genomic variants. Suicidal behaviors included lifetime history of suicidal thoughts and acts, including verified suicide deaths, scored using a ranking variable for the SB phenotype (range 0-4). We identified five loci significantly associated with SB and AUD, two of which are intergenic and three intronic on genes AACSP1, ANK1, and FBXO11. Nonsynonymous rare and low-frequency mutations in four genes including SERPINF1 (PEDF), ZNF30, CD34, and SLC5A9, and non-intronic rare and low-frequency mutations in genes OPRD1, HSD17B3 and one lincRNA were significantly associated with SB. One identified pathway related to hypoxia-inducible factor (HIF) regulation, whose 83 nonsynonymous rare and low-frequency variants on 10 genes were significantly linked to SB as well. Four additional genes, and two pathways related to vasopressin-regulated water metabolism and cellular hexose transport, also were strongly associated with SB. This study represents the first investigation of genetic factors for SB in an American Indian population that has high risk for suicide. Our study suggests that bivariate association analysis between comorbid disorders can increase statistical power; and rare and low-frequency variant analysis in a high-risk population enabled by whole-genome sequencing has the potential to identify novel genetic factors. Although such findings may be population specific, rare functional mutations relating to PEDF and HIF regulation align with past reports and suggest a biological mechanism for suicide risk and a potential therapeutic target for intervention.

Resilience and health in American Indians and Alaska Natives: A scoping review of the literature

American Indians and Alaska Natives suffer from disproportionately high rates of chronic mental and physical health conditions. These health inequities are linked to colonization and its downstream consequences. Most of the American Indian and Alaska Native health inequities research uses a deficit framework, failing to acknowledge the resilience of American Indian and Alaska Native people despite challenging historical and current contexts. This scoping review is based on a conceptual model which acknowledges the context of colonization and its consequences (psychological and health risk factors). However, rather than focusing on health risk, we focus on protective factors across three identified domains (social, psychological, and cultural/spiritual), and summarize documented relationships between these resilience factors and health outcomes. Based on the scoping review of the literature, we note gaps in extant knowledge and recommend future directions. The findings summarized here can be used to inform and shape future interventions which aim to optimize health and well-being in American Indian and Alaska Native peoples.

Alzheimer's disease and its related dementias in US Native Americans: A major public health concern

Alzheimer's disease (AD) and Alzheimer's related dementias (ADRD) are growing public health concerns in aged populations of all ethnic and racial groups. AD and ADRD are caused by multiple factors, such as genetic mutations, modifiable and non-modifiable risk factors, and lifestyle. Studies of postmortem brains have revealed multiple cellular changes implicated in AD and ADRD, including the accumulation of amyloid beta and phosphorylated tau, synaptic damage, inflammatory responses, hormonal imbalance, mitochondrial abnormalities, and neuronal loss. These changes occur in both early-onset familial and late-onset sporadic forms. Two-thirds of women and one-third of men are at life time risk for AD. A small proportion of total AD cases are caused by genetic mutations in amyloid precursor protein, presenilin 1, and presenilin 1 genes, and the APOE4 allele is a risk factor. Tremendous research on AD/ADRD, and other comorbidities such as diabetes, obesity, hypertension, and cancer has been done on almost all ethnic groups, however, very little biomedical research done on US Native Americans. AD/ADRD prevalence is high among all ethnic groups. In addition, US Native Americans have poorer access to healthcare and medical services and are less likely to receive a diagnosis once they begin to exhibit symptoms, which presents difficulties in treating Alzheimer's and other dementias. One in five US Native American people who are 45 years of age or older report having memory issues. Further, the impact of caregivers and other healthcare aspects on US Native Americans is not yet. In the current article, we discuss the history of Native Americans of United States (US) and health disparities, occurrence, and prevalence of AD/ADRD, and shedding light on the culturally sensitive caregiving practices in US Native Americans. This article is the first to discuss biomedical research and healthcare disparities in US Native Americans with a focus on AD and ADRD, we also discuss why US Native Americans are reluctant to participate in biomedical research.

COVID-19 pandemic effects on emotional health and substance use among urban American Indian and Alaska Native people

OBJECTIVE

The COVID-19 pandemic has disproportionately affected American Indian and Alaska Native (AI/AN) people, who experience a 3.2 times higher age-adjusted rate of hospitalization and nearly double the attributed deaths compared to non-Hispanic Whites. We examined pandemic effects on emotional health and substance use in urban AI/AN people.

METHODS

From January-May 2021 we collected cross-sectional data from 642 patients seen at five health organizations serving primarily AI/AN people in urban settings. The outcomes are self-reported, cross-sectional changes in emotional health and substance use since pandemic onset. Exposures of interest include infection history, COVID-19 risk perception, pandemic-related life disruption, and feared effects on AI/AN culture. Poisson regression was used to model adjusted multivariate associations.

RESULTS

Since pandemic onset, 46% of participants reported worsened emotional health; 20% reported increased substance use. Very or extremely disruptive pandemic experiences and increasing reported feared pandemic effects on culture were associated with worse pandemic emotional health [adjusted Prevalence Ratio 1.84; 95% CI 1.44, 2.35 and 1.11; 95% CI 1.03, 1.19], respectively. COVID-19 infection and risk perception were not associated with emotional health after adjustment for other factors. The primary exposures were not associated with change in substance use.

CONCLUSIONS

The COVID-19 pandemic has impacted the emotional health of urban AI/AN people. The finding that poor emotional health is associated with pandemic-related threats to AI/AN culture may signal a protective role for community and cultural resources. This warrants further study as exploratory analysis did not find hypothesized effect modification according to strength of affiliation with AI/AN culture.

Genetic Factors Associated with Suicidal Behaviors and Alcohol Use Disorders in an American Indian Population

American Indians (AI) demonstrate the highest rates of both suicidal behaviors (SB) and alcohol use disorders (AUD) among all ethnic groups in the US. Rates of suicide and AUD vary substantially between tribal groups and across different geographical regions, underscoring a need to delineate more specific risk and resilience factors. Using data from over 740 AI living within eight contiguous reservations, we assessed genetic risk factors for SB by investigating: (1) possible genetic overlap with AUD, and (2) impacts of rare and low frequency genomic variants. Suicidal behaviors included lifetime history of suicidal thoughts and acts, including verified suicide deaths, scored using a ranking variable for the SB phenotype (range 0-4). We identified five loci significantly associated with SB and AUD, two of which are intergenic and three intronic on genes AACSP1, ANK1, and FBXO11. Nonsynonymous rare mutations in four genes including SERPINF1 (PEDF), ZNF30, CD34, and SLC5A9, and non-intronic rare mutations in genes OPRD1, HSD17B3 and one lincRNA were significantly associated with SB. One identified pathway related to hypoxia-inducible factor (HIF) regulation, whose 83 nonsynonymous rare variants on 10 genes were significantly linked to SB as well. Four additional genes, and two pathways related to vasopressin-regulated water metabolism and cellular hexose transport, also were strongly associated with SB. This study represents the first investigation of genetic factors for SB in an American Indian population that has high risk for suicide. Our study suggests that bivariate association analysis between comorbid disorders can increase statistical power; and rare variant analysis in a high-risk population enabled by whole-genome sequencing has the potential to identify novel genetic factors. Although such findings may be population specific, rare functional mutations relating to PEDF and HIF regulation align with past reports and suggest a biological mechanism for suicide risk and a potential therapeutic target for intervention.

A Systematic Review of Trauma and Substance Use in American Indian and Alaska Native Individuals: Incorporating Cultural Considerations

INTRODUCTION

Disproportionate rates of psychiatric disorders, like substance use and posttraumatic stress disorders (SUD and PTSD), exist among American Indian and Alaska Native (AI/AN) individuals. This review examines substance use and trauma in existing AI/AN literature and utilizes an AI/AN-specific model to culturally inform the relationship between these factors and provide recommendations for future research.

