Angelita Lee

Understanding the Relationship between Substance Use and Self-Injury in American Indian Youth

Background: American Indian communities compared to other US populations are challenged by the largest health disparities in substance abuse and suicidal behavior among youth ages 15–24. Objectives: This article examines the co-occurrence of substance use and self-injury among reservation-based youth in the US. Methods: White Mountain Apache tribal leaders and Johns Hopkins University formed a partnership to address self-injury and substance abuse among Apache youth. Data on suicide (deaths, attempts, ideation), non-suicidal self-injury, and substance use were analyzed from the White Mountain Apache tribally mandated self-injury surveillance registry from 2007 to 2010, including 567 validated incidents from 352 individuals aged 15–24 years. Findings regarding characteristics of co-occurrence – including differences in the type of self-harm behavior, gender, and reported reasons for the act – were interpreted through a community-based participatory research process. Results: From 2007 to 2010, 64% (n = 7/11) of Apache youth ages 15–24 were “drunk or high” at the time of suicide death with data missing for 2/11 deaths; 75.7% (n = 118/156) were “drunk or high” during suicide attempt; 49.4% (n = 83/168) during suicidal ideation; and 49.4% (81/166) during non-suicidal self-injury. Co-occurrence of substance use was higher for more lethal acts and among males. Conclusion: High rates of co-occurring self-injury and substance use within this population highlight the importance of research to understand relationships between these behaviors to design preemptive and integrated interventions. Scientific Significance: Tribal-specific and culturally informed data on the co-occurrence of self-injury and substance use hold promise for reducing the combined toll of years of productive life lost among American Indian youth.

Risk Pathways for Suicide Among Native American Adolescents

Native American (Native) adolescents have the highest suicide rates in the United States, yet no conceptual models describing risk factors specific to this population exist. We sought to further hone a Native-specific conceptual model developed from quantitative data with qualitative data collected from a longitudinal series of interviews with (N = 22) Native adolescents who had attempted suicide. Four levels of suicide risk emerged, detailing individual, family, community, and societal factors that affect youths’ pathways to suicide, along with a variety of subthemes and constructs. Some themes parallel established models of suicide risk; however, others are unique to the experience of this sample, including the impact of overtaxed households and family composition, significant grief burden, contagion, and stigma surrounding treatment seeking. We suggest adaptations of existing themes and constructs in the model. We discuss practical implications for research and intervention development, along with strengths and limitations of the study.

Exploring sexual risk taking among American Indian adolescents through protection motivation theory.

ABSTRACT This paper examines decision-making around sexual behavior among reservation-based American Indian youth. Focus group discussions were conducted with youth ages 13–19 years old. Through these discussions, we explored youth’s knowledge, attitudes and behaviors related to sexual risk taking through the lens of the protection motivation theory to inform the adaptation of an evidence-based HIV prevention intervention. Findings suggest that condom use self-efficacy and HIV prevention knowledge is low, vulnerability to sexually transmitted infections is lacking and alcohol plays a significant role in sexual risk taking in this population. In addition, parental monitoring and peer influence may contribute to or protect against sexual risk taking. Results suggest that future HIV prevention interventions should be delivered to gender-specific peer groups, include a parental component, teach sexual health education and communication skills, integrate substance-use prevention, and work to remove stigma around obtaining and using condoms.

Exploring Binge Drinking and Drug Use among American Indians: Data from Adolescent Focus Groups

