American Indian Reservation Communities Research Articles

Food Stress and Diabetes-Related Psychosocial Outcomes in American Indian Communities: A Mixed Methods Approach

ObjectiveExplore the relationship between diabetes-related psychosocial outcomes and food stress in American Indian communities. DesignConvergence model of a mixed methods triangulation study. SettingFive American Indian reservation communities in the Midwest. ParticipantsOne-hundred ninety-two participants were randomly selected from tribal health centers using clinic patient records and were surveyed about diabetes distress, empowerment, and food stress across 4 different time points. Seventeen focus group discussions were conducted and transcribed, and a mix of purposive and convenience sampling was used. Phenomenon of InterestPsychosocial outcomes associated with (or related to) diabetes and food stress. AnalysisQuantitative: Multiple linear regression was performed to explore relationships between food stress and diabetes distress and empowerment. Qualitative: Open coding of data identified portions of the transcripts related to food followed by a deductive approach on the basis of the components of quantitative food stress. ResultsFood stress in the forms of (1) not having enough money for food and not having enough time for cooking or shopping (P = 0.08) and (2) inadequate food access and being on a special diet (P = 0.032) were associated with increased diabetes distress. Lower diabetes empowerment was associated with not having enough money for food and being on a special diet (P = 0.030). Our qualitative data mirrored quantitative findings that experiencing multiple forms of food stress negatively impacted diabetes psychosocial outcomes and illuminated the cyclical role mental health can play in relationships to food. Conclusions and ImplicationsOur findings highlight that experiencing food stress negatively affects diabetes empowerment and diabetes distress. These findings emphasize the importance of improving community food environments and addressing individual food access for diabetes management and prevention initiatives in American Indian communities.

Rationale, Design, and Methods for Nen Unkumbi/Edahiyedo ("We Are Here Now"): A Multi-Level Randomized Controlled Trial to Improve Sexual and Reproductive Health Outcomes in a Northern Plains American Indian Reservation Community.

American Indian (AI) youth in the United States experience disproportionate sexual and reproductive health (SRH) disparities relative to their non-Indigenous, white counterparts, including increased rates of sexually transmitted infections (STIs), earlier sexual debut, increased rates of teen birth, and reduced access to SRH services. Past research shows that to improve SRH outcomes for AI youth in reservation communities, interventions must address complex factors and multiple levels of community that influence sexual risk behaviors. Here, we describe development of a multi-level, multi-component randomized controlled trial (RCT) to intervene upon SRH outcomes in a Northern Plains American Indian reservation community. Our intervention is rooted in a community based participatory research framework and is evaluated with a stepped wedge design that integrates 5 reservation high schools into a 5-year, cluster-randomized RCT. Ecological Systems Theory was used to design the intervention that includes (1) an individual level component of culturally specific SRH curriculum in school, (2) a parental component of education to improve parent-child communication about SRH and healthy relationships, (3) a community component of cultural mentorship, and (4) a systems-level component to improve delivery of SRH services from reservation healthcare agencies. In this article we present the rationale and details of our research design, instrumentation, data collection protocol, analytical methods, and community participation in the intervention. Our intervention builds upon existing community strengths and integrates traditional Indigenous knowledge and values with current public health knowledge to reduce SRH disparities.

Understanding opioid use within a Southwestern American Indian Reservation Community: A qualitative study.

Morbidity and mortality due to nonprescription use of opioids has been well documented following the significant increase in the availability of prescription opioids in the early 2000s. The aim of this paper is to explore community beliefs about correlates of opioid risk, protective factors, and behavioral functions of opioid misuse among American Indian youth and young adults living on or near a reservation. Qualitative in-depth interviews were conducted with N = 18 youth and young adults who were enrolled in a parent research trial focused on American Indian youth suicide prevention. Participants were eligible if they endorsed the use of opioids themselves or by close friends or family members at any point during their trial participation. Major themes discussed include: (1) description of opioid use and those who use opioids; (2) acquisition; (3) initiation; (4) motivation to continue using; (5) consequences; and (6) possibilities for intervention. Family played an important role in the initiation of use, but was also highlighted as an important factor in treatment and recovery. A need for upstream prevention methods, including increased employment and after-school activities, was described. The insights gained through this work could help to inform treatment and prevention programs in the community. This work is timely due to the pressing urgency of the opioid epidemic nationally, and community capacity to address opioid use locally.