METHODS

We searched three databases through April 2021 for peer-reviewed articles that examined substance use and trauma in AI/AN individuals.

RESULTS

The search identified 289 articles and of those, 42 were eligible for inclusion, including 36 quantitative and 6 qualitative studies. Rates of lifetime trauma exposure varied from 21 to 98% and were correlated with increased rates of SUDs. A dose response of traumatic events also increased the likelihood of an SUD among reservation-based AI populations. Factors from the Indigenist Stress Coping model included cultural buffers such as traditional healing and cultural identity, which aided in recovery from SUD and trauma, and social stressors like boarding school attendance, discrimination, and historical loss.

CONCLUSIONS

SUD and trauma are highly correlated among AI/AN individuals though rates of PTSD are lower than might be expected suggesting resilience. However, this pattern may not be consistent across all AI/AN groups and further research is needed to better explain the existing relationship of SUD and PTSD and relevant historical and cultural factors. Further research is needed to culturally tailor, implement, and validate PTSD and SUD assessments and treatments to ameliorate these health inequities.

Emotion Regulation Strategies Relate to Ambulatory Cardiovascular Activity in an American Indian Community

OBJECTIVE

Poor emotion regulation is associated with risk for cardiovascular disease. However, much of this research is conducted in primarily White samples, thus limiting our understanding of this relationship in other racial/ethnic groups. American Indians (AIs) are uniquely and disproportionately at risk for cardiovascular disease. As such, the present study aimed to examine the relationships between emotion regulation strategies and ambulatory cardiovascular activity in an entirely AI sample.

METHODS

The sample consisted of 100 AI adults living on a tribal reservation. Emotion regulation strategies (expressive suppression, cognitive reappraisal) were assessed via the Emotion Regulation Questionnaire. Using ecological momentary assessment, daily measurements of psychological stress and ambulatory cardiovascular activity were taken during a 7-day monitoring period. Statistical analyses included bivariate correlations, hierarchical linear regression models, and mediation models.

RESULTS

Expressive suppression was associated with higher systolic and diastolic blood pressure, as well as higher pulse rate. In contrast, cognitive reappraisal was associated with lower systolic and diastolic blood pressure, lower pulse rate, and lower average daily psychological stress. These results remained statistically significant after adjusting for age, sex, body mass index, anxiety, depression, and early life trauma. In addition, psychological stress mediated the associations between blood pressure and cognitive reappraisal, but not expressive suppression.

CONCLUSIONS

These results provide preliminary evidence for divergent associations of two emotion regulation strategies with cardiovascular activity and psychological stress in an AI community. Modifying health interventions to include training in effective emotion regulation may be beneficial.

Coverage Parity And Racial And Ethnic Disparities In Mental Health And Substance Use Care Among Medicare Beneficiaries

Many older Americans do not receive needed care for mental health and substance use disorders (MHSUD), and there are substantial racial and ethnic disparities in receipt of this care across the lifespan. Medicare introduced cost-sharing parity for outpatient MHSUD care during the period 2010-14, reducing beneficiaries' out-of-pocket share of MHSUD spending from 50 percent to 20 percent. Among traditional Medicare beneficiaries ages sixty-five and older, we examined changes in MHSUD use and spending during the period 2008-18 for low-income beneficiaries with the cost-sharing reduction versus a control group of beneficiaries with free care throughout the study period among Black, Hispanic, Asian, and American Indian/Alaska Native versus White beneficiaries. Among older Medicare beneficiaries, overall use of MHSUD services increased during this period. For White beneficiaries, MHSUD cost-sharing parity was associated with an increased likelihood of having specialty MHSUD visits and medication use and a reduced likelihood of having unmonitored MHSUD medication use and MHSUD emergency department visits and hospitalizations. However, cost-sharing parity was associated with smaller or no gains in MHSUD services use for racial and ethnic minority beneficiaries compared with White beneficiaries, thus widening racial and ethnic disparities in MHSUD care.

Caring Texts, a strength-based, suicide prevention trial in 5 native communities: Research design and methods

BACKGROUND

Despite their intrinsic strengths and resilience, some American Indian and Alaska Native (AI/AN) communities experience among the highest rates of suicide of any racial and ethnic group. Caring Contacts is one of the only interventions shown to reduce suicide in clinical trials, but it has not been tested in AI/AN settings.

OBJECTIVE

To compare the effectiveness of Enhanced Usual Care (control) to Enhanced Usual Care augmented with a culturally adapted version of Caring Contacts (intervention) for reducing suicidal ideation, suicide attempts, and suicide-related hospitalizations.

METHODS

We are implementing a single blind randomized controlled trial of Caring Contacts in five AI/AN communities across the country (South Dakota, Montana, Oklahoma, and Alaska). Eligible participants have to be (1) actively suicidal or have made a suicide attempt within the past year; (2) at least 18 years of age; (3) AI/AN; (4) able to speak and read English; (5) able to participate voluntarily; (6) willing to be contacted by text, email or postal mail; and (7) able to provide consent. Following consent and baseline assessment, participants are randomized to receive either Enhanced Usual Care alone, or Enhanced Usual Care with 12 months (25 messages) of culturally adapted Caring Contacts. Follow-up assessments are conducted at 12 and 18 months.

CONCLUSIONS

If effective, this study of Caring Contacts will inform programs to reduce suicide in the study communities as well as inform future research on Caring Contacts in other tribal settings. Modifications to continue the trial during the COVID-19 pandemic are discussed.

CLINICAL TRIALS REGISTRATION

NCT02825771.

Trauma, historical trauma, PTSD and suicide in an American Indian community sample

AIMS

To study the associations between perceived historical trauma, current traumatic events, diagnoses of post-traumatic stress disorder (PTSD), and suicidal behaviors in an American Indian community sample.

METHODS

Participants were American Indians recruited from reservations who were assessed with the Semi-Structured Assessment for the Genetics of Alcoholism (SSAGA), as well as the Historical Loss Scale, Historical Loss Associated Symptoms Scale, and Stressful Life Events Scale.

RESULTS

In data from 447 American Indian adults (mean age = 33 years), twenty percent reported lifetime experiences of suicidal thoughts (ideation and/or plans) and 14% reported suicidal acts, (including either a suicide attempt history or verified death by suicide (n = 4)). Diagnosis of PTSD and experience of assaultive trauma were each significantly associated with suicidal thoughts and acts, although assaultive trauma did not remain significant in models adjusting for gender and PTSD. High endorsement of symptoms associated with historical trauma was significantly associated with suicidal acts, and this remained significant when adjusting for gender and PTSD.

CONCLUSIONS

PTSD and historical trauma have an association with suicide and suicidal attempts in this American Indian community. Although further research is needed to evaluate the causal nature of these relations, these findings suggest treatment and prevention programs for American Indian suicide may benefit from addressing issues related to feelings of historical losses, PTSD, and their associated symptomatology.

