Exploring alcohol use and pregnancy among American Indian and Alaska Native women
Abuse of alcohol and drugs, both before and during pregnancy, is associated with unintended pregnancy, late or no use of prenatal care, low birth weight, preterm birth, and both maternal and infant mortality. American Indian and Alaska Native (AI/AN) women face numerous sexual, reproductive, perinatal, and maternal health disparities compared to non-Hispanic white (NHW) women, yet data that speak to these disparities are scarce and limited. Key indicators related to AI/AN women are frequently omitted from national reports, such as the Centers for Disease Control and Prevention’s (CDC’s) Healthy People initiatives, due to inadequate sample sizes and reporting. Some smaller studies that have focused on individual Indigenous and Tribal communities have found that alcohol use and binge drinking among AI/AN women remains high, but that this varies by community.
Few studies have examined pre-pregnancy and prenatal experiences related to alcohol use among AI/AN women. I propose a multi-methods study to address these questions with three Specific Aims. First, I will perform a quantitative, multistate analysis using Pregnancy Risk Assessment Monitory System (PRAMS) data to estimate alcohol use and screening before and during pregnancy to understand patterns of use, screening, and counseling. Second, I will examine risk factors related to alcohol use before and during pregnancy, and how those factors differ for AI/AN women compared to a matched sample of NHW women in the PRAMS data. Third, in collaboration with investigators from Research Project 1 of the Native Center for Alcohol Research and Education, I will conduct focus groups to explore cultural norms, structural stigma, and social messages surrounding alcohol and pregnancy among 30 AI/AN women in urban and rural communities.
This study will use secondary data from multiple states and communities (Alaska, Washington, Oklahoma, New Mexico, and the Great Plains Tribal Council) and years (2014-2017) to assemble adequate sample sizes for analyses. Descriptive statistics of AI/AN and NHW women will be calculated and reported. Multiple regression modeling will be performed to determine risk factors for each outcome of interest (i.e., pre-pregnancy alcohol use, prenatal alcohol use, prenatal binge drinking) and compared between AI/AN and NHW women. Qualitative data will be analyzed for salient themes related to alcohol and pregnancy among AI/AN communities. Findings from this study will provide valuable information about alcohol use and pregnancy among Native women and inform development of culturally appropriate interventions.
NCARE Liaison: Dr. Michelle Sarche
Lucy Hebert, PhD
Luciana (Lucy) Hebert, PhD, is an Assistant Research Professor at the Institute for Research and Education to Advance Community Health (IREACH) and the Elson S. Floyd College of Medicine at Washington State University. She is an adolescent and women’s health researcher with expertise in family planning, maternal and child health, and sexual and reproductive health. She has formal training in demography and expertise in qualitative and quantitative data collection and analysis. She also serves on the IREACH Methods Core.
Real-time breathalyzer monitoring and contingency management for alcohol use in American Indian women
Fetal alcohol spectrum disorders (FASDs) manifest in a continuum of wide-ranging and devastating physical, neuropsychological, and behavioral deficits in children exposed to alcohol in utero. FASDs are a particularly grave public health concern in American Indian (AI) populations, as pregnant AI women are most likely to report prenatal binge drinking compared to other US racial and ethnic groups. As a result, the AI population is up to 10 times more likely than the general population to suffer from FASDs (2.0 vs. 0.2 per 1,000 births). Nonetheless, AI women have limited access to culturally appropriate evidence-based interventions for alcohol use in pregnancy. Few randomized controlled trials have examined alcohol interventions in AI populations to date, with only one targeting women of reproductive age and none targeting pregnant women. Contingency management (CM) is an effective behavior modification intervention in which financial or non-financial incentives are contingent on achieving an observable health goal. In order to increase its reach, CM is increasingly delivered using mobile technologies, including internet- and smartphone-based interventions. Our pilot data and studies conducted by others indicate that mobile alcohol monitoring (MAM) and CM are effective in increasing abstinence and reducing alcohol use in the general population, as well as decreasing smoking in pregnant women, but no study has tested a CM+MAM protocol for AI pregnant and postpartum women. In Washington, the Parent-Child Assistance Program (PCAP) provides case management and home visits to pregnant and parenting women at risk for having children with FASDs and has increased alcohol treatment completion and reduced self-reported alcohol use. While PCAP has been successful in reducing drug and alcohol use, the program has never systematically included CM or MAM interventions. PCAP is therefore an ideal setting to implement a culturally appropriate CM+MAM protocol for prenatal and postpartum alcohol use in AI women. We propose to develop and test a CM+MAM protocol to be used as an adjunctive treatment in home-based case management settings, such as PCAP, among AI women. We will first convene key subject area experts to revise our CM+MAM protocol and determine cultural appropriateness of CM+MAM for alcohol reduction or abstinence among AI women. Next, using a 9-week ABA (non-contingent, contingent, non-contingent) within-subjects design, we will evaluate feasibility, acceptability, and efficacy of CM+MAM on alcohol use reduction and abstinence among 15 AI women enrolled in PCAP. The proposed research responds to the National Institute on Alcohol Abuse and Alcoholism’s goals by developing an effective prevention and treatment strategy that addresses the physical, behavioral, and social consequences of alcohol misuse among mothers at risk for having children with FASDs.