Background: Risk factors for binge substance use and non-suicidal self-injury (NSSI) are similar, suggesting the importance of exploring how binge substance use and self-injury interrelate. Objectives: To gain insight from a sample of American Indian (AI) adolescents regarding how binge drinking and drug use function in their lives, including as overlapping forms of self-injury, and to identify community-based ideas for dual prevention strategies. Methods: A total of N = 58 White Mountain Apache (Apache) adolescents participated in ten mixed gender (n = 33 males, 55.9%) focus group discussions. Results were interpreted and categorized by Apache researchers and compared to Nock’s behavioral model of NSSI. Results: Participants reported substance use most commonly with “family” and “friends,” “at a house,” or “around the community.” Substance use was not confined to a particular time of day, and often occurred “at school.” Commonly endorsed reasons fell into two main categories: “to avoid problems” or “to reduce negative feelings,” versus “to be cool” or “to feel part of a group.” All adolescents but one thought that some youths use substances excessively as a way to harm/injure themselves (n = 25 responses). Prevention approaches included encouraging healthy relationships, teaching about consequences of use, providing alternative recreation, and changing/enforcing laws on the reservation. Conclusion: Tribal-specific data support the idea that binge substance use sometimes functions as a form of self-injury. Home/school environments are critical prevention settings, in addition to improved law enforcement and increased recreation. Scientific Significance: Understanding possible shared root causes and functions of binge substance use and self-injury may advance integrated prevention approaches.

Respecting the circle of life: one year outcomes from a randomized controlled comparison of an HIV risk reduction intervention for American Indian adolescents

Potential for widespread transmission of HIV/AIDS among American Indian (AI) adolescents exists, yet no evidence-based interventions (EBIs) have been adapted and evaluated with this population. Intensive psychoeducation may improve knowledge and decision-making which could potentially translate to reductions in HIV risk behaviors. A peer group randomized controlled comparison of an adapted EBI vs. control was delivered over an eight-day summer basketball camp in one reservation-based tribal community to adolescents ages 13–19. Outcome data were gathered immediately post-camp and at 6 and 12 months follow-up. Self-selected peer groups were randomized to intervention (n = 138) or control (n = 129) conditions for a total sample of 267 participants (56.2% female), mean age 15.1 years (SD = 1.7). Intervention participants had better condom use self-efficacy post-camp (Adjusted Mean Difference [AMD] = −0.75, p < 0.005) and at 6 (AMD = −0.44, p < 0.005) and 12 months (AMD = −0.23, p < 0.05) follow-up. Intervention participants also had higher HIV prevention and transmission knowledge (post-camp: AMD = 0.07, p < 0.01; 6 months: AMD = 0.06, p < 0.01) were more likely to believe condoms prevent sexually transmitted infections (post-camp: RR = 1.41, p < 0.005; 6 months: RR = 1.34, p < 0.05), to talk with an adult about HIV/AIDS (post-camp: RR=1.78, p < 0.005; 6 months: RR = 1.14, p < 0.005), had higher partner negotiation efficacy related to substance use during sex (post-camp: AMD = 0.37, p < 0.01), and were more likely to intend to use a condom (post-camp: RR = 1.39, p < 0.01). The adapted intervention had short- and medium-term impacts on AI adolescent risk for HIV/AIDS, but attenuated at 12 months. Intervention delivery through a community-based camp is feasible and acceptable with strong retention. Additional study is needed to evaluate the adapted interventions impact on sexual risk behaviors and if booster sessions and parent involvement translate to long-term impacts.

Risk and protective factors for heavy binge alcohol use among American Indian adolescents utilizing emergency health services

ABSTRACT Background: American Indian (AI) adolescents are disproportionately burdened by alcohol abuse and heavy binge use, often leading to problematic drinking in adulthood. However, many AI communities also have large proportions of adults who abstain from alcohol. Objective: To understand these concurrent and divergent patterns, we explored the relationship between risk and protective factors for heavy binge alcohol use among a reservation-based sample of AI adolescents. Methods: Factors at individual, peer, family, and cultural/community levels were examined using a cross-sectional case–control study design. Cases were adolescents with recent heavy binge alcohol use that resulted in necessary medical care. Controls had no lifetime history of heavy binge alcohol use. 68 cases and 55 controls were recruited from emergency health services visits. Participants were 50% male; average age 15.4 years old, range 10 to 19. Independent variables were explored using logistic regression; those statistically significant were combined into a larger multivariate model. Results: Exploratory analyses showed adolescents who were aggressive, impulsive, had deviant peers, poor family functioning or more people living at home were at greater risk for heavy binge alcohol use. Protective factors included attending school, family closeness, residential stability, social problem-solving skills, having traditional AI values and practices, and strong ethnic identity. Confirmatory analysis concluded that school attendance and residential stability reduce the probability of heavy binge alcohol use, even among those already at low risk. Conclusions: Findings deepen the understanding of AI adolescent heavy binge alcohol use and inform adolescent intervention development fostering trajectories to low-risk drinking and abstinence.