Anxiety and Depression in Northern Plains American Indian Youth: Evidence for Resilience and Risk

Developing research collaborations with Indigenous communities to understand the expression and experience of anxiety and depression in American Indian (AI) youth and identifying protective and risk factors may be an important first step toward addressing AI health inequities. We used a community-based participatory research (CBPR) approach to investigate anxiety and depressive disorder symptoms among AI youth living on a Northern Plains reservation. Moreover, we examined whether symptoms were related to two potential protective and risk factors, anxiety control beliefs and rumination. Our tribal research team collected multi-reporter survey data from 71 AI 3rd-6th graders (8-13-years-old; 62.3% female) attending a tribal school, their caregivers, and teachers. Results pointed toward resilience in this sample with 7.3% and 8.7% of AI youth reporting clinical levels of anxiety and depressive disorder symptoms, respectively, and on average experiencing symptoms "Sometimes." There were moderate correlations between youth- and teacher-reported anxiety and depressive disorder symptoms, but no correlation with caregivers. Anxiety control beliefs were lower in older compared to younger AI youth and negatively related to youth-reported anxiety and depressive disorder symptoms, while rumination was positively related to youth-reported anxiety and depressive disorder symptoms and teacher-reported anxiety disorder symptoms. Age moderated relations between anxiety control beliefs and both youth-reported anxiety and depressive disorder symptoms with only significant relations found for older youth. Our findings are consistent with research showing resilience to internalizing problems in AI youth living on a reservation, but replication of their relations to anxiety control beliefs and rumination in other Indigenous peoples is warranted.

Systematic review of Indigenous involvement and content in mental health interventions and their effectiveness for Indigenous populations

OBJECTIVE

To assess the effects of psychological, psychosocial, educational and alternative interventions on mental health outcomes of Indigenous adult populations in Australia, Canada, New Zealand and the United States and the Indigenous involvement and content in each study.

METHODS

We systematically searched databases, key journals and gray literature, for records until June 2020. Eligible studies were in English or French and examined the impact of interventions on mental health outcomes including anxiety disorders, posttraumatic stress disorder, depression, psychological distress or stress for Indigenous adults (⩾16 years). Data were extracted using a modified Cochrane Data Extraction Form and the Template for Intervention Description and Replication. Quality was evaluated using the Effective Public Health Practice Project quality assessment form.

RESULTS

In total, 21 studies were eligible, comprising 8 randomized controlled trials, 10 single-group pre-post studies and 3 pre-post studies with comparison groups. Twenty studies had Indigenous individuals or organizations involved in some decision-making capacity, though extent of involvement varied widely. In total, 9 studies were rated moderate and 12 weak in the Effective Public Health Practice Project quality assessment. Eight studies measuring depression, three measuring posttraumatic stress disorder, three measuring psychological distress and two measuring stress showed statistically significant improvements following the intervention.

CONCLUSION

A wide range of interventions demonstrated mental health improvements. However, it is difficult to draw generalizable conclusions on intervention effectiveness, given heterogeneity among studies. Studies should employ a thorough assessment of the Indigenous involvement and content of their interventions for reporting and for critical consideration of the implications of their research and whether they address Indigenous determinants of mental health.

Help-Seeking Patterns and Barriers to Care Among Latino Immigrant Men with Unhealthy Alcohol Use

Latino immigrant men have high rates of unhealthy alcohol use, a wide range of behaviors, from drinking above the recommended limits to severe alcohol use disorder, yet have low levels of treatment-seeking. Little is known about their preferred sources of care and barriers to care. Using survey data from a community-based sample of Latino immigrant men (N=121) with unhealthy alcohol use (AUDIT≥6), we described help-seeking patterns and perceived barriers to care. The mean AUDIT score was 20 (SD 10; range 6-40), and 49% of men had severe levels of unhealthy alcohol use (AUDIT score ≥ 20). We observed low help-seeking rates and high levels of perceived internal and external barriers. Thirty percent reported having sought help for drinking. Most men reported wanting to solve their drinking problem on their own (65%). Our findings were consistent with previous research. Future studies should further describe barriers to treatment among low-income Latino immigrant men with unhealthy alcohol use and identify ways to increase access to low-cost, high-quality treatment options.

Increasing Native Research Leadership Through an Early Career Development Program

Inequities impact American Indian, Alaska Native, and Native Hawaiian populations across various health conditions; in particular, many Native communities bear a disproportionate burden of substance use disorder. Such inequities persist despite concerted efforts of communities and significant research directed toward prevention and intervention. One factor hampering these efforts is the underrepresentation of researchers who are themselves Native and uniquely equipped to respond to the needs of their communities. This paper describes the innovative Native Children's Research Exchange (NCRE) Scholars program, now entering its ninth year of successful career development support for emerging Native scholars. We summarize the history of NCRE Scholars, outline the mentoring and training approaches taken to meet the unique needs of early-career Native scholars, and present key progress of program alumni. The current cohort of Scholars provide first-person perspectives on how four key program elements have supported their career development to date. NCRE Scholars has been an effective approach for supporting the next generation of Native research leaders and for helping to build an essential mass of Native researchers prepared to respond to Native community health priority needs.

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.

The Association Between Adverse Life Events, Psychological Stress, and Pain-Promoting Affect and Cognitions in Native Americans: Results from the Oklahoma Study of Native American Pain Risk

Native Americans (NAs) experience higher rates of chronic pain. To examine the mechanisms for this pain inequity, we have previously shown that NAs report higher levels of pain-related anxiety and pain catastrophizing, which are in turn related to pronociceptive (pain-promoting) processes. But, it is currently unclear why NAs would report greater pain-related anxiety and catastrophizing. Given that NAs are also more likely to experience adverse life events (ALEs) and associated psychological distress, it was hypothesized that higher anxiety/catastrophizing in NAs would be partially explained by higher rates of ALEs and psychological distress. Structural equation modeling was used to analyze these pathways (NA ethnicity ➔ ALEs ➔ psychological distress ➔ pain anxiety/catastrophizing) in 305 healthy, pain-free adults (N = 155 NAs, N = 150 non-Hispanic Whites [NHWs]). Pain-related anxiety and situational pain catastrophizing were assessed in response to a variety of painful tasks. The Life Events Checklist was used to assess cumulative exposure to ALEs that directly happened to each participant. A latent psychological distress variable was modeled from self-reported perceived stress and psychological symptoms. Results found that NAs experienced more ALEs and greater psychological distress which was associated with higher rates of pain-related anxiety and pain catastrophizing. Notably, NAs did not report greater psychological distress when controlling for ALE exposure. This suggests that a higher risk of chronic pain in NAs may be due, in part, to psychological distress, pain-related anxiety, and pain catastrophizing that are promoted by exposure to ALEs. These results highlight several targets for intervention to decrease NA pain risk.

Vaginal microbiota of American Indian women and associations with measures of psychosocial stress

Molecular-bacterial vaginosis (BV) is characterized by low levels of vaginal Lactobacillus species and is associated with higher risk of sexually transmitted infections (STI). Perceived psychosocial stress is associated with increased severity and persistence of infections, including STIs. American Indians have the highest rates of stress and high rates of STIs. The prevalence of molecular-BV among American Indian women is unknown. We sought to evaluate measures of psychosocial stress, such as historic loss (a multigenerational factor involving slavery, forced removal from one's land, legally ratified race-based segregation, and contemporary discrimination) and their association with the vaginal microbiota and specific metabolites associated with BV, in 70 Northwestern Plains American Indian women. Demographics, perceived psychosocial stressors, sexual practices, and known BV risk factors were assessed using a modified version of the American Indian Service Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project survey. Self-collected mid-vaginal swabs were profiled for bacterial composition by 16S rRNA gene amplicon sequencing and metabolites quantified by targeted liquid-chromatography mass spectrometry. Sixty-six percent of the participants were classified as having molecular-BV, with the rest being either dominated by L. crispatus (10%) or L. iners (24%). High levels of lifetime trauma were associated with higher odds of having molecular-BV (adjusted Odds Ratio (aOR): 2.5, 95% Credible Interval (CrI): 1.1-5.3). Measures of psychosocial stress, including historic loss and historic loss associated symptoms, were significantly associated with lifestyle and behavioral practices. Higher scores of lifetime trauma were associated with increased concentrations of spermine (aFC: 3.3, 95% CrI: 1.2-9.2). Historic loss associated symptoms and biogenic amines were the major correlates of molecular-BV. Historical loss associated symptoms and lifetime trauma are potentially important underlying factors associated with BV.

