Carol E. Kaufman

Within the hidden epidemic: sexually transmitted diseases and HIV/AIDS among American Indians and Alaska Natives.

Objectives: To review the epidemiology, research, and prevention programs for sexually transmitted diseases in American Indians and Alaska Natives (AI/ANs). Study Design: We reviewed the current national and regional trends in sexually transmitted diseases (STDs) for AI/ANs from 1998–2004, peer-reviewed studies from January 1996, through May 2006, and reports, unpublished documents, and electronic resources addressing AI/AN STD prevention and control. Results: STD prevalence among AI/ANs remains high. For example, the case rate of C. trachomatis in the North Central Plains AI/AN populations is 6 times the overall US rate. Trends for C. trachomatis also show sustained increases. Little research exists on STDs for this population, and most is focused on HIV/AIDS. Fear of compromised confidentiality, cultural taboos, and complex financial and service relationships inhibit effective surveillance, prevention, and management. Conclusions: Recommendations for STD control in this population include improved local surveillance and incorporation of existing frameworks of health and healing into prevention and intervention efforts. Research defining the parameters of cultural context and social epidemiology of STDs is necessary.

Contraceptive Use in South Africa Under Apartheid

In this paper, patterns of contraceptive use among black South African women in the late 1980s are examined. Multilevel logit models are used to evaluate the extent to which segregation of the African population into homelands gave rise to uneven patterns of contraceptive use; how this pattern was shaped by variations in family-planning acceptability; and the way in which the system of male labor migration and social and economic inequities across communities affected womens use of contraceptives. Results show that variation in contraceptive use across homeland areas diminished with the addition of community controls for development and migration. Controlling for unobserved heterogeneity indicated that localized conditions could offset the advantages or disadvantages of living in a former homeland.

Pregnant or positive: adolescent childbearing and HIV risk in KwaZulu Natal, South Africa.

Abstract In communities where early age of childbearing is common and HIV prevalence is high, adolescents may place themselves at risk of HIV because positive or ambivalent attitudes towards pregnancy reduce their motivation to abstain from sex, have sex less often or use condoms. In this study, we analyse cross-sectional survey data from KwaZulu Natal, South Africa, to explore whether an association exists between the desire for pregnancy and perceptions of HIV risk among 1,426 adolescents in 110 local communities. Our findings suggest that some adolescents, girls more than boys, were more concerned about a pregnancy if they lived in environments where youth were perceived to be at high risk of HIV infection. The probability that pregnancy was considered a problem by boys was positively correlated with the proportion of adult community members who thought youth were at risk of acquiring HIV, and for girls by the proportion of peers in the community who thought youth were at risk of HIV. We also found that becoming pregnant would be a bigger problem for the African girls than the white and Indian girls. The analysis suggests that for some adolescents, in addition to effects on educational and employment opportunities, the danger of HIV infection is becoming part of the calculus of the desirability of a pregnancy.

Trajectories of substance use among young American Indian adolescents: patterns and predictors

Substance use often begins earlier among American Indians compared to the rest of the United States, a troubling reality that puts Native youth at risk for escalating and problematic use. We need to understand more fully patterns of emergent substance use among young American Indian adolescents, risk factors associated with escalating use trajectories, and protective factors that can be parlayed into robust prevention strategies. We used growth mixture modeling with longitudinal data from middle-school students on a Northern Plains reservation (Wave 1 Nxa0=xa0381, M age at baselinexa0=xa012.77, 45.6xa0% female) to identify subgroups exhibiting different trajectories of cigarette, alcohol, and marijuana use. We explored how both risk (e.g., exposure to stressful events, deviant peers) and protective (e.g., positive parent–child relationships, cultural identity) factors were related to these trajectories. For all substances, most youth showed trajectories characterized by low rates of substance use (nonuser classes), but many also showed patterns characterized by high and/or escalating use. Across substances, exposure to stress, early puberty, and deviant peer relationships were associated with the more problematic patterns, while strong relationships with parents and prosocial peers were associated with nonuser classes. Our measures of emergent cultural identity were generally unrelated to substance use trajectory classes among these young adolescents. The findings point to the importance of early substance use prevention programs for American Indian youth that attenuate the impact of exposure to stressful events, redirect peer relationships, and foster positive parent influences. They also point to the need to explore more fully how cultural influences can be captured.

Reproductive control in apartheid South Africa

Since its inception in 1974, the South African family planning programme has been widely believed to be linked with white fears of growing black numbers. The programme has been repeatedly attacked by detractors as a programme of social and political control. Yet, in spite of the hostile environment, black womens use of services has steadily increased. Using historical and anthropological evidence, this paper delineates the links between the social and political context of racial domination and individual fertility behaviour. It is argued that the quantitative success of the family planning programme is rooted in social and economic shifts conditioning reproductive authority and fertility decision-making. State policies of racial segregation and influx control, ethnic homeland politics, and labour migration of men transformed opportunities and constraints for black women and men, and altered local and household expectations of childbearing. Women came to manage their own fertility as they increasingly found themselves in precarious social and economic circumstances.