Co-Investigator: Dr. Celestina Barbosa-Leiker
NCARE Liaisons: Dr. Michael McDonell & Dr. Sterling McPherson
Ekaterina Burduli, PhD
Dr. Ekaterina Burduli is an Assistant Professor in the College of Nursing at Washington State University. Dr. Burduli’s primary research focuses on the birth satisfaction and birth outcomes of women who use substances during pregnancy and the development of novel interventions for pregnant women with substance use disorders. Dr. Burduli’s work will lead to a better and more thorough examination of the birth experience among substance-using mothers and holds great promise to identify points of intervention, improve health outcomes for both mother and child, and ultimately, reduce health disparities for substance-using pregnant women. She has more than 16 peer-reviewed publications and has contributed to and led numerous grants. Dr. Burduli also has a high level of statistical methodology expertise in psychometrics, structural equation modeling, and clinical trial data analysis.
Pathways to recovery among urban Alaska Native and American Indian people with long-term abstinence from alcohol
Alaska Native and American Indian (ANAI) people experience dramatic alcohol-related health disparities compared to the general US population, yet have some of the highest rates of abstinence in the nation. This includes many ANAIs in sustained remission from alcohol use disorder (AUD) who have been abstinent for at least a year. Understanding how ANAIs with a history of AUD achieved abstinence could inform development of culturally appropriate and effective interventions. However, data are sparse on AUD recovery in ANAI populations. Research in rural ANAI communities has examined AUD recovery among individuals with long-term abstinence to identify protective factors against AUD risk. While these studies led to strengths-based, multilevel AUD prevention strategies in rural ANAI communities, they did not inform treatment of AUD. Further, no such data exists for urban settings, which is concerning since more than 70% of ANAIs reside in urban areas and this figure is growing. The substantial geographic, material, and sociocultural differences between rural and urban environments highlight the need to understand the recovery process in the urban environment. We propose a qualitative pilot study to begin addressing this need. This study will examine the experiences of ANAIs recovering from AUD with at least 3 years of alcohol abstinence in Anchorage, Alaska. As Alaska’s most populous city with a large ANAI community (>20,000) representing all 229 AN and many AI Tribes, Anchorage is an ideal setting to study urban ANAI recovery from AUD. Moreover, because alcohol-related mortality among ANAI people in Anchorage is substantially higher than in the overall US population, studying the city’s ANAIs with AUD in sustained remission will contribute to an understanding of what promotes or hinders this positive outcome. Specifically, we will describe how diverse ANAI adults with AUD achieved recovery with at least 3 years of abstinence in the urban setting. First, we will conduct semi-structured, in-depth interviews with 20 ANAI individuals to collect narratives of abstinence and recovery from AUD. We will enroll participants across a wide range of ANAI Tribes, genders, and ages who represent as many ANAI cultural and geographic communities as possible in the pilot study’s relatively small sample. Second, we will use interpretative phenomenological analysis to identify common patterns of experience, events, and resources that enabled urban ANAI adults with AUD to attain abstinence. The study will result in an in-depth description of the range of strategies and supports that participants recount in their recovery narratives, as well as themes of how participants attained meaningful and sustained AUD recovery in the urban context. This pilot project will result in important new knowledge about the AUD recovery process among urban ANAI people. The next stage of this research will be to use the pilot study findings to either culturally adapt an extant intervention or to develop a new one, if none exist to address an identified need.