American Indian/Alaska Native community infrastructure limitations amid the COVID-19 threat

Objective: The recent SARS-CoV-2 (COVID-19) pandemic that is spreading throughout the nation is a particular threat to American Indian and Alaska Native (AI/AN) communities. The use of recommended methods to prevent or mitigate the spread of the virus, such as hand washing, social distancing, masks, contact tracing and community education is highly problematic at many of these sites. The objective of this paper is to identify and examine structural or cultural barriers to implementing COVID-19 recommendations on select reservation sites.Methods: A qualitative approach that collected and analyzed data from existing sources including newsletter articles, relevant policies and other published reports was instituted in the Spring of 2020. The Centers for Disease Control and Prevention (CDC) policies regarding COVID-19 recommendations to halt the spread of the virus were selected as the standard for COVID-19 prevention, surveillance and mitigation. News articles between March 1, 2020 and December 1, 2020 were identified using various search engines and tribal websites. Information from news resources, including literature reviews, newsletter articles, social media reports, and tribal policy announcements, were gathered and reviewed. Two U.S. southwestern communities are used as examples for the review.Results: Data collected from various sources paint a picture of American Indian communities that lack adequate community infrastructures, and have problems of residential isolation, close living quarters, and contaminated and scarce water supplies. Unsafe or limited water restricts handwashing. Limited informational tools, such as telephone, internet, computer and newsletters, restricted adequate notification of the novel coronavirus to American Indian reservation communities. Often, the lack of a physical home address can create barriers to healthcare accessibility and surveillance, as it limits the identification and access to households. In addition, many traditional cultures of AI/ANs emphasize the interrelatedness of all in nature and thus require an ecological approach to health education and preventive measures, identified as a limitation for COVID-19 surveillance and mitigation.Conclusions: AI/AN communities face a serious threat of contracting COVID-19. Four key infrastructure limitations to effective COVID-19 prevention, surveillance and mitigation were identified: limited access to safe water, deficient telecommunication networks (telephone, internet, and television), housing isolation and shortages, and inadequate medical services – are experienced by many AI/AN communities. Although there are 574 federally recognized tribes in the United States, the two identified in this study subscribe to an ecological approach to health education and preventive measures in that they believe in the interrelatedness of all things in nature. Surveillance questions may be misunderstood or seem invasive and prevention measures (masks, social distancing, and handwashing) may seem to be extreme measures to groups so close to the environment. Together, these present serious barriers to prevention and mitigation of the COVID-19 virus in this underserved population.

Uranium Exposure in American Indian Communities: Health, Policy, and the Way Forward.

Background:Uranium contamination of drinking-water sources on American Indian (AI) reservations in the United States is a largely ignored and underfunded public health crisis. With an estimated 40% of the headwaters in the western U.S. watershed, home to many AI reservation communities, being contaminated with untreated mine waste, the potential health effects have largely been unexplored. With AI populations already facing continued and progressive economic and social marginalization, higher prevalence of chronic disease, and systemic discrimination, associations between various toxicant exposures, including uranium, and various chronic conditions, need further examination.Objectives:Uranium’s health effects, in addition to considerations for uranium drinking-water testing, reporting, and mitigation in reference to AI communities through the lens of water quality, is reviewed.Discussion:A series of environmental health policy recommendations are described with the intent to proactively improve responsiveness to the water quality crisis in AI reservation communities in the United States specific to uranium. There is a serious and immediate need for better coordination of uranium-related drinking-water testing and reporting on reservations in the United States that will better support and guide best practices for uranium mitigation efforts. https://doi.org/10.1289/EHP7537