Indigenous standpoint theory as a theoretical framework for decolonizing social science health research with American Indian communities

Theoretical frameworks rooted in Western knowledge claims utilized for public health research in the social sciences are not inclusive of American Indian communities. Developed by Indigenous researchers, Indigenous standpoint theory builds from and moves beyond Western theoretical frameworks. We argue that using Indigenous standpoint theory in partnership with American Indian communities works to decolonize research related to American Indian health in the social sciences and combats the effects of colonization in three ways. First, Indigenous standpoint theory aids in interpreting how the intersections unique to American Indians including the effects of colonization, tribal and other identities, and cultural context are linked to structural inequalities for American Indian communities. Second, Indigenous standpoint theory integrates Indigenous ways of knowing with Western research orientations and methodologies in a collaborative process that works to decolonize social science research for American Indians. Third, Indigenous standpoint theory promotes direct application of research benefits to American Indian communities.

Are Cardiometabolic Markers of Allostatic Load Associated With Pronociceptive Processes in Native Americans?: A Structural Equation Modeling Analysis From the Oklahoma Study of Native American Pain Risk

Native Americans (NAs) experience higher rates of chronic pain than the general U.S. population, but the risk factors for this pain disparity are unknown. NAs also experience high rates of stressors and cardiovascular and metabolic health disparities (eg, diabetes, cardiovascular disease) consistent with allostatic load (stress-related wear-and-tear on homeostatic systems). Given that allostatic load is associated with chronic pain, then allostatic load may contribute to their pain disparity. Data from 302 healthy, pain-free men and women (153 NAs, 149 non-Hispanic Whites [NHW]) were analyzed using structural equation modeling to determine whether cardiometabolic allostatic load (body mass index, blood pressure, heart rate variability) mediated the relationship between NA ethnicity and experimental measures of pronociceptive processes: temporal summation of pain (TS-pain) and the nociceptive flexion reflex (TS-NFR), conditioned pain modulation of pain (CPM-pain) and NFR (CPM-NFR), and pain tolerance. Results indicated that NAs experienced greater cardiometabolic allostatic load that was related to enhanced TS-NFR and impaired CPM-NFR. Cardiometabolic allostatic load was unrelated to measures of pain perception (CPM-pain, TS-pain, pain sensitivity). This suggests cardiometabolic allostatic load may promote spinal sensitization in healthy NAs, that is not concomitant with pain sensitization, perhaps representing a unique pain risk phenotype in NAs. PERSPECTIVE: Healthy, pain-free Native Americans experienced greater cardiometabolic allostatic load that was associated with a pronociceptive pain phenotype indicative of latent spinal sensitization (ie, spinal sensitization not associated with hyperalgesia). This latent spinal sensitization could represent a pain risk phenotype for this population.

Spiritual connectedness through prayer as a mediator of the relationship between Indigenous language use and positive mental health

OBJECTIVE

The objective of this study is to understand how Indigenous language and spirituality revitalization efforts may affect mental health within Indigenous communities. Although Indigenous communities experience disproportionate rates of mental health problems, research supporting language and spirituality's role in improving mental health is under-researched and poorly understood.

METHOD

Data for this study are from a Community-based Participatory Research Project involving five Anishinaabe tribes in Minnesota and Wisconsin. Participants were sampled from clinic records of adults with a diagnosis of type 2 diabetes, living on or near the reservation, and self-identifying as American Indian (mean age = 46.3; n = 191).

RESULT

Structural equation modeling illustrates that language use in the home is associated with positive mental health through spiritual connectedness.

CONCLUSION

Results support tribal community expressions of the positive effects of cultural involvement for Indigenous wellbeing, and improve what is known about the interconnectedness of language and spirituality. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Where there's a will, there's a way? Strategies to reduce or abstain from alcohol use developed by Northern Plains American Indian women participating in a brief, alcohol-exposed pregnancy preconceptual intervention

BACKGROUND

Alcohol-exposed pregnancy (AEP) is an ongoing concern, especially within low-resource, high-risk areas such as rural American Indian/Alaska Native (AIAN) communities. Brief, preconceptual AEP-reduction interventions are popular in such areas but have a small impact on alcohol use. Developing a strategic alcohol change plan is a key program component; however, there is little research on strategy selection, especially within contexts that positively or negatively impact selection (e.g., cultural strengths, trauma, collective efficacy within AIAN communities). This study qualitatively analyzed strategies chosen to reduce alcohol use by AIAN women participating in a culturally tailored, brief, preconceptual AEP-reduction intervention.

METHODS

One hundred-sixty Northern Plains AIAN women who were participating in a brief AEP-reduction program developed a plan to accomplish an alcohol reduction/abstention goal at the first and last program sessions. The plan included choosing 1 or more strategies to (1) achieve the goal, (2) mitigate barriers, and (3) use cultural strengths. Qualitative analysis of the data involved thematic open and structured coding of all 3 strategies separately. We also examined how many different themes (different individual strategies) participants reported for each strategy component.

RESULTS

Most participants reported only 1 strategy (theme) for each of the 3 components. Common goal-achieving and barrier-mitigation strategies included positive social supports and avoiding negative or alcohol-involved social environments. Other strategies involved circular logic (e.g., the strategy to reduce drinking was to drink less). Both traditional and western cultural strengths were reported as important resources, although many participants had no cultural resource strategy.

CONCLUSION

Programs aimed at reducing AEPs may need to provide participants more support to develop strong strategies to reduce alcohol use when implemented within areas with high levels of trauma and contextual barriers that can impact strategy selection. Such support could include ways to improve health on both interpersonal and community levels.

Buprenorphine/Naloxone for Opioid Use Disorder Among Alaska Native and American Indian People

OBJECTIVES

Opioid-related disparities are magnified among Alaska Native and American Indian (ANAI) people. Yet, no outcome studies on medication for addiction treatment, an effective treatment in other populations, among ANAI people exist. The objective of this study was to identify variables associated with buprenorphine/naloxone retention among ANAI people with opioid use disorder (OUD).

METHODS

The sample was 240 ANAI adults in Anchorage, Alaska who received buprenorphine/naloxone treatment for an OUD. We gathered data from the electronic health record from January 1, 2015 to December 31, 2019. We used survival analysis to explore possible predictors (demographic variables, psychiatric comorbidity, medical severity, previous opioid prescriptions, previous injury, alcohol use disorder, and co-occurring substance use) of length of treatment retention (in days) while accounting for right censoring.

RESULTS

We found that 63% of the 240 patients were retained in buprenorphine/naloxone treatment at 90 days, 51% at 6 months, and 40% at 1 year, slightly lower than the general US population. Younger age (hazard ratio 1.69, 95% confidence intervals 1.17-2.45) and co-occurring substance use (hazard ratio 2.95, 95% confidence intervals 1.99-4.38) were associated with increased rate of buprenorphine/naloxone treatment discontinuation.

CONCLUSIONS

Younger patients and those with co-occurring substance use remain at higher risk of discontinuing buprenorphine/naloxone treatment for OUD in this population of ANAI people. Treatment programs serving ANAI people may consider paying special attention to patients with these characteristics to prevent treatment discontinuation. Our study highlights the need to address poly-substance use among ANAI people in treatment.

Loneliness and sleep in the American Indian Blackfeet community

BACKGROUND

Sleep is largely understudied in American Indians (AIs), even though sleep is implicated in the chronic diseases which disproportionately affect AI communities.

OBJECTIVE

To investigate relationships between daily self-reported loneliness and sleep as measured with actigraphy.