Co-Investigator: Dr. Jennifer Shaw
NCARE Liaison: Dr. Dennis Donovan
Kate Lillie, PhD
Kate Lillie, PhD, is a Researcher at Southcentral Foundation in Anchorage, Alaska. Dr. Lillie has been involved with several behavioral health studies among Alaska Native and American Indian people, including studies on suicide prevention and substance misuse. Her primary expertise and training are in quantitative data collection and analysis. Dr. Lillie is Athabascan and has resided in Alaska most of her life.
Feasibility and impact of distance American Indian peer recovery coaches
The use of peer recovery coaches (PRCs) in assisting with alcohol addiction recovery has been expanding but research regarding their methods and impact has been limited. This study is designed to overcome many of the limitations of previous PRC research including unclear/inconsistent PRC role definitions, lack of a control group/randomization, no attention control group, no verification of relapses, no evaluation of distance-delivered PRC services, and no comparison of AI outcomes in various settings. We currently have a trial of AI PRCs delivering services in urban settings (n=30) and are comparing their impact to an attention control group (n=30). This proposal would add two arms to the current study to examine the delivery of PRC services through distance technology to a rural (n=30) and reservation (n=30) setting for individuals recovering from alcohol addiction. The overall goal of this program of research is to systematically evaluate the implementation and outcomes of AI-specific PRCs in a way that will facilitate optimization of AI PRC services for widespread adoption. The aims of the proposed study are to: 1. evaluate the feasibility of distance-delivered PRC services with people recovering from alcohol addiction to rural and reservation samples, 2. compare the number of relapses between the rural, reservation, urban, and attention control groups, and 3. measure and evaluate strategies used by PRCs in a rural and reservation setting. The primary outcomes that will be examined include daily breathalyzer results and self-reported alcohol use. Additional variables will include cravings/response to cravings, readiness/motivation to quit, alcohol self-efficacy, and sobriety activities (cultural, self-help, and family/friends contact).
Nick Guenzel, PhD, APRN
Nick Guenzel, PhD, APRN, is an Assistant Professor at the University of Nebraska Medical Center in the College of Nursing. He is a psychiatric mental health nurse practitioner and teaches in the UNMC psychiatric nurse practitioner program. He has conducted research with American Indian communities with a particular focus on addiction. Specifically, he seeks to draw on the ways that American Indian values and traditions can facilitate recovery from addiction.
Re-centering measures for alcohol misuse among American Indian and Alaska Native (AI/AN) communities
Negative drinking consequences disproportionately impact American Indian and Alaska Native (AI/AN) communities relative to other racial and ethnic groups. Paradoxically, this disparity persists despite the high prevalence rates of abstinence and comparable alcohol use and drinking patterns as non-AI/ANs. The ability to accurately assess drinking consequences is important for clinicians and researchers to effectively address and alleviate disparities related to alcohol misuse. By examining the impact of negative drinking consequences, individuals may increase their awareness around problems with alcohol, which can potentially lead to motivation to change, which has also been related to improved treatment outcomes. Further, clinicians can identify characteristics associated with poorer outcomes and areas for potential treatment goals. The 50-item self-report survey the Drinker Inventory of Consequences (DrInC) and its’ shorter 15-item, companion, the Short Inventory of Problems (SIP) assess five domains related to drinking consequences: (1) physical, (2) intrapersonal, (3) social responsibility, (4) interpersonal and (5) impulse control. These scales have good psychometric properties among diverse populations, including sexual minorities, adults with serious mental illness and individuals visiting the emergency room. Our recent study indicated the preliminary value of using the SIP in assessing the negative impact of drinking among urban AI/ AN adults, with results suggesting that drinking differentially impacts male and female AI/AN adults and that further cultural tailoring of the measure is necessary to more fully capture the range of negative drinking consequences among AI/AN adults. Potential areas not currently covered by either the DrInC or SIP are spirituality, religious participation, and collectivism such as impacts on extended family, clans, or Tribe. Members of the investigative team are some of the only researchers in the country that have previously developed and culturally adapted measures for AI/AN communities. The proposed research study is an exploratory sequential mixed methods design to culturally adapt the existing measures. The goals of the study are, 1) through Community-Based Participatory Research, convene a Community Advisory Board (CAB) with AI/AN leaders and content experts to assess the existing DrInC/SIP measure(s) for item content validity and to make recommendations for additional items to capture culturally relevant negative consequences associated with alcohol misuse. 2) Examine the applicability/appropriateness of the recommended items to the existing measure among Tribal communities and identify further areas for cultural adaptations. 3) Determine the psychometric properties of the adapted measures(s) through a test-retest reliability exercise among 150 self-identifying AI/AN adults who report “at risk” drinking according to the World Health Organization criteria.
