Summer Rosenstock

Sex differences in neonatal mortality in Sarlahi, Nepal: the role of biology and environment

Background Studies in South Asia have documented increased risk of neonatal mortality among girls, despite evidence of a biological survival advantage. Associations between gender preference and mortality are cited as reasons for excess mortality among girls. This has not, however, been tested in statistical models. Methods A secondary analysis of data from a population-based randomised controlled trial of newborn infection prevention conducted in rural southern Nepal was used to estimate sex differences in early and late neonatal mortality, with girls as the reference group. The analysis investigated which underlying biological factors (immutable factors specific to the newborn or his/her mother) and environmental factors (mutable external factors) might explain observed sex differences in mortality. Results Neonatal mortality was comparable by sex (Ref=girls; OR 1.06, 95% CI 0.92 to 1.22). When stratified by neonatal period, boys were at 20% (OR 1.20, 95% CI 1.02% to 1.42%) greater risk of early and girls at 43% (OR 0.70, 95% CI 0.51% to 0.94%) greater risk of late neonatal mortality. Biological factors, primarily respiratory depression and unconsciousness at birth, explained excess early neonatal mortality among boys. Increased late neonatal mortality among girls was explained by a three-way environmental interaction between ethnicity, sex and prior sibling composition (categorised as primiparous newborns, infants born to families with prior living boys or boys and girls, and infants born to families with only prior living girls). Conclusions Risk of neonatal mortality inverted between the early and late neonatal periods. Excess risk of early neonatal death among boys was consistent with biological expectations. Excess risk for late neonatal death among girls was not explained by overarching gender preference or preferential care-seeking for boys as hypothesised, but was driven by increased risk among Madeshi girls born to families with only prior girls.

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.

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.

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.

Characteristics of Substance Abuse and Self-Injury among American Indian Adolescents Who Have Engaged in Binge Drinking

Binge drinking appears to be a risk factor, facilitator, and method of suicidal and non-suicidal self-injury for some American Indian (AI) youth. We examined characteristics, patterns, and motivations for binge use among AI adolescents (N = 69; 10-19 years-old) who recently engaged in binge drinking. The majority used alcohol alone (53.7%) or a combination of alcohol and marijuana (31.3%) for their binge event. Gender differences emerged with boys more severely affected than girls. Forty-seven percent reported lifetime suicidal thoughts. This study represents one of the first in-depth examinations of substance use and related behaviors among AI adolescents who have engaged in recent binge use.

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.