Preventing Risk for “Deaths of Despair” Among American Indian Youths: Unanswered Questions for Future Research

Increases in “deaths of despair”—alcohol-related liver disease mortality, drug overdoses, and suicides—have led to an unprecedented rise in midlife mortality in the United States among non-Hispanic White men and women with educational attainment of a high school diploma or less.¹ Although these rising mortality rates are now rightly capturing considerable public and scientific attention, these deaths of despair have long been endemic among American Indian (AI) and Alaska Native populations, with minimal attention or alarm. All-cause and suicide mortality rates among AIs and Alaska Natives are nearly 50% greater than are those of non-Hispanic Whites.² Even more dreadful, death rates attributable to chronic liver disease and injuries are, respectively, 5.0 and 2.5 times greater among AIs and Alaska Natives than among non-Hispanic Whites.³ Clearly, the alcohol prevention partnership that Moore et al. (p. 1035) report on addresses an urgent and challenging public health and prevention science priority, and I commend them for their successful partnership, resourcefulness, and important prevention efforts.

QUASIEXPERIMENTAL COMMUNITY TRIAL PARTNERSHIP

Moore et al. report on a long-term collaboration between clinicians, prevention scientists, and tribal leaders from nine rural California Indian reservations to prevent and reduce alcohol use among underage youths. The team designed a strong quasiexperiment with repeated measures and multiple comparison groups to evaluate a multilevel intervention designed to reduce the prevalence and frequency of alcohol use among youths. To assess alcohol use patterns, the team cleverly made use of the biannual California Healthy Kids Survey and analyzed patterns of anonymous self-reported alcohol use among 9th and 11th grade students before (2002–2007) and after (2008–2015) the intervention was initiated. They compared three groups of students: (1) AI youths in the schools serving the nine reservations participating in the intervention, (2) non-AI youths in those same schools but reportedly not exposed to the individual- or community-level interventions, and (3) AI youths in schools serving nine comparison reservations.

To further evaluate the individual-level intervention, the team conducted an embedded randomized trial at the intervention reservations to test the effectiveness of a brief intervention. They compared motivational interviewing by a counselor with a psychoeducation video; both were delivered in either an individual or a group session. The community-level intervention included community mobilization and awareness activities, as well as an intervention to reduce the sales of alcohol to underage youths at off-premise alcohol outlets near the reservations.

MULTILEVEL INTERVENTION ON NINE RESERVATIONS

Clear strengths of the project included the successful long-term collaboration between tribal leaders, practitioners, and prevention scientists not only to implement evidence-based prevention strategies but also to embark on a National Institutes of Health–funded study to evaluate the prevention efforts. The community intervention involved nearly 300 community awareness activities and three “reward and reminder” visits to 13 off-premise alcohol outlets within 10 miles of the nine reservations. The intervention rewarded those who do not sell alcohol without checking age identification and reminded those that do that it is against the law. Moore et al. did not provide details on how participation and implementation success varied across the nine reservations.

In the individual-level intervention, 109 youths aged 13 to 20 years from the nine reservations (representing one sixth of the youth population) received either the motivational interviewing or the video intervention. Moore et al. did not observe any significant differences in alcohol use outcomes between the two individual-level interventions. This is an important finding and has implications for dissemination of individual-level strategies because a video is likely much less expensive and less complicated to implement than is involving someone with the necessary credentials, training, and oversight requirements for proficient implementation of a motivational interviewing intervention.⁴

COMPLEX PATTERN OF STUDY RESULTS

The team of Moore et al. hypothesized that the “combined individual- and community-level interventions to reduce alcohol consumption by tribal youths in reservation settings would be associated with lower prevalence and frequency of alcohol consumption than among tribal youths in reservations outside the intervention catchment area.” In their Table 1, Moore et al. present pre- and postintervention alcohol use rates by study condition; they find a complicated pattern. The prevalence of lifetime and 30-day alcohol use among all three groups was lower during the postintervention period (2008–2015) than the preintervention period (2002–2007); this reflects the similar national pattern of approximately 20% to 30% reductions in lifetime and 30-day rates of alcohol use among 8th and 10th grade students from 2002 to 2015.⁵

Their Table 1 shows that lifetime prevalence was down 20% among the AI intervention group, 17% among the AI comparison group, and 25% among the non-AI comparison group. Thirty-day prevalence was down 2% among the AI intervention group, 24% among the AI comparison group, and 16% among the non-AI comparison group. Notably, Moore et al. reported that these differences from the pre- to the postchanges among all three groups were not statistically significant. The study results of Moore et al. presented in their Tables 1 and 2 and their Figures 1 and 2 for drinking frequency among drinkers shows a more consistent beneficial pattern among the AI intervention group (25% to 31% reductions in drinking frequency across items) than among the two comparison groups (14% increase to 17% reduction across items). The intervention’s effect seems to be most notable in reducing drinking frequency among those who drank. However, it is puzzling that past month prevalence seemed to be stable among the intervention group but decreasing among the comparison groups.

COMMENDATION FOR SUCCESSFUL PARTNERSHIP

I commend the team for a successful partnership in implementing a complex multilevel intervention across multiple years, their use of important design elements to strengthen causal inference, and their detailed reports of study results. The results suggest that the intervention package led to reductions in number of drinking days and heavy drinking days, which is an important achievement and will hopefully lead to reductions in alcohol-related harms during adolescence and into adulthood. It is unclear why Moore et al. observed no significant differences between the study conditions in lifetime prevalence and 30-day drinking prevalence.

COMMUNITY TRIALS AS A RESEARCH PRIORITY

Moore et al. also raise important questions for future research. What were the key ingredients of the multilevel intervention that supported a reduction in the number of drinking days? Did the community intervention activities vary across the nine reservations, and was anything learned about specific influences on implementation success? Were there institutional, structural, or policy changes resulting from the intervention that will support continued prevention benefits over a longer period of time? Which strategies or structural changes are most important for the continued implementation of prevention efforts? What are the implications for the dissemination of individual-level strategies considering the significant cost and implementation complexity differences between the two strategies? Would a randomized stepped-wedge design, allowing a rigorous experimental trial with eventual delivering of the intervention to all communities, be acceptable to AI tribes?

The answers to these and other questions require multilevel and multidisciplinary research collaboratives. Such research would require expanded investment through multiple National Institutes of Health institutes in often-expensive community intervention trials as a necessary step to advance the science base for effective structural and community-level interventions addressing the diseases of despair.