Nicole Neault

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.

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.

A Home-Visiting Diabetes Prevention and Management Program for American Indian Youth The Together on Diabetes Trial

Purpose The purpose of this study was to test the feasibility of a family-based, home-visiting diabetes prevention/management intervention for American Indian (AI) youth with or at risk for type 2 diabetes. Methods The Together on Diabetes program, developed through community-based participatory research, enrolled 255 AI youth (aged 10-19 years) with or at risk for type 2 diabetes and 223 support persons. Delivered by local AI paraprofessionals in 4 rural AI communities, the program included home-based lifestyle education and psychosocial support, facilitated referrals, and community-based healthy living activities. Changes in AI youth participants’ knowledge, behavior, psychosocial status, and physiological measurements were assessed over 12 months. Results Over one-half (56.1%) of youth were boys. The median age was 13.2 years. At baseline, 68.0% of youth reported no physical activity in the past 3 days; median percentages of kilocalories from fat (36.18%) and sweets (13.67%) were higher than US Department of Agriculture recommendations. Nearly 40% of participants reported food insecurity in the past month; 17.1% screened positive for depression. Support persons were predominantly family members, few reported having home Internet access (38.6%), and the majority reported being long distances (>30 minutes) from food stores. Whereas support persons were primarily responsible (≥69%) for obtaining medical care for the youth, the youth had a greater role in behavioral outcomes, indicating joint diabetes prevention/management responsibility. Conclusions: Baseline results confirmed the need for family-based youth diabetes prevention interventions in rural AI communities and indicated that enrolling at-risk youth and family members is feasible and acceptable.

The Impact of a Home-Based Diabetes Prevention and Management Program on High-Risk American Indian Youth

Purpose The purpose of this study was to examine the impact of a home-based diabetes prevention and management program on high-risk American Indian youth. Methods Together on Diabetes (TOD) was designed via a participatory approach with 4 tribal communities in the southwestern United States. A multisite pre- and postevaluation design was used to evaluate the efficacy of the TOD intervention on improving youth’s psychosocial, knowledge, behavioral, and physiological outcomes at 4 time points from baseline to 12 months postenrollment. Results A total of 256 youth and 225 support persons were enrolled in the TOD program. At 12 months postenrollment, improvements were observed in youth’s quality of life (P < .001), depressive symptoms (P < .001), knowledge related to TOD content (P < .001), standardized body mass index scores (P = .004), and hypertension (P = .026). Improvements in mean A1C were observed among diabetic youth with baseline A1C >6.5% (P = .036). Conclusions The TOD program was feasible, acceptable, and effective in lowering diabetes risk among reservation-based American Indian youth. It is the first efficacious youth-focused diabetes prevention and management program developed and implemented in partnership with tribal communities.

Increasing Healthy Food Availability, Purchasing, and Consumption: Lessons Learned from Implementing a Mobile Grocery

Abstract:Background: A mobile grocery (MoGro) was developed through a partnership with community stakeholders, community advisory boards (CABs), Rick and Beth Schnieders, and the Johns Hopkins Center for American Indian Health (JHCAIH). MoGro provided access to subsidized healthy foods, with complementary events, including fitness activities and cooking classes.Objectives: MoGro is an innovative approach to promoting food security.Methods: Within a community-based participatory action research (CPBAR) framework, the JHCAIH and partners designed and administered household surveys at baseline and 3 months after MoGros launch. A randomly selected 20% of households participated at each timepoint.Results: About 75% of respondents indicated that MoGro had changed the foods they purchased, and 68% reported that MoGro had changed how their families ate. After MoGros launch, food availability increased significantly and food insecurity decreased.Conclusions: The evaluation documented MoGros impact in the community; high self-reported positive changes, significant increases in food availability, and decreases in food insecurity.

Engaging Native American Caregivers in Youth-Focused Diabetes Prevention and Management

Native American youth aged 10 to 19 years are disproportionately affected by type 2 diabetes. Intergenerational programs may improve health in tribal communities. We evaluated Together on Diabetes, a diabetes prevention and management program, among 257 participating Native American youths with or at risk for type 2 diabetes and their adult caregivers. Feasibility, acceptability, and demographic data were collected from 226 adult caregivers. Data on physical measurements (weight, height, waist circumference) were collected from 37 of the caregivers. Results indicated that engaging adult caregivers was feasible, acceptable, and effective. Furthermore, a subset of adult caregivers reduced their body mass index (weight in kilograms divided by height in m2) significantly from the start to the end of the program, a 12 month period (P = .02). Findings suggest the feasibility of engaging adult caregivers in youth diabetes prevention programs.