Participatory Research Brings Knowledge and Hope to American Indian Communities

Abstract

This month, Walkup et al. deliver on the promise they made in their August 2008 editorial in the Journal to use Bcreativity and cost-efficiency[ to address the mental health needs of American Indian children and their families. They have accomplished this by publishing a randomized, clinical trial of an in-home intervention for young (mostly teenage) American Indian mothers. This 25-session intervention (Family Spirit) was delivered to 81 women by paraprofessionals recruited from the two participating reservation communities. The intervention included lessons on prenatal health, parenting, family planning, substance abuse prevention, and coping skills. Family Spirit was compared with a 23-session breast-feeding and nutrition program that was delivered to 86 women. This intervention was also home based. The authors followed the mothers and their children for 1 year postpartum, although attrition was substantialV approximately 50% at 1 year. Nonetheless, the use of generalized linear mixed models allowed the authors to make optimal use of these valuable data, and their results suggest Family Spirit had a significant impact on parental knowledge and infant behavioral outcomes at 12 months. This study is a major advance in both explicit and implicit terms. The explicit study results are easily discerned. As Walkup et al. noted in this article and their previous Editorial, the mental health needs of American Indian children and their families are substantial, yet our knowledge regarding effective preventive and clinical interventions is almost nonexistent. The Family Spirit intervention thus represents a promising new preventive intervention for American Indian communities that was designed to meet their specific needs and draw on readily available human resourcesVparaprofessionals. Indeed, for communities where nurses and other clinically trained professionals may be largely unavailable for preventive workVincluding these and other American Indian reservation communitiesVthese results provide hope that it is indeed possible for paraprofessionals to be effective interventionists despite previously disappointing results by Olds et al. with such an approach. I wonder if the inherent cultural competence of these paraprofessionalsV all of whom were community members and spoke their tribal languageVcompensated for their limited clinical training. Larger, longer, and more methodologically advanced studies will help us determine how far the promise of Family Spirit can advance prevention efforts in American Indian and other underserved communities. The implicit implications of this study, although intimately tied to the above explicit findings, are less apparent, despite the fact that they are of far greater importance. First, part of what makes this study so important is the dearth of mental health intervention research for American Indians. In their review of the literature regarding mental health and substance abuse interventions for American Indian children and adults, Gone and Alcantara were able to identify only two intervention studies that used even quasi-experimental designsVand both were published over a decade ago. Why is this the case? A big part of this comes from the wariness of many tribal communities to participate in research in generalVand intervention research in particular. For communities that have suffered to such an extraordinary degree over the past 517 years, research is often perceived as another form of colonial oppression. In addition, the conduct of researchers who all too often did their work without involving the community in any part of the research process (i.e., identifying relevant research questions, generating hypotheses, collecting and analyzing data disseminating results) has only reinforced these concerns. Even worse are the cases of frank harm to individuals and communities. The memories of these events linger and represent a potentially stifling legacy that all tribal-researcher collaborations must grapple with as they move forward. The authors note that this was certainly the case for this partnership as Ba history of exploitative research predominates Accepted January 17, 2009. This article was reviewed under and accepted by AdHoc Editor Bonnie T. Zima, M.D., M.P.H. Dr. Novins is with the Centers for American Indian and Alaska Native Health and the University of Colorado, e-mail: douglas.novins@uchsc.edu. 0890-8567/09/4806-0585 2009 by the American Academy of Child and Adolescent Psychiatry. DOI: 10.1097/CHI.0b013e3181a1f575 E D I T O R I A L