Aligning three substance use disorder interventions among a tribe in the Southwest United States: Pilot feasibility for cultural re-centering, dissemination, and implementation

In this article we describe cultural re-centering, dissemination, and implementation activities in partnership between an American Indian reservation community and a university in the Southwest United States. We offer examples of cultural adaptation and implementation of evidence-based treatments (e.g., Motivational Interviewing, Community Reinforcement Approach and the Community Reinforcement and Family Training) using the Interactive Systems Framework. Facilitators and barriers are described within each study including recruitment strategies, training, and sustainability of counselors in the community. Through this Tribal-university partnership, we offer insight on the cultural adaptation and implementation process that will be translatable and clinically meaningful to other rural and reservation communities.

Community Readiness Model for Prevention Planning: Addressing Childhood Obesity in American Indian Reservation Communities.

The community readiness model (CRM) is a stage-matched assessment protocol to assess community readiness to address a public health issue. To identify appropriate, culturally sensitive, and community-specific intervention strategies for preventing obesity in children, researchers, and community members formed a partnership to address childhood obesity within one American Indian Reservation. The CRM guided 30 interviews in five communities to direct the team's efforts in addressing obesity among children residing on the reservation. Interviews were scored across six dimensions on an anchored scale of one through nine; scores were then averaged to determine an overall readiness score for each community. A thematic analysis of interview responses aided in interpretation of the readiness scores and identified areas for prevention planning and intervention development. The overall community readiness score for the communities was 2.9 (SD = 0.5), which falls between 2 (denial/resistance) and 3 (vague awareness) on the anchored rating scale. The thematic analysis resulted in a hierarchal classification scheme with six broad themes that corresponded to the CRM dimensions and 13 sub-themes. The low readiness scores directed the team to implement corresponding strategies to increase awareness, while the thematic analysis suggested that action-based approaches might also be appropriate. The narrow range of scores suggest that community-wide assessments may be sufficient unless specific information is needed for each region of the community. The CRM may be an effective way to assess community readiness to address childhood obesity on an American Indian Reservation.

Rural Parent Support of Child Health Behavior in the Home Environment: A Qualitative Study on an American Indian Reservation.

Background. Obesity rates are disproportionately high among rural and American Indian (AI) children. Health behaviors contributing to child obesity are influenced by parents at home. Engaging parents remains a challenge, particularly among low-income and ethnic minority families. Aims. The aim of this study was to learn how AI parents living on a rural AI reservation support and engage with their children’s nutrition and physical activity behaviors at home. Methods. Parents with children ages 6 to 12 years living on one, rural AI reservation participated. Focus groups and interviews were conducted, using a 14-question moderator’s guide. A systematic, iterative content analysis was applied to the transcripts. Results. Twenty-five parents (52% AI or Alaska Native) participated in 3 focus groups (n = 17) and interviews (n = 8). Themes related to enhancers included role modeling and whole family and child-initiated activities. Barriers included resources, child safety concerns, driving distances, and competing family priorities. Themes related to strategies for change included opportunities for peer learning from other local families, creating fun, program support for all supplies and incentives, and incorporation of storytelling and multicultural activities. Discussion. This study advances knowledge to promote parental engagement with child health behavior in the home, including unique themes of inclusiveness, culture-focused, and intergenerational activities. Conclusion. Results may inform interventions seeking to engage parents living in rural and AI reservation communities in home-based child behavior change efforts.

Variation in WIC Cash-Value Voucher Redemption Among American Indian Reservation Communities in Washington State

ABSTRACTIn 2009, a cash-value voucher (CVV) was added to the U.S. Department of Agriculture (USDA) Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) package to encourage fresh fruits and vegetable purchases. Access to fresh fruit and vegetables on American Indian (AI) reservations is limited. We compared the average proportion of CVVs redeemed between 27 reservation-based WIC clinics with 185 non-reservation-based WIC clinics and the proportion of CVVs redeemed in WIC clinics in tribes with high access to fresh fruits and vegetables with their counterparts with low access. Reservation-based WIC clinics had significantly lower CVV redemption compared to non-reservation-based clinics (65 vs 81%, respectively, P < .0001). Additionally, CVV redemption was similar among reservation-based WIC clinics where a supermarket was located within or outside the reservation. CVV redemption is significantly lower in tribal than non-tribal WIC clinics. Research is needed to identify barriers to CVV redemption within the tribal WIC population.

