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In real-world settings, eligible populations and intervention effectiveness for a translational intervention likely vary across time. To determine the optimal strategies for effective large-scale implementation of evidence-based interventions, it is critical to investigate these potential variabilities. The purpose of this study is to evaluate whether patient characteristics and intervention effectiveness differed by year of enrollment in a multiyear evidence-based translational intervention. The Special Diabetes Program for Indians Healthy Heart (SDPI-HH) Demonstration Project is an intensive case management intervention designed to reduce cardiovascular disease risk among American Indians and Alaska Natives with diabetes. SDPI-HH participants recruited from 2006 through 2008 were included. Baseline characteristics were compared by year of enrollment. We also evaluated the differences in improvements in clinical and behavioral risk factors for cardiovascular disease among participants recruited in different years. The baseline characteristics of the three cohorts significantly differed in demographics, diabetes duration, health behaviors, level of motivation, and clinical measures. Improvements in 13 clinical and behavioral outcomes also differed by enrollment year with the 2006 cohort having the greatest number of significant improvements and the highest rates of participation and retention. Further investigation into the ways to modify the intensive case management model to address differences in levels of motivation and participation is warranted to improve the management of chronic disease in Indian health. Given the evolving nature of translational initiatives of this kind, our analysis results highlight the need to understand and adapt during the natural progression of health behavioral interventions.

ObjectiveThis study evaluated whether regression from impaired glucose regulation (IGR) to normal glucose regulation (NGR) after 1 year of a lifestyle intervention reduces diabetes risk in American Indians and Alaska Natives (AI/ANs). In addition, we sought to identify predictors for regression to NGR and understand possible mechanisms for the association between NGR and future diabetes risk.Research design and methodsData from participants enrolled from 2006 to 2009 in the Special Diabetes Program for Indians Diabetes Prevention Program with IGR at baseline and an oral glucose tolerance test at year 1 were analyzed (N = 1,443). Cox regression models were used to estimate the subsequent diabetes risk (year 1 to year 3) by year 1 glucose status. Mediation analysis was used to estimate the proportions of the association between year 1 glycemic status and diabetes risk explained by specific factors.ResultsThose who reverted to NGR at year 1 (38%) had lower diabetes risk than those with sustained IGR (adjusted hazard ratio 0.28, 95% CI 0.12-0.67). The lower risk associated with regression to NGR was explained by both baseline risk factors and differences in weight loss. Metformin use, weight loss, and an increase in exercise were modifiable risk factors associated with higher odds of regression to NGR.ConclusionsPatients with prediabetes who reverted to NGR had a reduced risk of developing type 2 diabetes over the next 2 years. Both baseline and modifiable risk factors explained the risk reduction associated with NGR.

Many community-based translations of evidence-based interventions are designed as one-arm studies due to ethical and other considerations. Evaluating the impacts of such programs is challenging. Here, we examine the effectiveness of the lifestyle intervention implemented by the Special Diabetes Program for Indians Diabetes Prevention (SDPI-DP) demonstration project, a translational lifestyle intervention among American Indian and Alaska Native communities. Data from the landmark Diabetes Prevention Program placebo group was used as a historical control. We compared the use of propensity score (PS) and disease risk score (DRS) matching to adjust for potential confounder imbalance between groups. The unadjusted hazard ratio (HR) for diabetes risk was 0.35 for SDPI-DP lifestyle intervention vs. control. However, when relevant diabetes risk factors were considered, the adjusted HR estimates were attenuated toward 1, ranging from 0.56 (95% CI 0.44-0.71) to 0.69 (95% CI 0.56-0.96). The differences in estimated HRs using the PS and DRS approaches were relatively small but DRS matching resulted in more participants being matched and smaller standard errors of effect estimates. Carefully employed, publicly available randomized clinical trial data can be used as a historical control to evaluate the intervention effectiveness of one-arm community translational initiatives. It is critical to use a proper statistical method to balance the distributions of potential confounders between comparison groups in this kind of evaluations.