METHODS

In a sample of 98 Blackfeet adults living on the Blackfeet reservation in Montana, we used Ecological Momentary Assessment and actigraphy over a week-long period to investigate relationships between loneliness and sleep. Loneliness was measured daily using the Short Loneliness Scale and actigraphy was used to measure total sleep time, sleep onset latency (SOL), wake after sleep onset (WASO), and sleep efficiency (SE).

RESULTS

Using a series of generalized linear mixed-effects models controlling for demographic characteristics, anxiety and depressive symptoms, and adverse childhood experiences, we found that those who were lonelier had higher WASO and SOL, and lower SE relative to those who were less lonely. Within-subject effects indicate that participants who were lonelier for a given day relative to their own weekly average had higher WASO that night relative to their own weekly average.

CONCLUSIONS

Our findings provide initial preliminary evidence suggesting that loneliness may be a psychosocial factor which contributes to poor sleep in AI communities.

Health Care Access and Utilization for American Indian Elders: A Concept-Mapping Study

OBJECTIVES

Inequities in access to and utilization of health care greatly influence the health and quality of life of American Indian elders (AIEs). This study explores the importance and perceived prevalence of factors affecting health care use within this population and assesses the changeability of these factors to produce a list of action items that are timely and relevant to improving health care access and utilization.

METHOD

Concept mapping was conducted with AIEs (n = 65) and professional stakeholders (n = 50), including tribal leaders, administrators of public-sector health systems, outreach workers, and health care providers. Data were analyzed using multidimensional scaling and cluster analyses.

RESULTS

The final concept-map model comprised nine thematic clusters related to factors affecting elder health care: Difficulties Obtaining and Using Insurance; Insecurity from Lack of Knowledge; Limited Availability of Services; Scheduling Challenges; Provider Issues and Relationships; Family and Emotional Challenges; Health-Related Self-Efficacy and Knowledge; Accessibility and Transportation Barriers; and Tribal/National Policy.

DISCUSSION

Findings suggest that improvements in access to and utilization of health care among AIEs will require actions across multiple domains, including health system navigation services, workforce improvements, and tribal, state, and federal policy. A multilevel socioecological approach is necessary to organize and undertake these actions.

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.

Gender differences in the assessment of depression in American Indian older adults: The Strong Heart Study

The validation of the assessment of depression across ethnic groups is critical yet deficient for American Indian (AI) adults. Therefore, we assessed the psychometric properties of the Center for Epidemiological Studies-Depression (CES-D) in AI elders and tested differences in depression constructs between gender. Participants were 817 AI adults (68% women), mean age 73.2 years (SD = 6.1, range: 64-95) for women and 72.6 years (SD = 5.3, range: 65-90) for men., in the Cerebrovascular Disease and Its Consequences in AIs Study. We evaluated the factor structure of the 20-item and 12-item CES-D and tested measurement invariance between gender. Results demonstrated a poor fit for the 20-item CES-D and partial gender measurement invariance of the 12-item CES-D. AI female elders had significantly higher depression levels than AI male elders on the Depressed Affect subscale, the Somatic Symptoms subscale, and the Well-Being (reverse-coded) subscale. Further replication is needed, and we recommend future psychometric work with the 12-item CES-D with AI elders. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Alcohol policy effects on 100% chronic alcohol-attributable mortality across racial/ethnic subgroups

In the United States, some racial/ethnic minorities suffer from higher rates of chronic alcohol problems, and alcohol-related morbidity and mortality than Whites. Furthermore, state-level alcohol policies may affect racial/ethnic subgroups differentially. We investigate effects of beverage-specific taxes and government control of spirits retail on alcohol-related mortality among non-Hispanic Whites, non-Hispanic Blacks, non-Hispanic American Indians/Alaska Natives (AI/AN) and Hispanics using death certificate and state-level alcohol policy data for 1999-2016. Outcomes were analyzed as mortality rates (per 10,000) from 100% alcohol-attributable chronic conditions ("100% chronic AAD"). Statistical models regressed racial/ethnic-specific logged mortality rates on state-level, one-year lagged and logged beer tax, one-year lagged and logged spirits tax, and one-year lagged government-controlled spirits sales, adjusted for mortality trends, fixed effects for state, and clustering of standard errors. Government control was significantly (P < 0.05) related to 3% reductions in Overall and non-Hispanic White mortality rates, and 4% reductions in Hispanic mortality rates from 100% chronic AAD. Tax associations were not robust. Results support that government control of spirits retail is associated with significantly lower 100% AAD from chronic causes Overall and among non-Hispanic Whites and Hispanics. Government control of spirits retail may reduce both population-level 100% chronic AAD as well as racial/ethnic disparities in 100% chronic AAD.

Integrating Cultural Relevance into a Behavioral mHealth Intervention for Native American Youth

Native American communities are disproportionately affected by a number of behavioral health disparities, including higher rates of depression, substance abuse, and suicide. As mobile health (mHealth) interventions gain traction as methods for addressing these disparities, they continue to lack relevance to Native American youth. In an effort to explore the design of relevant behavioral mHealth intervention for Native American communities, we have developed ARORA (Amplifying Resilience Over Restricted Internet Access), a prototype behavioral mHealth intervention that has been co-designed with Native American youth, a community advisory board, and a clinical psychologist. In this paper, we qualitatively analyze our co-design and focus group sessions using a grounded theory approach and identify the key themes that Native American community members have identified as being critical components of relevant mHealth designs. Notably, we find that the Native American youth who participated in our focus groups desired a greater level of didactic interaction with cultural and behavioral health elements. We conclude with a discussion of the significant challenges we faced in our efforts to co-design software with Native American stakeholders and provide recommendations that might guide other HCI researchers and designers through challenges that arise during the process of cross-cultural design.

Pathways of Adaptation: Two Case Studies with One Evidence-Based Substance Use Prevention Program Tailored for Indigenous Youth

Indigenous communities often face disproportionate challenges across a variety of health domains, and effective prevention strategies are sorely needed. Unfortunately, evidence is scant regarding what approaches are effective for these communities. A common approach is to take an evidence-based practice or program with documented effectiveness in other populations and implement it with Indigenous populations. While a science of intervention adaptation is emerging, there remains little guidance on processes for adaptation that strategically leverage both existing scientific evidence and Indigenous prevention strategies. In this paper, two case studies illustrate promising practices for adaptation, documenting the approaches of two research teams funded under the National Institutes of Health's initiative to support Intervention Research to Improve Native American Health (IRINAH). These teams worked with distinct Indigenous populations in the USA and Canada to culturally adapt the same prevention program, the Iowa Strengthening Families Program for Parents and Youth 10-14. The approaches of these two teams and the programs that resulted are compared and contrasted, and critical elements of adaptation in partnership with Indigenous communities are discussed.

American Indian women cancer survivors' perceptions and experiences with conventional and non-conventional mental health care for depressive symptoms

Background: Despite cancer and depression being disproportionately high for American Indian and Alaska Native (AI/AN) women, such cancer survivors' help-seeking practices and perceptions related to depression are absent in extant research. A broader context of historical oppression has set the stage for unequal health outcomes and access to quality services. The purpose of this article was to explore AI women cancer survivors' experiences with conventional mental health services and informal and tribally-based assistance, as well as barriers related to mental health service utilization.Methods: A qualitative descriptive study methodology, with qualitative content analysis, was used to examine the experiences of AI women cancer survivors as they related to help-seeking experiences for depressive symptoms. The sample included 43 AI women cancer survivors (n = 14 breast cancer, n = 14 cervical cancer, and n = 15 colon and other types of cancer survivors).Results: Since receiving a cancer diagnosis, 26 (62%) participants indicated they had feelings of depression. Some participants (n = 13) described mixed perceptions of the mental health service system. Generally, participants viewed families and informal support systems as primary forms of assistance, whereas conventional services were reported as a supplementary or 'as needed' forms of support, particularly when the informal support system was lacking. Participants received help in the forms of psychotropic medications and psychotherapy, as well as help from family and AI-specific healing modalities (e.g. sweat lodges and healing ceremonies). Stigma and confidentiality concerns were primary barriers to utilizing conventional services as described by 12 (29%) participants.Discussion: Participants' help primarily came from family and tribally-based entities, with conventional mental health care being more salient when informal supports were lacking. The mixed perceptions espoused by participants may be related to a broader context of historical oppression; family and social support and tribally-based services may be protective factors for cancer survivors with depression.