Co-Investigators: Dr. Kamilla Venner & Dr. J. Scott Tonigan
Katherine Hirchak, PhD, APRN
Dr. Katherine (Kait) Hirchak is an Assistant Research Professor in the Elson S. Floyd College of Medicine at Washington State University and is a federally recognized descendant of the Eastern Shoshone Tribe. She completed her postdoctoral training at the University of New Mexico’s Center on Alcohol, Substance use, And Addictions (CASAA) as a NIAAA T32 Fellow. For more than 10 years, she has partnered with Tribal communities to address health inequities and enhance well-being. Broadly, Dr. Hirchak’s research interests, activities, and training include health policy, assessing alcohol and substance use disorder interventions among American Indian and Alaska Native communities, conducting clinical trials and mixed-methods research in diverse settings, and culturally adapting evidence-based interventions.
Assessment of alcohol use, mental health risks, and COVID-19 experiences among Native Americans living along the Eastern and Southern seaboard of the U.S.
This study focuses on examining the individual and joint contributions of socio-cultural determinants of health (SCDoH), depression, and anxiety on alcohol use, and risky driving (AURD) among Southern and Eastern Tribes (SET) from the ongoing parent study title “COVID-19 Native American Health Survey Project for Colonial Era Tribes along the Eastern and Southern Seaboard of the U.S.” with Dr. John Lowe. Through collaboration with and mentorship by experts in the fields of epidemiology, AURD, advanced statistical analysis, and health disparities, the candidate will investigate the alcohol risk trend by treating AURD as the outcome to examine if AURD shifted and increased during COVID by comparing findings to the proposed study. Florida State University (FSU) provides many opportunities to advance the candidate’s research trajectory, such as seminars, mock reviews, collaboration, and sharing of resources with the University of Florida (UF) as part of the joint UF-FSU Clinical and Translational Science Award (CTSA) K-scholar program. The Center for Indigenous Nursing Research for Health Equity at FSU College of Nursing will provide additional mentorship, training, and resources to implement community-based participatory research. In addition, support from Dr. John Lowe’s at The University of Texas at Austin and Dr. Jacquelyn Taylor at Columbia University will be available to the candidate. The proposed project will be a sub-study under parent study by Dr. Lowe, which seeks to develop a COVID Virtual Talking Circle intervention and conduct a randomized controlled study to examine the impact of the COVID Virtual Talking Circle intervention. The proposed project’s specific aims are to explore the (1) Explore the relationship of SCDoH (health care access, income, and education), depression, and anxiety on AURD among SETs., and (2) Examine the differences (SCDoH, anxiety, depression, and AURD) between pre-and-post COVID using data from 2018-2019 BRFSS and comparing to findings in the proposed study. By examining the main and cumulative impact of SCDoH, anxiety, depression, on AURD, this proposal aligns with NIAAA’s goals “to improve diagnostic, tracking, development, and strategies to prevent alcohol misused/use disorder and alcohol-related consequences.” This study is expected to have a positive impact by providing necessary data to measure alcohol disparities among SET and for public health practitioners, researchers, and health care providers, as well as Tribal governments and health systems, to develop alcohol use and risky driving prevention programs.