ObjectiveTo examine the association between food choice and distress in a large national sample of American Indians/Alaska Natives (AI/AN) with type 2 diabetes.DesignParticipants completed a sociodemographic survey, an FFQ and the Kessler-6 Distress Scale. Foods were identified as 'healthy' or 'unhealthy' using a classification grounded in the health education provided by the programme case managers; healthy and unhealthy food scores were calculated using reported intake frequencies. Pearson's correlation coefficients for distress and food scores were calculated for all participants and by gender. Multiple linear regression models stratified by gender assessed the association between distress and food scores, controlling for sociodemographics and duration of type 2 diabetes.SettingRural AI reservations and AN villages.SubjectsAI/AN (n 2484) with type 2 diabetes.ResultsBoth males (34·9 %) and females (65·1 %) had higher healthy food scores than unhealthy scores. In bivariate analysis, distress level had a significant negative correlation with healthy food scores among female participants, but the association was not significant among males. Significant positive correlations between distress and unhealthy food scores were found in both genders. In the final multivariate models, healthy food scores were not significantly related to distress; however, unhealthy food scores showed significant positive relationships with distress for both genders (females: β=0·078, P=0·0007; males: β=0·139, P

ObjectiveEvidence for long-term translational effectiveness of lifestyle interventions in minority populations is scarce. This article reports long-term outcomes, for up to 10 years, of such an intervention to prevent diabetes in American Indian and Alaska Native (AI/AN) communities.Research design and methodsFrom January 2006 to July 2016, the Special Diabetes Program for Indians Diabetes Prevention Program implemented the Diabetes Prevention Program lifestyle intervention among 46 AI/AN health care programs. Enrolled participants underwent a thorough clinical assessment at baseline, after completing the Lifestyle Balance Curriculum (postcurriculum assessment), and annually thereafter. Proportional hazards regression was used to estimate the association between diabetes incidence and postcurriculum weight loss status.ResultsOf 8,652 enrolled participants, 65% finished the postcurriculum assessment. The assessment completion rate diminished over time to 13% in year 10. Among those with postcurriculum weight measurements, 2,028 (36%) lost >5% of their initial weight, 978 (17%) lost 3-5%, whereas 2,604 (47%) had 5% weight loss had a 64% (95% CI 54-72) lower risk of developing diabetes during the first 6 years of follow-up, whereas those with 3-5% weight loss had 40% (95% CI 24-53) lower risk.ConclusionsModerate to small weight loss was associated with substantially reduced long-term risk of diabetes in diverse AI/AN communities. High participant attrition rates and nonoptimal postcurriculum weight loss are important challenges found in this translational effort implemented in an underserved population.

Growing evidence reveals various neighborhood conditions are associated with the risk of developing type 2 diabetes. It is unknown, however, whether the effectiveness of diabetes prevention interventions is also influenced by neighborhood characteristics. The purpose of the current study is to examine the impact of neighborhood characteristics on the outcomes of a lifestyle intervention to prevent diabetes in American Indians and Alaska Natives (AI/ANs). Year 2000 US Census Tract data were linked with those from the Special Diabetes Program for Indians Diabetes Prevention Program (SDPI-DP), an evidence-based lifestyle intervention implemented in 36 AI/AN grantee sites across the US. A total of 3394 participants started the intervention between 01/01/2006 and 07/31/2009 and were followed by 07/31/2016. In 2016-2017, data analyses were conducted to evaluate the relationships of neighborhood characteristics with intervention outcomes, controlling for individual level socioeconomic status. AI/ANs from sites located in neighborhoods with higher median household income had 38% lower risk of developing diabetes than those from sites with lower neighborhood income (adjusted hazard ratio = 0.65, 95% CI: 0.47-0.90). Further, those from sites with higher neighborhood concentrations of AI/ANs achieved less BMI reduction and physical activity increase. Meanwhile, participants from sites with higher neighborhood level of vehicle occupancy made more improvement in BMI and diet. Lifestyle intervention effectiveness was not optimal when the intervention was implemented at sites with disadvantaged neighborhood characteristics. Meaningful improvements in socioeconomic and other neighborhood disadvantages of vulnerable populations could be important in stemming the global epidemic of diabetes.

