Urban Indians: What we don't know can kill them

Below is a 10-year plan to scientifically investigate American Indians living in urban communities. As the below plan indicates, we know very little about urban folks. It will take a significant effort to build our knowledge. As an urban Indian myself, I hope we can get some movement on our plan. Please know I am happy to hear your thoughts, ideas. Peace DAP


A behavioral epidemiology approach to investigating substance use disorder in American Indian urban communities: Ten-year study plan 

The problem. Substance use disorder (SUD) is a chronic and often relapsing illness costing the United States more than $600 billion annually in healthcare, productivity, and crime-related costs.1 

While more than 23 million, or nearly 10%, of all Americans aged 12 years or older misuse substances, up to 90% of those with SUD are not receiving high-quality care, signaling a substantial treatment gap.2 

The most substantial deficiency within our scientific literature as it relates to behavioral epidemiology is SUD’s impact on American Indian communities. While there is empirical knowledge on rural, reservation-based AIs, urban-based AIs have received little attention from our nation’s scientists.3 

The Indian Relocation Act of 1956 was a United States law intended to integrate American Indians (AIs) into urban settings in order to better assimilate into American culture. Indian Bureau promises lured native people away from their pastoral reservation existence, where they struggled to come to terms with modernity. 

In 1976 Congress passed the Indian Health Care Improvement Act, in part, to address concerns that health services are not providing culturally appropriate services to AIs who left the reservation. In 2016, 29 Urban Indian Health Organizations were funded through Indian Health Services (IHS) to provide a wide range of healthcare services located in 10 different areas across the U.S. This represents less than 1% of IHS’s overall budget.4 

Currently about 71% of AIs live in urban, suburban, or rural non-reservation area settings.5 Over the last 30 years, more than 1 million AI have moved to metropolitan areas.5 Historical traumas, including urban relocations and cultural assimilation, continue to affect AI communities in significant ways.6 The most significant mental health concerns today are the high prevalence of depression, substance use disorders, suicide, and anxiety.6 American Indians generally use and abuse alcohol and other drugs at younger ages, and at higher rates, than all other ethnic groups in the U.S.7,8 

While our scientific literature on AIs remains limited, our knowledge as it relates specifically to AIs living in urban areas who suffer from a SUD, is virtually non-existent. A search in NIH RePORTER in the past 10-years (NIDA, NIAAA) for research targeting urban AIs, resulted in two funded projects. One exploring motivational intervening and culture for urban youth (R01) and one investigating urban Native Americans and Alcoholics Anonymous (R21). Our illiteracy on urban AIs is so momentous that no singular, one-off, innovative research project can remedy it. A well-planned, long-term and sequential investigative strategy is required. 

The solution. Because we lack the basic epidemiological knowledge of substance use disorder (SUD) in urban living AIs, we will follow Sallis and colleague’s9 behavioral epidemiological systematic framework of research on health promotion and disease prevention. Their framework classifies the specific sequence of phases (e.g., research studies) that lead to evidence based public health interventions directed at populations. 

There are 5 phases, which have been adapted to focus specifically on SUD, consisting of: 
 Phase 1: Establishing the link between substance use behaviors and health. 
 Phase 2: Developing methods for measuring substance use behavior. 
 Phase 3: Identifying factors that influences substance use behavior. 
 Phase 4: Evaluating interventions that change substance use behavior. 
 Phase 5: Translating research into urban SUD practice. 

Years 1-5 plan 
Our first five years will focus specifically on phases 1-3. These studies will be exploratory, developmental and planning efforts using R21 and R34 mechanisms. The aims will consist of cross-sectional, population-based studies examining the link of SUD with targeted health outcomes (Phase 1). We will develop, test the validity, reliability and psychometric properties of existing and our own health questionnaires (Phase 2). We will finally explore and identify factors that shape, influence and change behaviors which lead to high risk alcohol and drug use and a SUD (Phase 3). We will use as our beginning analysis, Center for Disease Control and Prevention’s, Behavioral Risk Factor Surveillance System (BRFSS) Selected Metropolitan/Micropolitan Area Risk Trends (SMART) of BRFSS (SMART BRFSS). Years 6-10 plan The knowledge developed in years 1-5 will lead us to Phases 4 & 5. Phase 4 studies will be random control trials using R01 mechanisms as well as U01s and P series grants. The aims of these studies might include development and testing of AI specific SUD treatment methods and implementation and dissemination strategies into urban treatment systems. 

Resources at Washington University in St Louis’s Brown School 

This effort will sprout from the Kathryn M. Buder Center for American Indian Studies , which is housed in Washington University in St Louis’s Brown School of Social Work and Public Health. Founded in 1990 to provide scholarships for AIs, the Buder Center has grown into one of the most respected centers in the nation for the academic advancement and study of AI health and wellness issues. There are 156 AI Buder Scholar alumni across the U.S. working in various AI social work and public health services. There are 24 current Buder Scholars enrolled in the Brown School’s masters of social work and/or public health programs. The Buder Center has also produced 10 PhD scholars with an additional 5 obtaining a JD. There are four current AI doctoral scholars in our PhD program.

Community-based Resources and Stakeholders 

We will also convene a gathering of Urban Indian Health Organizations and other potential researchers who are providing or interested in investigating SUD services. Our Buder Center has a Memorandum Of Understanding with Indian Health Services to educate and train social workers and public health scholars as well as develop research studies to better understand AI health and wellness issues. 

Increasing diversity in biomedical and community services 

Part of this plan will include training and supporting AIs and other underrepresented minorities to enter biomedical and community services professions. We will seek supports through NIH Career Awards, Diversity Supplements, R24 & 25, and P Series. 


References 
1. National Drug Intelligence Center. The economic impact of illicit drug use on american society. Washington, D. C.: United States Department of Justice; 2011. http://www.justice.gov/archive/ndic/pubs44/44731/44731p.pdf. 
2. Substance Abuse and Mental Health Services Administration. Results from the 2012 national survey on drug use and health: Summary of national findings. NSDUH Series H-46, HHS Publication No. (SMA) 13-4795, MD: SAMHSA. 2013. 
3. Urban Indian Health Institute. Supporting sobriety among american indians and alaska natives: A literature review. http://www.uihi.org/download/Supporting-Sobriety_A-Literature-Review_WEB.pdf. Updated 2014. Accessed 9/28, 2016. 
4. U.S. Department of Health and Human Services. Fiscal year 2014 indian health service: Justification of estimates for appropriations committees. . 2013. 
5. Urban Indian Health Commission. Invisible tribes: Urban indians and their health in a changing world. http://www.uihi.org/download/UIHC_Report_FINAL.pdf. Updated 2015. Accessed 10/24, 2016. 
6. Beals J, Manson SM, Whitesell NR, Spicer P, Novins DK, Mitchell KM. Prevalence of DSM-IV disorders and attendant help-seeking in american indian reservation populations. Arch Gen Psychiatry. 2005;62(1):99-108. 
7. Office of Minority Health. Mental health disparities: American indian and alaska natives. american psychiatric association. www.psych.org. Accessed 9/22, 2016. 
8. Buchwald D, Beals J, Manson SM. Use of traditional health practices among native american in a primary care settings. Medical Care. 2000;38(12):1191-1199. 
9. Sallis JF, Owen N, Fotheringham MJ. Behavioral epidemiology: A systematic framework to classify phases of research on health promotion and disease prevention. Annuals of Behavioral Medicine. 2000;22(4):294-8.