Britta Mullany

Toward Understanding Suicide Among Youths: Results From the White Mountain Apache Tribally Mandated Suicide Surveillance System, 2001-2006

OBJECTIVES We examined suicide and suicide attempt rates, patterns, and risk factors among White Mountain Apache youths (aged < 25 years) from 2001 to 2006 as the first phase of a community-based participatory research process to design and evaluate suicide prevention interventions. METHODS Apache paraprofessionals gathered data as part of a tribally mandated suicide surveillance system. We compared findings to other North American populations. RESULTS Between 2001 and 2006, 61% of Apache suicides occurred among youths younger than 25 years. Annual rates among those aged 15 to 24 years were highest: 128.5 per 100 000, 13 times the US all-races rate and 7 times the American Indian and Alaska Native rate. The annual suicide attempt incidence rate in this age group was 3.5%. The male-to-female ratio was 5:1 for suicide and approximately 1:1 for suicide attempts. Hanging was the most common suicide method, and third most common attempt method. The most frequently cited attempt precipitants were family or intimate partner conflict. CONCLUSIONS An innovative tribal surveillance system identified high suicide and attempt rates and unique patterns and risk factors of suicidal behavior among Apache youths. Findings are guiding targeted suicide prevention programs.

Paraprofessional-Delivered Home-Visiting Intervention for American Indian Teen Mothers and Children: 3-Year Outcomes From a Randomized Controlled Trial

OBJECTIVE The Affordable Care Act provides funding for home-visiting programs to reduce health care disparities, despite limited evidence that existing programs can overcome implementation and evaluation challenges with at-risk populations. The authors report 36-month outcomes of the paraprofessional-delivered Family Spirit home-visiting intervention for American Indian teen mothers and children. METHOD Expectant American Indian teens (N=322, mean age=18.1 years) from four southwestern reservation communities were randomly assigned to the Family Spirit intervention plus optimized standard care or optimized standard care alone. Maternal and child outcomes were evaluated at 28 and 36 weeks gestation and 2, 6, 12, 18, 24, 30, and 36 months postpartum. RESULTS At baseline the mothers had high rates of substance use (>84%), depressive symptoms (>32%), dropping out of school (>57%), and residential instability (51%). Study retention was ≥83%. From pregnancy to 36 months postpartum, mothers in the intervention group had significantly greater parenting knowledge (effect size=0.42) and parental locus of control (effect size=0.17), fewer depressive symptoms (effect size=0.16) and externalizing problems (effect size=0.14), and lower past month use of marijuana (odds ratio=0.65) and illegal drugs (odds ratio=0.67). Children in the intervention group had fewer externalizing (effect size=0.23), internalizing (effect size=0.23), and dysregulation (effect size=0.27) problems. CONCLUSIONS The paraprofessional home-visiting intervention promoted effective parenting, reduced maternal risks, and improved child developmental outcomes in the U.S. population subgroup with the fewest resources and highest behavioral health disparities. The methods and results can inform federal efforts to disseminate and sustain evidence-based home-visiting interventions in at-risk populations.

Women’s empowerment and male involvement in antenatal care: analyses of Demographic and Health Surveys (DHS) in selected African countries

BackgroundIncreasing women’s status and male involvement are important strategies in reducing preventable maternal morbidity and mortality. While efforts to both empower women and engage men in maternal health care-seeking can work synergistically, in practice they may result in opposing processes and outcomes. This study examines whether a woman’s empowerment status, in sum and across economic, socio-familial, and legal dimensions, is associated with male partner accompaniment to antenatal care (ANC).MethodsWomen’s empowerment was measured based on the sum of nine empowerment items in the 2010–2011 Demographic and Health Surveys in eight sub-Saharan African countries: Burkina Faso (n = 2,490), Burundi (n = 1,042), Malawi (n = 1,353), Mozambique (n = 414), Rwanda (n = 1,211), Senegal (n = 505), Uganda (n = 428) and Zimbabwe (n = 459). In cross-sectional analyses, bivariate and multivariable logistic regressions models were used to examine the odds of male partner accompaniment to ANC between women with above-average versus below-average composite and dimensional empowerment scores.ResultsIn the majority of countries, male accompaniment to ANC was not uncommon. However, findings were mixed. Positive associations in women’s composite empowerment and male involvement were observed in Burkina Faso (OR = 1.27, 95% CI: 1.08, 1.50) and Uganda (OR = 1.53, 95% CI: 1.00-2.35), and in the economic empowerment dimension in Burkina Faso (OR = 1.24, 95% CI: 1.05-1.47). In Malawi, significant negative associations were observed in the odds of male accompaniment to ANC and women’s composite (OR = 0.77, 95% CI: 0.62-0.97) and economic empowerment scores (OR = 0.75, 95% CI: 0.59-0.94). No significant differences were observed in Burundi, Mozambique, Rwanda, Senegal, or Zimbabwe.ConclusionWomen’s empowerment can be positively or negatively associated with male antenatal accompaniment. Male involvement efforts may benefit from empowerment initiatives that promote women’s participation in social and economic spheres, provided that antenatal participation does not undermine women’s preferences or autonomy. The observation of mixed and null findings suggests that additional qualitative and longitudinal research may enhance understanding of women’s empowerment in sub-Saharan African settings.

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.

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.

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.

The Respecting the Circle of Life trial for American Indian adolescents: rationale, design, methods, and baseline characteristics

This paper describes the rationale, design, methods, and baseline results of a randomized controlled trial to evaluate the impact of an adapted evidence-based intervention (EBI), “Respecting the Circle of Life” (RCL) to reduce behavioral risks for HIV/AIDS among American Indian (AI) adolescents. A participatory approach shaped intervention adaptation and study design. A total of 267 participants (aged 13–19) were randomized by peer groups of the same sex to receive the RCL intervention or a control condition. Self-report assessments were administered at four intervals. The sample was predominately female (57%), had low HIV knowledge prevention scores, early sexual initiation (mean 14.6 years), and 56% reported intention to use a condom at next sex. Baseline characteristics were evenly distributed between groups with the exception of age and extrinsic reward scores. This is the first rigorous evaluation of an adapted EBI for HIV/AIDS prevention among AI adolescents, an at-risk and understudied population.

Fatherhood roles and drug use among young American Indian men

Background: High rates of substance abuse among young American Indian (AI) fathers pose multigenerational challenges for AI families and communities. Objective: The objective of this study was to describe substance use patterns among young AI fathers and examine the intersection of substance use with men’s fatherhood roles and responsibilities. Methods: As part of a home-visiting intervention trial for AI teen mothers and their children, in 2010 we conducted a descriptive study of fatherhood and substance use on three southwestern reservations. Substance use and parenting data were collected from n = 87 male partners of adolescent mothers using audio computer-assisted self-interviews. Results: Male partners were on average 22.9 years old, primarily living with their children (93%), unmarried (87%), and unemployed (70%). Lifetime substance use was high: 80% reported alcohol; 78% marijuana; 34% methamphetamines; 31% crack/cocaine; and 16% reported drinking binge in the past 6 months. Substance use was associated with history of alcohol abuse among participants’ fathers (but not mothers); participants’ poor relationships with their own fathers; unemployment status; and low involvement in child care. Conclusion: Drug and alcohol abuse may be obstructing ideal fatherhood roles among multiple generations of AI males. Scientific Significance: Targeting drug prevention among young AI men during early fatherhood may provide special opportunity to reduce substance use and improve parenting. Intergenerational approaches may hold special promise.