Study objectivesWe examine the association between self-reported sleep duration and diabetes incidence in a national sample of American Indians/ Alaska Natives (AI/ANs) with prediabetes.MethodsData were derived from the Special Diabetes Program for Indians Diabetes Prevention demonstration project. This longitudinal analysis included 1,899 participants with prediabetes recruited between January 1, 2006 and July 31, 2009 who reported sleep duration and completed all 16 classes of the lifestyle intervention consisting of diet, exercise, and behavior modification sessions to promote weight loss. Three years of follow-up data were included to fit Cox regression models to compute hazard ratios (HRs) for diabetes incidence across sleep duration categories.ResultsThe crude diabetes incidence rate was 4.6 per 100 person-years among short sleepers (≤ 6 h per night) compared to 3.2 among those sleeping 7 h and 3.3 among those sleeping 8 h or more. After adjustment for age and sex, short sleep (≤ 6 h vs. others) was associated with increased diabetes risk (HR 1.55 [95% confidence interval 1.11-2.17]); risk remained significantly elevated after controlling for socioeconomic characteristics, health behaviors, and health status. When adjusting for body mass index and percent weight loss, the short sleep-diabetes relationship was attenuated (HR 1.32 [95% confidence interval 0.92-1.89]). No significant long sleep-diabetes association was found. Further, short sleepers lost significantly less weight than others (3.7% vs. 4.3%, P = 0.003).ConclusionsShort sleep duration, but not long duration, was significantly associated with increased diabetes risk and less weight loss among AI/ANs in a lifestyle intervention. Further exploration of the complex factors underlying short sleep duration is warranted.

Participant attrition in clinical trials and community-based interventions is a serious, common, and costly problem. In order to develop a simple predictive scoring system that can quantify the risk of participant attrition in a lifestyle intervention project, we analyzed data from the Special Diabetes Program for Indians Diabetes Prevention Program (SDPI-DP), an evidence-based lifestyle intervention to prevent diabetes in 36 American Indian and Alaska Native communities. SDPI-DP participants were randomly divided into a derivation cohort (n = 1600) and a validation cohort (n = 801). Logistic regressions were used to develop a scoring system from the derivation cohort. The discriminatory power and calibration properties of the system were assessed using the validation cohort. Seven independent factors predicted program attrition: gender, age, household income, comorbidity, chronic pain, site's user population size, and average age of site staff. Six factors predicted long-term attrition: gender, age, marital status, chronic pain, site's user population size, and average age of site staff. Each model exhibited moderate to fair discriminatory power (C statistic in the validation set: 0.70 for program attrition, and 0.66 for long-term attrition) and excellent calibration. The resulting scoring system offers a low-technology approach to identify participants at elevated risk for attrition in future similar behavioral modification intervention projects, which may inform appropriate allocation of retention resources. This approach also serves as a model for other efforts to prevent participant attrition.