The rewarding recovery study: a randomized controlled trial of incentives for alcohol and drug abstinence with a rural American Indian community

AIMS

To test if contingency management (CM) interventions for alcohol and drug abstinence were associated with increased alcohol and drug abstinence among American Indian adults with alcohol dependence who also use drugs.

DESIGN

In this 2 × 2 factorial randomized controlled trial, American Indian adults with alcohol dependence who also used drugs were randomized to four conditions: (1) incentives for submission of urine samples only (control condition), (2) CM incentives for alcohol abstinence, (3) CM incentives for drug abstinence or (4) CM incentives for abstinence from both alcohol and drugs.

SETTING

A Northern Plains Reservation in the United States.

PARTICIPANTS

A total of 114 American Indian adults aged 35.8 years (standard deviation = 10.4); 49.1% were male.

INTERVENTION AND COMPARATOR

Participants received incentives if they demonstrated abstinence from alcohol (CM for alcohol, n = 30), abstinence from their most frequently used drug (CM for drugs, n = 27) or abstinence from both alcohol and their most frequently used drug (CM for alcohol and drugs, n = 32) as assessed by urine tests. Controls (n = 25) received incentives for submitting urine samples only.

MEASUREMENTS

Primary outcomes were urine ethyl glucuronide (alcohol) and drug tests conducted three times per week during the 12-week intervention period. Data analyses included listwise deletion and multiple imputation to account for missing data.

FINDINGS

The three CM groups were significantly (P < 0.05) more likely to submit alcohol-abstinent urine samples compared with the control condition, with odds ratios ranging from 2.4 to 4.8. The CM for drugs (OR = 3.2) and CM for alcohol and drugs (OR = 2.5) were significantly more likely to submit urine samples that indicated drug abstinence, relative to the control condition (P < 0.05). However, these differences were not significant in multiple imputation analyses (P > 0.05).

CONCLUSIONS

Contingency management (CM) incentives for abstinence were associated with increased alcohol abstinence in American Indian adults diagnosed with alcohol dependence who also used drugs, living on a rural reservation. The effect of CM incentives on drug abstinence was inconclusive.

Sleep, psychopathology and cultural diversity

Research on ethnic/racial disparities in sleep in the United States finds minorities to have shorter self-reported and actigraphy-recorded sleep duration and poorer sleep quality. Disparities in mental health mirror disparities in sleep with ethnic/racial minorities reporting higher prevalence and more severe struggles. This review focuses on recent research in sleep and mental health disparities and considers ethnic/racial discrimination as an important third variable that may link these two domains of disparities research. For example, research has found discrimination to mediate ethnic/racial disparities in sleep; at the same time, sleep has been observed to mediate the link between discrimination and mental health. The review concludes with the importance of considering ethnicity/race and accompanying sociodemographic, environmental, and behavioral influences on sleep and mental health research.

Linking coping strategies to locally-perceived aetiologies of mental distress in northern Rwanda

INTRODUCTION

How and why people in a particular setting turn to a specific coping strategy for their distress is pivotal for strengthening mental healthcare and this needs to be understood from a local point of view. Prior research in northern Rwanda documented common local concepts of distress for the population that cannot receive assistance despite severe adversities; however, the locally-perceived causes, manifestation and coping strategies and their associations are still unclear.

METHODS

The qualitative study in the Musanze district, northern Rwanda, was informed by Interpretative Phenomenological Analysis. In-depth interviews were conducted with people with lived experience and those in close contact with people with lived experience of distress. Ethnographic observation was conducted and the analyses were complimented by an earlier ethnography in the same village.

RESULTS

Study participants (n=15) included community members with lived experience of mental distress and/or those with close friends or family with lived experience. The perceived manifestations of the mental distresses were diverse and the causal attributions shifted from more social, concrete and explainable (eg, loss) towards magical, more abstract and unexplainable (eg, poisoning). Finally, participants sought coping strategies in accordance with their causal attribution in ways that made sense to them.

CONCLUSION

The coping strategies were chosen according to the perceived aetiology of the symptoms and they were perceived to be effective for their distress. Local coping strategies that match people's help-seeking patterns should therefore be supported in policy and programmes. In Rwanda this requires a mutual training of medical professionals and traditional healers and establishing co-treatment within two parallel systems. This also requires the support for programmes and initiatives that strengthen positive interactions and change in circumstances.

Traumatic Stress, Social Support, and Health Among Older American Indians: The Native Elder Care Study

OBJECTIVES

To estimate the prevalence of lifetime traumatic experiences, describe related symptoms of traumatic stress, and examine their association with perceived social support and physical and mental health among older American Indians.

METHOD

Analyses of existing interview data from the Native Elder Care Study, a random age-stratified sample of 505 tribal members ≥55 years of age conducted in partnership with a large Southeastern tribe. Interviews assessed trauma exposure, traumatic stress, measures of social support, and physical and mental health status.

RESULTS

Overall, 31% of participants had experienced a traumatic event; of these, 43% reported traumatic stress at the time of the interview. Higher perceived social support was associated with a reduced prevalence of traumatic stress. Compared to their counterparts without traumatic stress, women participants reporting traumatic stress reported more symptoms of depression, and both symptomatic men and women had a higher prevalence of cardiovascular disease and chronic pain.

DISCUSSION

Traumatic stress was associated with less perceived social support and poorer health. Social support was not found to moderate the relationship between traumatic stress and physical and mental health.

Assessing peripheral fibers, pain sensitivity, central sensitization, and descending inhibition in Native Americans: main findings from the Oklahoma Study of Native American Pain Risk

Native Americans (NAs) have a higher prevalence of chronic pain than other U.S. racial/ethnic groups, but there have been few attempts to understand the mechanisms of this pain disparity. This study used a comprehensive battery of laboratory tasks to assess peripheral fiber function (cool/warm detection thresholds), pain sensitivity (eg, thresholds/tolerances), central sensitization (eg, temporal summation), and pain inhibition (conditioned pain modulation) in healthy, pain-free adults (N = 155 NAs, N = 150 non-Hispanic Whites [NHWs]). Multiple pain stimulus modalities were used (eg, cold, heat, pressure, ischemic, and electric), and subjective (eg, pain ratings and pain tolerance) and physiological (eg, nociceptive flexion reflex) outcomes were measured. There were no group differences on any measure, except that NAs had lower cold-pressor pain thresholds and tolerances, indicating greater pain sensitivity than NHWs. These findings suggest that there are no group differences between healthy NAs and NHWs on peripheral fiber function, central sensitization, or central pain inhibition, but NAs may have greater sensitivity to cold pain. Future studies are needed to examine potential within-group factors that might contribute to NA pain risk.

