Carlotta Ching Ting Fok

SUICIDE PREVENTION AS A COMMUNITY DEVELOPMENT PROCESS: UNDERSTANDING CIRCUMPOLAR YOUTH SUICIDE PREVENTION THROUGH COMMUNITY LEVEL OUTCOMES

Abstract Objectives. Community-based models have become increasingly prominent in prevention, and have special relevance for suicide prevention in circumpolar Indigenous communities. It follows that outcomes from circumpolar suicide prevention programs might be more completely understood at the community level. We present here a methodology for analysis at this level. This paper seeks to understand a cultural prevention program for rural Yup’ik youth in Alaska targeting suicide and co-occurring alcohol abuse as a community development process through changes at the community level. Study Design. Quasi-experimental design with assessment at pre-and post-intervention or at 4 time points. The community development process for this project began in October 2004. The first program baseline assessment began in November 2006, prior to prevention activities with youth and parents, and the post-intervention assessment concluded in March 2008. Methods. Five key informants pre-and post-intervention completed a community readiness assessment, which is a structured procedure assessing a community’s awareness of suicide as an issue and its organizational readiness for prevention programming. Forty-three adult caregivers or sponsors of youth in the prevention program completed an assessment of behaviours that contributed to community protective factors from youth suicide and alcohol abuse at 4 time points before, during and after the intervention. The 54 youth who participated in the prevention program completed an assessment of community protective factors, also at 4 time points before, during and after the intervention. The community protective factors from suicide that were assessed included safety, enforcement of alcohol prohibitions, role models, support and opportunities for youth. Results. Community readiness for the prevention efforts increased to new developmental stages of readiness post-intervention, and a trend in the data suggested community protective factors increased in the amount of protective behaviours performed by adults (slope estimate=0.0162, 95% CI-0.0028–0.0351, d=.55) and in the perceptions of youth (slope estimate=0.0148, 95% CI-0.0004–0.0291, d=.45), in a dose response relationship to the number of prevention program sessions attended by adults and youth. Conclusions. Using data from a feasibility study, this paper demonstrates the feasibility and potential utility of methodological approaches that use community-level variables beyond individual level outcomes in circumpolar suicide prevention research.

Assessment of Awareness of Connectedness as a Culturally-based Protective Factor for Alaska Native Youth

Research with Native Americans has identified connectedness as a culturally based protective factor against substance abuse and suicide. Connectedness refers to the interrelated welfare of the individual, ones family, ones community, and the natural environment. We developed an 18-item quantitative assessment of awareness of connectedness and tested it with 284 Alaska Native youth. Evaluation with confirmatory factor analysis and item response theory identified a 12-item subset that functions satisfactorily in a second-order four-factor model. The proposed Awareness of Connectedness Scale (ACS) displays good convergent and discriminant validity, and correlates positively with hypothesized protective factors such as reasons for living and communal mastery. The measure has utility in the study of culture-specific protective factors and as an outcomes measure for behavioral health programs with Native American youth.

A Protective Factors Model for Alcohol Abuse and Suicide Prevention Among Alaska Native Youth

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

Increasing the Sensitivity of Measures to Change

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

Patterns of protective factors in an intervention for the prevention of suicide and alcohol abuse with Yup'ik Alaska Native youth

Background: Community-based participatory research (CBPR) with American Indian and Alaska Native communities creates distinct interventions, complicating cross-setting comparisons. Objective: The objective of this study is to develop a method for quantifying intervention exposure in CBPR interventions that differ in their forms across communities, permitting multi-site evaluation. Methods: Attendance data from 195 youth from three Yup’ik communities were coded for the specific protective factor exposure of each youth, based on information from the intervention manual. The coded attendance data were then submitted to latent class analysis to obtain participation patterns. Results: Five patterns of exposure to protective factors were obtained: Internal, External, Limits, Community/family, and Low Protection. Patterns differed significantly by community and youth age. Conclusion: Standardizing interventions by the functions an intervention serves (protective factors promoted) instead of their forms or components (specific activities) can assist in refining CBPR interventions and evaluating effects in culturally distinct settings.

Research Designs for Intervention Research with Small Samples II: Stepped Wedge and Interrupted Time-Series Designs

The stepped wedge design (SWD) and the interrupted time-series design (ITSD) are two alternative research designs that maximize efficiency and statistical power with small samples when contrasted to the operating characteristics of conventional randomized controlled trials (RCT). This paper provides an overview and introduction to previous work with these designs and compares and contrasts them with the dynamic wait-list design (DWLD) and the regression point displacement design (RPDD), which were presented in a previous article (Wyman, Henry, Knoblauch, and Brown, Prevention Science. 2015) in this special section. The SWD and the DWLD are similar in that both are intervention implementation roll-out designs. We discuss similarities and differences between the SWD and DWLD in their historical origin and application, along with differences in the statistical modeling of each design. Next, we describe the main design characteristics of the ITSD, along with some of its strengths and limitations. We provide a critical comparative review of strengths and weaknesses in application of the ITSD, SWD, DWLD, and RPDD as small sample alternatives to application of the RCT, concluding with a discussion of the types of contextual factors that influence selection of an optimal research design by prevention researchers working with small samples.