Co-Investigator: Dr. John Lowe
Eugenia Millender, PhD, RN, PMHNP-BC, CDE
Dr. Eugenia Millender is currently the Co-Founding Director and Associate Director of the Center for Population Sciences and Health Equity at Florida State University. This research center was created to lead and implement community-engaged, scientific, operational research and practice using population sciences principles and tools that promote health equity among marginalized, underserved, and vulnerable populations both nationally and internationally. She is also an Associate Professor at the College of Nursing, Florida State University. Previously, Dr. Millender was a Research Associate Professor for the Center for Indigenous Nursing Research for Health Equity (INRHE) at Florida State University. In 2013, she founded and directed the nurse-led Florida Atlantic University Christine E. Lynn Community Health Center grounded in a Caring and Social model that was transformative in integrating data-driven interventions that use sociocultural approaches to provide health care to underserved populations. She developed the Center’s clinical data repository so that data-driven interventions could be implemented.
Dr. Millender’s research program is to investigate ways to reduce mental health disparities related to alcohol use, stress and trauma among Indigenous and vulnerable populations. Dr. Millender’s research focus is on studying the efficacy of culturally relevant surveillance and interventions in community settings to mitigate or prevent mental health and co-occurring cardiovascular disease disparities. As an Indigenous Afro-Latina, Dr. Millender’s career has been dedicated to increasing access to quality care, decreasing co-occurring mental disparities and cardiovascular disease, and providing culturally appropriate care.
Relationship of food security and alcohol use among American Indian and Alaska Native parents of young children
AI/ANs are almost three times as likely to die from alcohol-attributable deaths than Non-Hispanic White adults. Policies that could reduce or prevent problematic alcohol use among AI/ANs should be pursued. To inform these policies, it is critical to identify predictors of problematic alcohol use. Some identified predictors of problematic alcohol use among AI/ANs include being male, having been a victim of violence, and a history of depression, but identifying additional risk factors, particularly those that are modifiable, is important ongoing work. Food insecurity, defined as insufficient access to nutritious foods, is one such factor that has been overlooked. Though related to poverty, food insecurity is independently associated with chronic disease, higher healthcare costs, and earlier mortality, while controlling for income. Negative effects on social, mental, and physical wellbeing have also been documented for children in food insecure households. Research on AI/AN food insecurity is limited, but data estimates that 25% of AI/AN household’s experience food insecurity nationally. Prior studies suggest a cross-sectional relationship between food insecurity and heavy alcohol use. However, the lack of longitudinal analyses, with AI/AN respondents disaggregated, has precluded our understanding of food insecurity’s relationship with problematic alcohol use. I propose to conduct a secondary data analysis to assess whether food insecurity is longitudinally related to problematic alcohol use among AI/AN parents. The data are from a nationally representative sample of 14,000 children born in the U.S. in 2001. Data were collected from the child, at least one parent, and any childcare providers at 4 annual assessments across a 5-year period. AI/AN respondents were oversampled, resulting in approximately 550 AI/AN mothers, 400 AI/AN fathers, and 750 AI/AN children. Given the wealth of child-level data, I will conduct an additional exploratory analysis to assess the joint relationship of food insecurity and parental problematic alcohol use with children’s development. My aims are to: 1) evaluate the longitudinal relationship between household food insecurity and problematic alcohol use among AI/AN parents; and 2) assess the main and joint associations of household food insecurity and problematic alcohol use among AI/AN parents on the socioemotional development of their young children. Food insecurity was measured at each annual assessment with the Household Food Security Survey Module. Problematic alcohol use will be based on parental reports of heavy drinking or binge drinking provided at all 4 assessments. Children’s socioemotional development will be based on childcare providers’ assessments during the last two annual assessments. For Aim 1, the longitudinal association of problematic alcohol use and food insecurity across assessment periods will be analyzed using marginal structural modeling. For Aim 2, child socioemotional development will be analyzed with generalized estimating equation models that include food insecurity, parental problematic alcohol use, and the interaction of the two variables.