Identifying Competing Life Reinforcers for Substance Use in First Nation Adolescents

Background: Indigenous youth are at increased risk of initiating substance use at early ages and suffer greater negative consequences related to substance use as compared to non-Indigenous youth. Behavioral Theories of Choice suggests that substance use is contingent on the availability of substances and the availability of alternatives to substance use. Objectives: The present study aimed to investigate risk and protective factors associated with substance use in one group of First Nation adolescents. Methods: Using a modified grounded theory approach, the present study conducted qualitative focus groups and individual interviews with fifteen reserve-dwelling (75% female, M age = 15.2 years) First Nation adolescents to assess categories of risk and protective factors based upon Behavioral Theories of Choice. Results: Adolescents identified peer influences, parental/family influences, and community influences and issues as risk and protective factors associated with substance use. Conclusions: Results highlight possible targets of culturally appropriate prevention strategies for Indigenous populations.

An Internet-Based Therapeutic Tool for American Indian/Alaska Native Adults With Posttraumatic Stress Disorder: User Testing and Developmental Feasibility Study

Background

Posttraumatic stress disorder (PTSD) is a major public health concern among American Indian and Alaska Native populations. Primary care clinics are often the first point of contact for American Indian and Alaska Natives seeking health care and are feasible locations for trauma-focused interventions.

Objective

Web-based therapeutic interventions have the potential to reduce PTSD symptoms by offering psychoeducation and symptom self-management tools. We investigated the feasibility of a culturally adapted Web-based therapeutic intervention in two American Indian and Alaska Native–serving primary care sites. We developed and tested a self-guided Web-based therapeutic intervention aimed at improving knowledge and awareness of, and provision of guidance, support, and symptom-management for, PTSD symptoms.

Methods

A community-based participatory research process was used to refine adaptations to the veteran’s administration’s PTSD Coach Online, to develop new content, and to guide and interpret the results of the feasibility pilot. This process resulted in a 16-guide intervention “Health is Our Tradition: Balance and Harmony after Trauma” website. The feasibility pilot included 24 American Indian and Alaska Natives aged 18 years and older who scored positive on a primary care PTSD screener. Enrolled participants completed a demographic questionnaire, an experience with technology questionnaire, and baseline behavioral health measures. Once measures were complete, research staff described weekly text messages, minimum study expectations for website use, and demonstrated how to use the website. Feasibility measures included self-reported website use, ratings of satisfaction and perceived effectiveness, and website metrics. Feasibility of obtaining measures for an effectiveness trial was also assessed to include behavioral health symptoms and service utilization through self-report instruments and electronic health record queries. Self-reported measures were collected at enrollment and at 6 and 12 weeks post enrollment. Electronic health records were collected from 12 months before study enrollment to 3 months following study enrollment. Changes between enrollment and follow-up were examined with paired t tests, analysis of variance or logistic regression, or the Wilcoxon signed rank test for nonnormally distributed data.

Results

The culturally adapted website and associated text message reminders were perceived as satisfactory and effective by participants with no differences by age or gender. The majority of participants (86%, 19/24) reported use of the website at 6 weeks and nearly all (91%, 20/22) at 12 weeks. At 6 weeks, 55% (12/22) of participants reported using the website at the recommended intensity (at least three times weekly), dropping to 36% (8/22) at 12 weeks. Participant use of modules varied from 8% (2/24) to 100% (24/24), with guide completion rates being greater for guides that were only psychoeducational in nature compared with guides that were interactive. There were no significant changes in patterns of diagnoses, screening, medications, or service utilization during exposure to the website.

Conclusions

“Health is Our Tradition: Balance and Harmony after Trauma” shows promise for an effectiveness pilot.

The Mediating Role of Diabetes Distress and Depressive Symptoms in Type 2 Diabetes Medication Adherence Gender Differences

Background. Medication adherence is negatively related to both diabetes distress (DD) and depressive symptoms (DS). Past research suggests gender differences in adherence, DD, and DS. A gap exists in determining if gender differences in adherence are mediated by DD and DS, or if gender moderates differences in adherence by DD/DS. Aims. This study investigated the relationship between gender, DD, DS, and medication adherence and tested for mediating and moderating effects on medication adherence among American Indian adults with type 2 diabetes. Method. The Maawaji idi-oog mino-ayaawin (Gathering for Health) study was a community-based participatory research collaboration with five American Indian tribes. Participants, randomly recruited from clinic records, shared information during computer-assisted personal interviews. This study includes the 166 participants who reported using medications to treat their diabetes. The relationship between gender, DD, DS, and medication adherence are explored. Possible mediating and moderating effects on medication were tested using regression and path analysis. Results. Females had higher levels of DD and DS and lower levels of medication adherence. Higher levels of DD and DS were both associated with lower medication adherence. No evidence was found that gender moderates the relationship between DD or DS and medication adherence. Instead, DD and DS mediated the relationship between gender and medication adherence. Conclusions. Medication adherence differences in male and female patients may be attributable to DD and DS. The present research highlights both DD and DS as targets for clinicians and researchers alike.

American Indian women cancer survivors' coping with depressive symptoms

OBJECTIVE

Depressive symptoms have been identified as a primary predictor of quality of life among cancer patients. Depression and cancer are co-occurring and disproportionately elevated for American Indian and Alaska Native (AI/AN) women. The purpose of this article is to examine American Indian (AI) women cancer survivors' coping mechanisms for depressive symptoms.

RESEARCH APPROACH

The methodology included a qualitative descriptive approach with conventional content analysis to examine the coping strategies of AI women cancer survivors associated with depressive symptoms. The interview guide was semi-structured and developed in collaboration with a community advisory board (CAB). Data-derived qualitative analysis was used to generate codes inductively from the data.

PARTICIPANTS

A sample of 43 AI women cancer survivors (n = 14 cervical cancer, n = 14 breast cancer, and n = 15 other cancers) from the Northern Plains region, in the state of South Dakota were interviewed. Data were collected from June 2014 to February 2015. Methodological approach: Qualitative content analysis was used for data analysis, which allowed themes to emerge inductively from the data. Analysis revealed 430 preliminary codes. After de-briefing, validation, and discussion among coauthors, these were then sorted into 67 codes. Member checks with all available participants were conducted to minimize misinterpretation.

FINDINGS

A total of 26 participants (62%) indicated they had feelings of depression since their cancer diagnosis. Women coped with depressive feelings by (a) participating in faith traditions; (b) seeking creative and positive outlets; (c) martialing family and social support; and (d) keeping busy with other life activities.

INTERPRETATION

AI women experienced depressive symptoms following a cancer diagnosis and used a variety of positive coping mechanisms to create personal meaning. Implications for Psychosocial Providers or Policy: AI women may need unique support following a cancer diagnosis, and interventions should incorporate AI beliefs and traditions, such as storytelling and talking with family and community members.

The measurement invariance of the Patient Health Questionnaire-9 for American Indian adults

BACKGROUND

American Indian people have high suicide rates. However, little epidemiological data is available on depression prevalence, a suicide risk factor, in this population. Some research suggests that depression scales may perform differently for American Indian people. However, the Patient Health Questionnnaire-9 (PHQ-9), a depression scale widely-used in clinical practice, had not been assessed for cross-cultural measurement invariance with American Indian people.

METHODS

In this retrospective study of existing electronic health record (EHR) data in an upper Midwestern healthcare system, we assessed the measurement invariance of the standard one-factor PHQ-9 and five previously identified two-factor models for 4443 American Indian and 4443 Caucasian American adults (age >= 18) with a PHQ-9 in the EHR from 12/1/2005 to 12/31/2017. We also conducted subgroup analyses with adults ages >= 65.

RESULTS

Models showed good fits (e.g., CFI > 0.99, RMSEA < 0.05) and internal consistency reliability (ordinal alpha > 0.80). All models displayed measurement invariance between racial groups. Factor correlation was high for two-factor models, providing support for the one-factor model. American Indian adults had significantly higher odds of PHQ-9 total scores >= 10 and >= 15 than Caucasian American adults.

LIMITATIONS

Data came from a single healthcare system.