Peer Recovery Support in American Indian Communities: A Qualitative Intrinsic Case-Study Approach

Peer recovery support (PRS) offers significant benefits for individuals in recovery from substance abuse disorders. This research describes the experiences of the first 12 months of a tribally led, American Indian community-based PRS project in two American Indian communities. An intrinsic qualitative case-study design was used to answer the research question, “What are some considerations for implementing PRS services in an American Indian reservation community?” Results showed PRS services fill a much-needed gap in American Indian communities where recovery support resources are limited and substance abuse is pervasive.

Unconscious biases: racial microaggressions in American Indian health care.

This article reports on the prevalence and correlates of microaggressive experiences in health care settings reported by American Indian (AI) adults with type 2 diabetes mellitus (T2DM). This community-based participatory research project includes two AI reservation communities. Data were collected via in-person article-and-pencil survey interviews with 218 AI adults diagnosed with T2DM. Greater than one third of the sample reported experiencing a microaggression in interactions with their health providers. Reports of microaggressions were correlated with self-reported history of heart attack, worse depressive symptoms, and prior-year hospitalization. Depressive symptom ratings seemed to account for some of the association between microaggressions and hospitalization (but not history of heart attack) in multivariate models. Microaggressive experiences undermine the ideals of patient-centered care and in this study were correlated with worse mental and physical health reports for AIs living with a chronic disease. Providers should be cognizant of these subtle, often unconscious forms of discrimination.

Challenges Faced in Engaging American Indian Mothers in an Early Childhood Caries Preventive Trial.

Objective. This study explores the challenges faced by the research implementation team in engaging new mothers in a community oral health prevention intervention in an American Indian (AI) reservation community. Methods. Qualitative methods in the form of in-depth interviews were used in the study. Qualitative data were collected from research staff workers at a field site, who were involved in the implementation of a culturally tailored, randomized controlled trial of a behavioral intervention utilizing Motivational Interviewing (MI). Results. Several challenges were described by the field staff in engaging new mothers, including low priority placed on oral health, lack of knowledge, and distractions that reduced their ability to engage in learning about oral health of their child. Other difficulties faced in engaging the mothers and the AI community at large were distrust related to racial differences and physical and environmental barriers including poor road conditions, lack of transportation and communication, and remoteness of data collection sites. The field staff developed and applied many strategies, including conducting home visits, applying new communication strategies, and interacting with the community at various venues. Conclusion. Prevention interventions for ECC need to target AI mothers. Strategies developed by the field staff were successful for engaging mothers in the study.

Lifetime Prevalence of Posttraumatic Stress Disorder in Two American Indian Reservation Populations

Posttraumatic stress disorder (PTSD) has been found to be more common among American Indian populations than among other Americans. A complex diagnosis, the assessment methods for PTSD have varied across epidemiological studies, especially in terms of the trauma criteria. Here, we examined data from the American Indian Service Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project (AI-SUPERPFP) to estimate the lifetime prevalence of PTSD in two culturally distinct American Indian reservation communities, using two formulas for calculating PTSD prevalence. The AI-SUPERPFP was a cross-sectional probability sample survey conducted between 1997 and 2000. Southwest (n = 1,446) and Northern Plains (n = 1,638) tribal members living on or near their reservations, aged 15-57 years at time of interview, were randomly sampled from tribal rolls. PTSD estimates were derived based on both the single worst and 3 worst traumas. Prevalence estimates varied by ascertainment method: single worst trauma (lifetime: 5.9% to 14.8%) versus 3 worst traumas (lifetime, 8.9% to 19.5%). Use of the 3-worst-event approach increased prevalence by 28.3% over the single-event method. PTSD was prevalent in these tribal communities. These results also serve to underscore the need to better understand the implications for PTSD prevalence with the current focus on a single worst event.