Stages of change measure an individual's readiness to alter a health behavior. This study examined the latent longitudinal patterns of stages of change (SoC) for regular exercise over time among individuals participating in a lifestyle intervention project. It also investigated the association between the longitudinal patterns of SoC and intervention outcomes using a new statistical method to assess the relationship between latent class membership and distal outcomes. We analyzed data from the Special Diabetes Program for Indians Diabetes Prevention Program, a lifestyle intervention program to prevent diabetes among American Indians and Alaska Natives. Latent class analysis (LCA) was conducted to identify the longitudinal patterns of SoC for regular exercise reported at three time points. LCA with distal outcomes was performed to investigate the associations between latent class membership and behavioral changes after the intervention. The parameters and standard errors of the LCA with distal outcomes models were estimated using an improved three-step approach. Three latent classes were identified: Pre-action, Transition, and Maintenance classes. The Transition class, where stage progression occurred, had the greatest improvements in physical activity and weight outcomes at both time points post-baseline among female participants. It also had the largest improvements in weight outcomes among male participants. Furthermore, the Pre-action class had more attenuation in the improvements they had achieved initially than the other two classes. These findings suggest the potential importance of motivating participants to modify their readiness for behavioral change in future lifestyle interventions.

The association of psychosocial factors (psychological distress, coping skills, family support, trauma exposure, and spirituality) with initial weight and weight loss among American Indians and Alaska Natives (AI/ANs) in a diabetes prevention translational project was investigated. Participants (n = 3,135) were confirmed as prediabetic and subsequently enrolled in the Special Diabetes Program for Indians Diabetes Prevention (SDPI-DP) demonstration project implemented at 36 Indian health care programs. Measures were obtained at baseline and after completing a 16-session educational curriculum focusing on weight loss through behavioral changes. At baseline, psychological distress and negative family support were linked to greater weight, whereas cultural spirituality was correlated with lower weight. Furthermore, psychological distress and negative family support predicted less weight loss, and positive family support predicted greater weight loss, over the course of the intervention. These bivariate relationships between psychosocial factors and weight remained statistically significant within a multivariate model, after controlling for sociodemographic characteristics. Conversely, coping skills and trauma exposure were not significantly associated with baseline weight or change in weight. These findings demonstrate the influence of psychosocial factors on weight loss in AI/AN communities and have substantial implications for incorporating adjunctive intervention components.

IntroductionAmerican Indians/Alaska Natives (AI/ANs) have a disproportionately high rate of type 2 diabetes. Changing food choices plays a key role in preventing diabetes. This study documented changes in the food choices of AI/ANs with diagnosed prediabetes who participated in a diabetes prevention program.MethodsThe Special Diabetes Program for Indians-Diabetes Prevention Demonstration Project implemented the evidence-based Diabetes Prevention Program (DPP) lifestyle intervention in 36 health care programs nationwide, engaging 80 AI/AN communities. At baseline, at 30 days post-curriculum, and at the first annual assessment, participants completed a sociodemographic survey and 27-item food frequency questionnaire and underwent a medical examination assessing fasting blood glucose (FBG), blood pressure, body mass index (BMI), low-density lipoprotein [LDL], high-density lipoprotein [HDL], and triglycerides. Multiple linear regressions were used to assess the relationship between temporal changes in food choice and other diabetes risk factors.ResultsFrom January 2006 to July 2010, baseline, post-curriculum, and first annual assessments were completed by 3,135 (100%), 2,046 (65%), and 1,480 (47%) participants, respectively. An increase in healthy food choices was associated initially with reduced bodyweight, BMI, FBG, and LDL and increased physical activity. At first annual assessment, the associations persisted between healthy food choices and bodyweight, BMI, and physical activity.ConclusionAI/AN adults from various tribal and urban communities participating in this preventive intervention made sustained changes in food choices and had reductions in diabetes risk factors. The outcomes demonstrate the feasibility and effectiveness of translating the DPP lifestyle intervention to community-based settings.