O07.6 Exploring the role of sex and sexual experience in predicting american indian adolescent condom use intention using protection motivation theory

Introduction Worldwide, indigenous communities including American Indian(AI) youth in the United States experience poor sexual health outcomes. Inconsistent condom use among AI youth is a primary factor driving these inequalities. The Protection Motivation Theory (PMT) is valuable in explaining condom use intention (CUI) among youth and can inform the development of interventions to improve CUI and actual condom use. This analysis identifies factors of the PMT across sex and sexual experience, for predicting CUI among AI youth. Methods 267 AIs ages 13–19 from one reservation community completed a self-report measuring sociodemographic variables, psychosocial intentions and behaviours and PMT constructs (self-efficacy, response efficacy, response cost, intrinsic reward, extrinsic reward, severity, and vulnerability). Analyses were conducted using generalised estimating equation regression models, Poisson for dichotomous. Results Mean age was 15.1 years, 56% were girls and 22% sexually experienced. Among inexperienced youth, belief condoms prevent HIV, perceived severity of HIV and extrinsic rewards of sex were significantly associated with CUI. Among girls and boys, belief condoms prevent HIV, vulnerability to HIV and extrinsic rewards were significantly associated with CUI. Perceived severity was associated with CUI among boys and intrinsic rewards among girls. Conclusion This is the first study to examine PMT constructs by sex and sexual experience among AI youth. Among all but sexually active youth, PMT factors were associated with CUI indicating utility for the PMT in predicting CUI among AI youth. Results indicate HIV prevention programs may be more impactful if tailored by sex and sexual experience; among AI boys and inexperienced youth, knowledge about consequences of unsafe sex may be beneficial while addressing factors associated with internal satisfaction from sexual risk behaviours may be efficacious for girls. Programs addressing factors associated with CUI by sex and sexual experience may be more efficacious in reducing risk behaviours among AI youth.

O07.5 Predictors of responsiveness among american indian adolescents to a community-based hiv risk-reduction intervention

Introduction American Indian/Alaska Native (AI/AN) adolescents suffer disparities in sexually transmitted infection, HIV/AIDS and unintended pregnancy. Deficits in culturally relevant risk-reduction interventions exacerbate sexual health inequalities. Our tribal-academic partnership evaluated a culturally congruent HIV risk-reduction intervention called: Respecting the Circle of Life (RCL) through a randomised controlled trial. This analysis assesses individual level predictive factors for unresponsiveness to the RCL program. Methods 267 AIs ages 13–19 participated; data was collected at baseline, immediately post, 6- and 12 months post-intervention. Regression analyses examined how baseline levels of 5 factors, established as pre-requisites for behaviour change, predicted responsiveness to the RCL program including: HIV prevention/treatment knowledge, belief condoms prevent pregnancy/infection, condom use intention, condom use self-efficacy, and partner negotiation on condom use. Results The strongest intervention impact was observed immediately post-intervention. RCL had greater impact on all 5 factors among low and medium initial scorers. Overall, high initial scorers in HIV prevention/treatment knowledge and belief that condoms prevent pregnancy/infection were predictive of unresponsiveness to RCL. Specifically, never skipping school was predictive of unresponsiveness to RCL for HIV/AIDS knowledge; female gender was predictive of unresponsiveness for condom belief; and high baseline HIV/AIDS knowledge was predictive of unresponsiveness for condom use intention. Conclusion Results suggest AI youth with higher risk factors (lower levels of knowledge, beliefs, intentions and skills) are more likely to respond to RCL. By identifying characteristics of unresponsive youth, we can modify RCL to improve its effectiveness among these subgroups. RCL is one of the first HIV risk-reduction programs developed for and rigorously evaluated with AI communities, thus replication implications are relevant for other AI/AN and indigenous populations.