Circle of Life: Rationale, Design, and Baseline Results of an HIV Prevention Intervention Among Young American Indian Adolescents of the Northern Plains

In spite of significant disparities in sexual health outcomes for American Indian youth, no studies exist examining the effectiveness of HIV-prevention interventions. Circle of Life is an HIV-prevention intervention specifically developed for American Indian middle-school youth. We describe the rationale, methodology, and baseline results of a longitudinal randomized trial of Circle of Life conducted among American Indian youth aged 11–15 in a reservation community. The innovative design includes two pre-intervention waves to determine patterns of behavior prior to the intervention that might be associated with a differential impact of the intervention on sexual risk. We used one-way analysis of variance and chi-square tests to test for significant differences between randomized group assignment at each baseline wave and generalized estimating equations (GEE) to test significant differences in the rate of change in outcomes by group longitudinally. We present the collaborative and adaptive strategies for consenting, assenting, and data collection methodology in this community. Achieved response rates are comparable to other similar studies. Results from the two baseline waves indicate that few outcomes significantly varied by randomized intervention assignment. Ten percent of youth reported having had sex at Wave 1, rising to 15% at Wave 2. Among those who had had sex, the majority (>70%) reported using a condom at last sex. The project is well positioned to carry out the longitudinal assessments of the intervention to determine the overall impact of the Circle of Life and the differential impact by pre-intervention patterns of behavior across youth.

Effectiveness of Circle of Life, an HIV-Preventive Intervention for American Indian Middle School Youths: A Group Randomized Trial in a Northern Plains Tribe

OBJECTIVESnWe assessed the effectiveness of Circle of Life (COL), an HIV-preventive intervention developed specifically for American Indian and Alaska Native (AI/AN) middle school youths.nnnMETHODSnBy partnering with a tribal community, we conducted a longitudinal wait-listed group randomized trial with 635 seventh and eighth graders in 13 schools of a Northern Plains tribe. We surveyed participants at baseline, 3 months, and 12 months from 2006 to 2007.nnnRESULTSnCOL was found to increase HIV knowledge in the short term, but had no effect on sexual activity compared with those who did not receive it. However, COL was found to be effective for delaying the onset of sexual activity, with the greatest reduction in risk occurring for those receiving COL at early ages.nnnCONCLUSIONSnCommunity partnership was key to successful project design, implementation, and analysis. The project confirmed the importance of the timing of interventions in early adolescence. COL may be a key resource for reducing sexual risk among AI/AN youths.

Patterns of Substance Use Initiation among Young Adolescents in a Northern Plains American Indian Tribe

Background: Substantial evidence documents problematic substance use in Northern Plains American Indian communities. Studies suggest that disparities can be traced to disproportionate rates of early substance use, but most evidence comes from the retrospective reports of adults or older adolescents. Objective: To use a prospective longitudinal design to examine substance use initiation patterns as they emerge among young American Indian adolescents. Methods: Four waves of data were collected across three consecutive school years from middle school students on a Northern Plains reservation (N = 450). Discrete-time survival analyses were used to estimate risks of initiation of cigarettes, alcohol, and marijuana from age 10 to 13. Results: Risk for cigarette initiation was relatively high at age 10 and stable until age 13. Marijuana risk was low at age 10 but increased sharply by age 12. Alcohol initiation lagged, not surpassing risk for cigarette initiation until age 13 and remaining below risk for marijuana initiation throughout middle school. Hazards for girls trended higher than those for boys across all substances, but differences did not reach significance. Conclusion: Initiation patterns among these American Indian adolescents differed from patterns reported in other US groups, particularly with respect to deviation from the sequence characterized the initiation of marijuana before alcohol that is predicted by the gateway theory. Scientific Significance: Findings suggest that prevention efforts with youth in this community should begin early with a primary focus on marijuana use. They also suggest the importance of examining sequences of substance initiation among youth in other American Indian communities.

Identifying diverse HIV risk groups among American Indian young adults: the utility of cluster analysis.

We demonstrate the utility of cluster analysis for identifying diverse HIV risk groups found in a community-based sample. Within a group of 706 American Indian young adults, we used cluster analysis to identify four profiles of HIV risk/protection. The High Efficacy/Low Risk cluster had high levels of knowledge/education, self-efficacy, and outcome expectations about HIV protection, with low levels of risk behaviors. Low Efficacy/Low Risk had low levels of HIV knowledge/education, self-efficacy, and outcome expectations, but high levels of perceived risk for HIV with low levels of HIV risk behaviors. Low Efficacy/Moderate Risk was similar to the previous group, but its members had moderately higher levels of several risk behaviors and higher condom use. Low Efficacy/High Risk had high rates of several high-risk behaviors such as exchanging sex for money or injection drug use. Validation analyses highlighted differences that can be useful for the development of preventive interventions.

Circle of Life HIV/AIDS-Prevention Intervention for American Indian and Alaska Native Youth

This article describes the objectives, theoretical bases, development process, and evaluation efforts to-date for the Circle of Life (COL) curricula, HIV/AIDS prevention interventions designed for American Indian and Alaska Native (AI/AN) youth. The curricula are based on Indigenous models of learning and behavior encompassing concepts of Western theories of health behavior change. The curricula underwent extensive national and community review. Subsequent advances include the development of a computer-based version of the intervention.