Trauma and conditional risk of posttraumatic stress disorder in two American Indian reservation communities

To determine conditional risk of posttraumatic stress disorder (PTSD) in two culturally distinct American Indian reservation communities. Data derived from the American Indian Service Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project, a cross-sectional population-based survey that was completed between 1997 and 2000. This study focused on 1,967 participants meeting the DSM-IV criteria for trauma exposure. Traumas were grouped into interpersonal, non-interpersonal, witnessed, and "trauma to close others" categories. Analyses examined distribution of worst traumas, conditional rates of PTSD following exposure, and distributions of PTSD cases deriving from these events. Bivariate and multivariate logistic regressions estimated associations of lifetime PTSD with trauma type. Overall, 15.9% of those exposed to DSM-IV trauma qualified for lifetime PTSD, a rate comparable to similar US studies. Women were more likely to develop PTSD than were men. The majority (60%) of cases of PTSD among women derived from interpersonal trauma exposure (in particular, sexual and physical abuse); among men, cases were more evenly distributed across trauma categories. Previous research has demonstrated higher rates of both trauma exposure and PTSD in American Indian samples compared to other Americans. This study shows that conditional rates of PTSD are similar to those reported elsewhere, suggesting that the elevated prevalence of this disorder in American Indian populations is largely due to higher rates of trauma exposure.

The New American Gang? Gangs in Indian Country

Gangs remain a problem across the country. American Indian communities started to see increased gang activity in the 1990s. Despite this, there is little information on American Indian gangs in the literature. This article provides an overview of the characteristics of American Indian gang members and gangs from a Western American Indian reservation community. Utilizing survey responses from 6th, 8th, 10th, and 12th graders, the authors explore the characteristics of American Indian gangs, the members who belong to these groups, and the risk factors that differentiate those individuals who become involved in gangs in tribal communities from youth who do not. This study contributes to the overall understanding of gangs and provides additional knowledge regarding American Indian gangs to help target law enforcement, prevention, and intervention services.

Protective Factors in American Indian Communities and Adolescent Violence

With their distinct cultural heritage and rural boundaries, American Indian reservation communities offer a unique opportunity to explore protective factors that help buffer adolescents from potential risk behaviors such as violence. Prior published research on Indian communities has not explored three potential protective factors for violence-parental monitoring of adolescents and friends, adolescents' self-efficacy to avoid fighting, and adolescents' interest in learning more about their traditional culture. This paper explores the relationship between these factors and reduced risk of reported violence. In 1998, 630 American Indian students in grades 6-12 were surveyed in five Midwestern, rural Indian reservation schools. Path analysis was used to identify the direct and indirect association of the three potential protective factors with reduced violence behavior. There were significant gender differences both in perceived parental monitoring and in adolescents' self-efficacy. For female adolescents, parental monitoring had the strongest inverse relationship with female adolescents' involvement in violence. Female adolescents' self-efficacy and their interest in learning more about their culture were also inversely associated with violence and therefore potentially important protectors. Male adolescents who reported more interest in learning the tribe's culture had better self-efficacy to avoid violence. However, self-efficacy did not successfully predict their reported involvement in peer violence. These findings support exploring gender differences, parental monitoring, self-efficacy training as well as cultural elements in future violence intervention studies. Further investigation is needed to identify protective factors for risk behaviors among male adolescents and test the generalizability to non-reservation based adolescents.

Food insecurity and household eating patterns among vulnerable American-Indian families: associations with caregiver and food consumption characteristics.