Umyuangcaryaraq “Reflecting”: Multidimensional Assessment of Reflective Processes on the Consequences of Alcohol Use among Rural Yup’ik Alaska Native Youth

Background and aims: Concerns in some settings regarding the accuracy and ethics of employing direct questions about alcohol use suggest need for alternative assessment approaches with youth. Umyuangcaryaraq is a Yup’ik Alaska Native word meaning “Reflecting.” Objectives: The Reflective Processes Scale was developed as a youth measure tapping awareness and thinking over potential negative consequences of alcohol misuse as a protective factor that includes cultural elements often shared by many other Alaska Native and American Indian cultures. This study assessed multidimensional structure, item functioning, and validity. Methods: Responses from 284 rural Alaska Native youth allowed bifactor analysis to assess structure, estimates of location and discrimination parameters, and convergent and discriminant validity. Results: A bifactor model of the scale items with three content factors provided excellent fit to observed data. Item response theory analysis suggested a binary response format as optimal. Evidence of convergent and discriminant validity was established. Conclusion: The measure provides an assessment of reflective processes about alcohol that Alaska Native youth engage in when thinking about reasons not to drink. Scientific significance: The concept of reflective processes has potential to extend understandings of cultural variation in mindfulness, alcohol expectancies research, and culturally mediated protective factors in Alaska Native and American Indian youth.

Maybe Small Is Too Small a Term: Introduction to Advancing Small Sample Prevention Science

Prevention research addressing health disparities often involves work with small population groups experiencing such disparities. The goals of this special section are to (1) address the question of what constitutes a small sample; (2) identify some of the key research design and analytic issues that arise in prevention research with small samples; (3) develop applied, problem-oriented, and methodologically innovative solutions to these design and analytic issues; and (4) evaluate the potential role of these innovative solutions in describing phenomena, testing theory, and evaluating interventions in prevention research. Through these efforts, we hope to promote broader application of these methodological innovations. We also seek whenever possible, to explore their implications in more general problems that appear in research with small samples but concern all areas of prevention research. This special section includes two sections. The first section aims to provide input for researchers at the design phase, while the second focuses on analysis. Each article describes an innovative solution to one or more challenges posed by the analysis of small samples, with special emphasis on testing for intervention effects in prevention research. A concluding article summarizes some of their broader implications, along with conclusions regarding future directions in research with small samples in prevention science. Finally, a commentary provides the perspective of the federal agencies that sponsored the conference that gave rise to this special section.

The Brief Family Relationship Scale A Brief Measure of the Relationship Dimension in Family Functioning

The Relationship dimension of the Family Environment Scale, which consists of the Cohesion, Expressiveness, and Conflict subscales, measures a person’s perception of the quality of his or her family relationship functioning. This study investigates an adaptation of the Relationship dimension of the Family Environment Scale for Alaska Native youth. The authors tested the adapted measure, the Brief Family Relationship Scale, for psychometric properties and internal structure with 284 12- to 18-year-old predominately Yup’ik Eskimo Alaska Native adolescents from rural, remote communities. This non-Western cultural group is hypothesized to display higher levels of collectivism traditionally organized around an extended kinship family structure. Results demonstrate a subset of the adapted items function satisfactorily, a three-response alternative format provided meaningful information, and the subscale’s underlying structure is best described through three distinct first-order factors, organized under one higher order factor. Convergent and discriminant validity of the Brief Family Relationship Scale was assessed through correlational analysis.

Why Small is Too Small a Term: Prevention Science for Health Disparities, Culturally Distinct Groups, and Community-Level Intervention

Implications of the Advancing Small Sample Prevention Science Special Section are discussed. Efficiency and precision are inadequately considered in many current prevention-science methodological approaches. As a result, design and analytic practices pose difficulties for the study of contextual factors in prevention, which often involve small samples. Four primary conclusions can be drawn from the Special Section. First, contemporary statistical and measurement approaches provide a number of underutilized opportunities to maximize power. These strategies maximize efficiencies by optimizing design and resource allocation parameters, allowing for the detection of effects with small samples. Second, several alternative research designs provide both rigor and further optimize efficiencies through more complete use of available information, allowing study of important questions in prevention science for which only small samples may be accessible. Third, mixed methods hold promise for enhancing the utility of qualitative data in studies with small samples. Finally, Bayesian analytic approaches, through their use of prior information, allow for even greater efficiencies in work with small samples, and through their introduction in the routines of mainstream software packages, hold particular promise as an emergent methodology in prevention research.