Co-Investigator: Dr. Michael McDonell
Cassandra Nikolaus, PhD
Dr. Cassandra Nikolaus is a Research Assistant Professor at Washington State University in the Elson S. Floyd College of Medicine and the Institute for Research and Education to Advance Community Health (IREACH). Dr. Nikolaus’ training is in dietetics and nutritional sciences, with specific expertise in food insecurity and community nutrition education efforts. The goal of her work is to bridge the gap between “what we know” and “what we do” about food insecurity in the U.S., particularly for Indigenous and low-income groups.
Exploring the Impact of the Loss of Connectedness during the COVID-19 Pandemic on AUD among Rural Native American Young Adults
Native Americans have been disproportionately affected by the COVID-19 pandemic. Mask wearing, social distancing, and isolation have increased the loss of being connected for many Native Americans. Studies have shown that social connectedness improves mental health. Connectedness provides a sense of belonging and is rooted in a collective, group, and community experience for many Native Americans. Living in a rural setting during a pandemic decreases connectedness thus impacting alcohol use and wellbeing. In particular, rural Native American young adults are vulnerable to alcohol use. After leaving high school, the pressures and stress of continuing an education, finding work/employment, and the responsibilities related to family and Tribal community obligations result in the rural Native American young adult being more vulnerable to alcohol use. Due to the COVID-19 pandemic, many Native Americans have been forced to spend more time alone, and feelings of anxiety, depression, and loneliness and alcohol use have been heightened, especially for those who live in rural and remote areas. Using a mixed method design, this study will innovatively explore the relationship of connectedness, stress, anxiety, trauma, depression, and alcohol use among rural Native American young adults, ages 18-24, during the COVID-19 pandemic. This study will be conducted in partnership with the United Keetoowah Band of Cherokee Indians. 75 rural Native American young adult participants ages 18-24 who participated in the Talking Circle intervention for the prevention of alcohol and drug use will complete another set of the same measures that assessed connectedness, stress, anxiety, trauma, depression, and alcohol use that were used baseline/pre- and 6-month post the intervention in Fall 2019. A subset of 20 participants will be interviewed to gain deeper insights regarding their experiences with alcohol use during the COVID-19 pandemic and the impact of having participated in the Talking Circle intervention prior to the pandemic.
Co-Investigator: Dr. John Lowe
Cynthia Greywolf, PhD, DNP-PMHNP, APRN-Rx, BC
Dr. Cynthia Greywolf is an Assistant Professor of Nursing and a member of the Cherokee Nation of Oklahoma. Since becoming a Registered Nurse, she has been dedicated to the practice of nursing in both her professional and academic careers. She has endeavored to use culturally safe approaches to achieve equitable health outcomes for underserved and vulnerable populations such as American Indians, Native Hawaiians, LBGTQIA communities, and older adults in long-term care settings. Her research focuses on colonization, historical trauma, and links to alcohol use disorders among Native Hawaiians and Native Americans.
Dr. Greywolf completed two doctorates in Nursing, a Doctor of Nursing Practice (DNP) and a PhD. She also completed a master’s in community health nursing and two certificates of advanced graduate study, including a Psychiatric Mental Health Certificate and a John A. Hartford Institute Geriatric Nursing Teaching Certificate. She has more than 20 years of practice as a psychiatric nurse practitioner. In 2015, Dr. Greywolf was chosen to be a fellow of the Minority Fellowship Program (MFP) funded by Substance Abuse and Mental Health Services (SAMHSA) of the U.S. Department of Health. She was a fellow from 2015 to 2020 for her doctoral research exploring a shared history of historical trauma with Native Hawaiians and links to the use of alcohol. She was awarded the University of Hawai’i at Mānoa Nursing Dean’s Scholarly Project Award in 2020 for her research.
Before joining the University of Hawai’i at Mānoa, Dr. Greywolf completed a postdoctoral fellowship. In 2021, she was one of two applicants to be competitively chosen to be a fellow in the Provost’s Early Career Cohort Fellowship Program (PECCFP) at the University of Texas at Austin’s School of Nursing to conduct health equity research with the United Keetoowah Band of Cherokee Indians and other American Indian Tribes in Oklahoma and Texas.