To identify factors associated with food insecurity and household eating patterns among American-Indian families with young children. Cross-sectional survey among households with young children that were receiving emergency food services. We collected information on food insecurity levels, household eating patterns, experiences with commercial and community food sources and demographics, and used multivariate regression techniques to examine associations among these variables. Four Southwestern American-Indian reservation communities. A total of 425 parents/caregivers of young children completed the survey. Twenty-nine per cent of children and 45 % of adults from households participating in the survey were classified as 'food insecure'. Larger household size was associated with increased food insecurity and worse eating patterns. Older respondents were more likely than younger respondents to have children with food insecurity (relative risk = 2·19, P < 0·001) and less likely to have healthy foods available at home (relative risk = 0·45, P < 0·01). Consumption of food from food banks, gas station/convenience stores or fast-food restaurants was not associated with food insecurity levels. Respondents with transportation barriers were 1·46 times more likely to be adult food insecure than respondents without transportation barriers (P < 0·001). High food costs were significantly associated with greater likelihoods of adult (relative risk = 1·47, P < 0·001) and child (relative risk = 1·65, P < 0·001) food insecurity. Interventions for American-Indian communities must address challenges such as expense and limited transportation to accessing healthy food. Results indicate a need for services targeted to older caregivers and larger households. Implications for innovative approaches to promoting nutrition among American-Indian communities, including mobile groceries and community gardening programmes, are discussed.

Cognitive behavioral treatment for trauma symptoms in American Indian youth: preliminary findings and issues in evidence-based practice and reservation culture

This study reports on the use of Cognitive Behavioral Intervention for Trauma in Schools (CBITS), an evidence-based practice, with 43 students in six schools on three American Indian reservation communities. CBITS was helpful in treating the majority of American Indian children and adolescents who were experiencing symptoms of post-traumatic stress disorder and depression. Using a limited quasi-experimental design, on a measure of traumatic stress, there was symptom reduction with the passage of time; however, symptoms reduced more substantially with treatment. Local cultural experts, that is, Tribal Elders, were invited to provide traditional cultural activities and teachings in the introductory lesson and at graduation. A 3-year follow-up involving school counselors reported on acceptability and additional impacts of the program. They expressed that treating trauma was a priority for their students, CBITS was perceived as an advantageous approach, and counselors said they would use it in the future. Fur...

Nonsuicidal Self-Injury in an American Indian Reservation Community: Results From the White Mountain Apache Surveillance System, 2007–2008

To describe characteristics and correlates of nonsuicidal self-injury (NSSI) among the White Mountain Apache Tribe. NSSI has not been studied before in American Indian samples despite associated risks for suicide, which disproportionately affect American Indian youth. Apache case managers collected data through a tribally mandated surveillance system. Data from 2007 and 2008 (N = 182) were examined for rates, methods, precipitants, functions, past history of self-injury and service use, by age and gender. The rate of NSSI among all ages was 600 in 100,000, with individuals 10 to 14 years old disproportionately affected at a rate of 3,000 in 100,000. More females (65%) reported NSSI, and cutting was the preferred method (98%) for both genders combined. Most frequently reported precipitants were peer pressure/copying, conflict with boy/girlfriend and "depression." A substantial proportion (22%) was intoxicated/high at the time. More reported the function of NSSI was to "effect internal state" (45%) than "effect circumstances" (15%). More than one-third (39%) received ED treatment and referrals for aftercare (36%). Of those referred, only 30% followed up with services. Most (79%) reported past NSSI; 30% reported past suicidal ideation and 25% attempts. NSSI is a significant, largely unaddressed mental health problem among the White Mountain Apache Tribe and likely other reservation communities, especially as NSSI could serve as a precursor to suicide in this population. Interestingly, another self-destructive behavior, severe substance use, was reported to the surveillance system by Apaches and described in terms similar to NSSI, an important preliminary finding worth further exploration.

A Women's Shelter in a Rural American Indian Community

The author presents a case study and personal story about a group of community members initiating a women's shelter in a rural American Indian reservation community. Problems are identified and their resolutions described in organizing a community group, encountering community resistance, locating the shelter, raising funds, and developing procedures for operating the shelter. Lessons learned by the group are provided to illustrate possible solutions to problems that other community groups may encounter when seeking to open a women's shelter in a rural American Indian community.