ObjectiveTo investigate possible socioeconomic disparities in weight and behavioral outcomes among American Indian and Alaska Native (AI/AN) participants in a translational diabetes prevention project.Research design and methodsWe analyzed data from the Special Diabetes Program for Indians Diabetes Prevention (SDPI-DP) Program, an evidence-based lifestyle intervention to prevent diabetes in 36 AI/AN grantee sites. A total of 2,553 participants started the 16-session Lifestyle Balance Curriculum between 1 January 2006 and 31 July 2008. Linear mixed models were used to evaluate the relationships of participant and staff socioeconomic characteristics with weight and behavioral outcomes at the end of the curriculum.ResultsA strong, graded association existed between lower household income and less BMI reduction, which remained significant after adjusting for other socioeconomic characteristics. Compared with others, participants with annual income

ObjectiveAmerican Indians and Alaska Natives (AI/ANs) suffer a disproportionate burden of diabetes. Identifying food choices of AI/ANs at risk of type 2 diabetes, living in both rural and urban settings, is critical to the development of culturally relevant, evidence-based education strategies designed to reduce morbidity and mortality in this population.DesignAt baseline, 3135 AI/AN adults participating in the Special Diabetes Program for American Indians Diabetes Prevention Demonstration Project (SDPI-DP) completed a socio-demographic survey and a 27-item food frequency questionnaire (FFQ). The primary dietary behavior goal of SDPI-DP education sessions and lifestyle coaching is changes in food choices, i.e., increased fruits, vegetables and whole grains, decreased high sugar beverages, red meat, and processed foods. Subsequently, program assessment focuses on changes in food types. Foods were delineated using a 'healthy' and 'unhealthy' classification as defined by the educators advising participants. Urban and rural differences were examined using χ(2) tests and two sample t-tests. Multiple linear regressions and linear mixed models were used to assess the association between socio-demographic factors and food choice.ResultsRetired participants, those living in urban areas and with high income and education selected healthy foods most frequently. Young males, those with low income and education consumed unhealthy foods most frequently. Selection of unhealthy foods did not differ by urban and rural setting.ConclusionsThe ubiquitous nature of unhealthy food choices makes them hard to avoid. Food choice differences by gender, age, income, and setting suggest that nutrition education should more effectively target and meets the needs of young AI/AN males.

Using multilevel analysis, this study investigated participant and site characteristics associated with participant retention in a multisite diabetes prevention translational project among American Indian and Alaska Native (AI/AN) people. We analyzed data from the Special Diabetes Program for Indians Diabetes Prevention Program (SDPI-DP), a lifestyle intervention to prevent diabetes implemented in 36 AI/AN grantee sites. A total of 2,553 participants were recruited and started the intervention between January 1, 2006 and July 31, 2008. They were offered the 16-session Lifestyle Balance Curriculum from the Diabetes Prevention Program (DPP) in the first 16-24 weeks of intervention. Generalized estimating equation models and proportional hazards models with robust standard error estimates were used to evaluate the relationships of participant and site characteristics with retention. As of July 31, 2009, about 50 % of SDPI-DP participants were lost to follow-up. Those who were younger, male, with lower household income, no family support person, and more baseline chronic pain were at higher risk for both short-term and long-term retention failure (i.e., not completing all 16 DPP sessions and loss to follow-up, respectively). Sites with large user populations and younger staff had lower likelihood of retaining participants successfully. Other site characteristics related to higher risk for retention failure included staff rating of participant disinterest in SDPI-DP and barriers to participant transportation and child/elder care. Future translational initiatives need to pay attention to both participant- and site-level factors in order to maximize participant retention.

ObjectivesWe evaluated cardiovascular disease (CVD) risk factors in American Indians/Alaska Natives (AI/ANs) with diabetes in the Special Diabetes Program for Indians Healthy Heart (SDPI-HH) Demonstration Project.MethodsMultidisciplinary teams implemented an intensive case management intervention among 30 health care programs serving 138 tribes. The project recruited 3373 participants, with and without current CVD, between 2006 and 2009. We examined data collected at baseline and 1 year later to determine whether improvements occurred in CVD risk factors and in Framingham coronary heart disease (CHD) risk scores, aspirin use, and smoking status.ResultsA1c levels decreased an average of 0.2% (P