CONCLUSIONS

The PHQ-9 exhibited cross-cultural measurement invariance between American Indian and Caucasian American adults, supporting the PHQ-9 as a depression screening tool in this clinical care population. American Indian adults also had higher levels of depression than Caucasian Americans. Future research could confirm the generalizability of our findings to other American Indian populations.

Childhood Sexual Abuse and Depression among American Indians in Adulthood

The present study investigated distal and proximal factors associated with depression among a sample of 479 American Indian (AI) adults in the Midwest. Distal factors included histories of childhood sexual abuse (CSA) and other childhood adversities. Proximal factors included levels of health self-efficacy and treatment for alcohol problems. The study also examined the moderating effect of treatment for alcohol problems on the relationship between CSA and depression. In model 1, results indicate that CSA was positively related to depression after controlling for demographic and background variables. In model 2, childhood adversities and treatment for alcohol problems were associated with increased depression in AI adults; CSA became nonsignificant. As a protective factor, level of health self-efficacy was negatively associated with depression. In model 3, treatment for alcohol problems magnified the effect of CSA on depression. These findings suggest that early traumatic experiences may have persistent, harmful effects on depression among AIs; one mechanism exacerbating the impact of CSA on depression is treatment for alcohol problems. Targeted interventions are needed to mitigate the long-term negative health effects of childhood trauma in this population and to strengthen proximal protective factors, such as health self-efficacy.

Parenting after a history of childhood maltreatment: A scoping review and map of evidence in the perinatal period

Background and aims

Child maltreatment is a global health priority affecting up to half of all children worldwide, with profound and ongoing impacts on physical, social and emotional wellbeing. The perinatal period (pregnancy to two years postpartum) is critical for parents with a history of childhood maltreatment. Parents may experience ‘triggering’ of trauma responses during perinatal care or caring for their distressed infant. The long-lasting relational effects may impede the capacity of parents to nurture their children and lead to intergenerational cycles of trauma. Conversely, the perinatal period offers a unique life-course opportunity for parental healing and prevention of child maltreatment. This scoping review aims to map perinatal evidence regarding theories, intergenerational pathways, parents’ views, interventions and measurement tools involving parents with a history of maltreatment in their own childhoods.

Methods and results

We searched Medline, Psychinfo, Cinahl and Embase to 30/11/2016. We screened 6701 articles and included 55 studies (74 articles) involving more than 20,000 parents. Most studies were conducted in the United States (42/55) and involved mothers only (43/55). Theoretical constructs include: attachment, social learning, relational-developmental systems, family-systems and anger theories; ‘hidden trauma’, resilience, post-traumatic growth; and ‘Child Sexual Assault Healing’ and socioecological models. Observational studies illustrate sociodemographic and mental health protective and risk factors that mediate/moderate intergenerational pathways to parental and child wellbeing. Qualitative studies provide rich descriptions of parental experiences and views about healing strategies and support. We found no specific perinatal interventions for parents with childhood maltreatment histories. However, several parenting interventions included elements which address parental history, and these reported positive effects on parent wellbeing. We found twenty-two assessment tools for identifying parental childhood maltreatment history or impact.

Conclusions

Perinatal evidence is available to inform development of strategies to support parents with a history of child maltreatment. However, there is a paucity of applied evidence and evidence involving fathers and Indigenous parents.

Group Gardening in a Native American Community: A Collaborative Approach

Background. There is increasing awareness of the potential health benefits derived from gardening activities. Gardening practices are gaining momentum in Native American (NA) communities, yet no efforts have applied a community-based participatory research approach within a social-ecological model to understand opportunities and barriers for group gardening on an American Indian reservation. Objectives. The primary objective of this study was to identify influences across social-ecological levels that promote or hinder the implementation of community gardens and use of locally grown foods on the reservation; a secondary objective was to assess the feasibility of implementing a group gardening program for NA adults and potential of collecting health outcome measures. Method. Community members and academicians collaborated to develop and implement this study. The study (1) conducted interviews with key stakeholders to identify influences across social-ecological levels that promote or hinder the implementation of community gardens and using locally produced food and (2) assessed the physical and psychological well-being of NA adults participating in a group gardening feasibility study. Results. Major factors influencing using locally grown food and community gardens that emerged from nine interviews included knowledge/experience, self-efficacy, Elders, traditional ways, community values, generational gaps, and local tribal policies. Twenty NA adults with prediabetes or diabetes participated in the feasibility study. The Profile of Mood States Inventory showed consistently positive change in score for participants in the group gardening program versus the comparison group. Conclusions. This study identified key influences for growing locally grown food, and approaches for implementing group gardening programs for NA adults.

Race/Ethnicity Does Not Moderate the Relationship Between Adverse Life Experiences and Temporal Summation of the Nociceptive Flexion Reflex and Pain: Results From the Oklahoma Study of Native American Pain Risk

Adverse life experiences (ALEs) are associated with hyperalgesia and chronic pain, but the underlying mechanisms are poorly understood. One potential mechanism is hyperexcitability of spinal neurons (ie, central sensitization). Given that Native Americans (NAs) are more likely to have ALEs and to have a higher prevalence of chronic pain, the relationship between ALEs and spinal hyperexcitability might contribute to their pain risk. The present study assessed temporal summation of the nociceptive flexion reflex (TS-NFR; a correlate of spinal hyperexcitability) and pain (TS-Pain) in 246 healthy, pain-free non-Hispanic whites and NAs. The Life Events Checklist was used to assess the number of ALEs. Multilevel growth models were used to predict TS-NFR and TS-Pain, after controlling for age, perceived stress, psychological problems, negative and positive affect, and painful stimulus intensity. ALEs and negative affect were significantly associated with greater pain, but not enhanced TS-Pain. By contrast, ALEs were associated with enhanced TS-NFR. Race did not moderate these relationships. This finding implies that ALEs promote hyperalgesia as a result of increased spinal neuron excitability. Although relationships between ALEs and the nociceptive flexion reflex/pain were not stronger in NAs, given prior evidence that NAs experience more ALEs, this factor might contribute to the higher prevalence of chronic pain in NAs. PERSPECTIVE: This study found a dose-dependent relationship between ALEs and spinal neuron excitability. Although the relationship was not stronger in NAs than non-Hispanic whites, given prior evidence that NAs experience more ALEs, this could contribute to the higher prevalence of chronic pain in NAs.

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.

Depression management interests among Alaska Native and American Indian adults in primary care

BACKGROUND

Depression remains the second leading cause of disability worldwide. Symptoms of depression are expressed and experienced differently across cultural groups, impacting treatment decisions. Patient preferences predict service utilization, treatment selection and persistence, as well as health outcomes for medical and behavioral health conditions, including depression. We identified depression management preferences of Alaska Native and American Indian (AN/AI) people who receive care within a comprehensive, integrated, tribally owned and operated healthcare facility in Anchorage, Alaska.

METHODS

Adult AN/AI patients who screened positive for depression (10 or greater on the Patient Health Questionnaire - 9 (PHQ-9)) completed a culturally-tailored decision-support tool to assess their depression management interests.

RESULTS

The 125 eligible patients, who screened positive for depression, preferred counseling and medications to peer support groups, herbal remedies, and spiritual support. Those 18-39 years of age were more likely to prefer medications and less likely to prefer spirituality and peer support than those 40 years of age and older. Patients with moderate and severe depression were more likely to prefer exercise, healthy eating, and stress reduction than individuals with mild depression.

LIMITATIONS

Women comprised 78% of the sample. Responses may not adequately represent the views of men.

CONCLUSIONS

Counseling and medications should consistently be made available earlier in the course of depression management. Patient interest in exercise, stress reduction, and healthy eating to manage depression, especially among those with moderate and severe depression, offers opportunity for additional collaboration in an integrated care setting.