ObjectiveDepression is a major debilitating disease. For American Indians living in tribal reservations, who endure disproportionately high levels of stress and poverty often associated with depression, determining the patterns and correlates is key to appropriate clinical assessment and intervention development. Yet little attention has been given to the cultural context of correlates for depression, including the influence of family, cultural traditions or practices, or community conditions.MethodWe used data from a large representative psychiatric epidemiological study among American Indians in 2 reservation communities to estimate nested individual and multilevel models of past-year major depressive episode (MDE) accounting for family, cultural, and community conditions.ResultsWe found that models including culturally informed individual-level measures significantly improved the model fit over demographics alone. We found significant community-level variation in the probability of past-year MDE diagnosis in 1 tribe even after accounting for individual-level characteristics.ConclusionsAccounting for culture, family, and community context will facilitate research, clinician assessment, and treatment of depression in diverse settings.

The Kessler Screening Scale for Psychological Distress (K6; Kessler et al., 2002) has been used widely as a screener for mental health problems and as a measure of severity of impact of mental health problems. However, the applicability and utility of this measure for assessments within American Indian communities has not been explored. Data were drawn from a large-scale epidemiological study conducted in cooperation with 2 American Indian populations. Participants (N = 3,084) were 15-54 years of age and living on or near their home reservations; each completed an interview that included a version of the Composite International Diagnostic Interview (Robins, Wing, Wittchen, & Helzer, 1988) and the K6. A measure of both physical- and mental-health-related quality of life--the Medical Outcome Study's Short Form-36 (Ware & Sherbourne, 1992)--was used to examine the importance of the K6 over and above psychiatric diagnoses. The K6 was shown to be an appropriate screening and severity measure for mood disorders in these 2 samples. It also predicted health-related quality of life over and above that predicted by diagnoses alone. Inclusion of a measure such as the K6 as a complement to more traditional dichotomous diagnoses in both research and clinical practice is recommended. (Contains 4 figures and 3 tables.)

In their recent article, N. Spillane and G. Smith suggested that reservation-dwelling American Indians have higher rates of problem drinking than do either non-American Indians or those American Indians living in nonreservation settings. These authors further argued that problematic alcohol use patterns in reservation communities are due to the lack of contingencies between drinking and "standard life reinforcers" (SLRs), such as employment, housing, education, and health care. This comment presents evidence that these arguments were based on a partial review of the literature. Weaknesses in the application of SLR constructs to American Indian reservation communities are identified as is the need for culturally contextualized empirical evidence supporting this theory and its application. Cautionary notes are offered about the development of literature reviews, theoretical frameworks, and policy recommendations for American Indian communities. (Contains 1 footnote.)

Objectives: To examine the relationship of childhood physical and sexual abuse with reported parenting satisfaction and parenting role impairment later in life among American Indians (AIs). Methods: AIs from Southwest and Northern Plains tribes who participated in a large-scale community-based study (n=3,084) were asked about traumatic events and family history; those with children were asked questions about their parenting experiences. Regression models estimated the relationships between childhood abuse and parenting satisfaction or parenting role impairment, and tested for mediation by depression or substance use disorders. Results: Lifetime substance use disorder fully mediated the relationship between childhood physical abuse and both parenting satisfaction and parenting role impairment in the Northern Plains tribe. There was only partial mediation between childhood sexual abuse and parenting role impairment in the Southwest. In both tribes, lifetime depression did not meet the criteria for mediation of the relationship between childhood abuse and the two parenting outcomes. Instrumental and perceived social support significantly enhanced parenting satisfaction; negative social support reduced satisfaction and increased the likelihood of parenting role impairment. Exposure to parental violence while growing up had deleterious effects on parenting outcomes. Mothers and fathers did not differ significantly in the relation of childhood abuse experience and later parenting outcomes. Conclusions: Strong effects of social support and mediation of substance abuse disorders in the Northern Plains offer direct ways in which childhood victims of abuse could be helped to avoid negative attributes of parenting that could put their own children at risk. Practice implications: Mothers were not significantly different from fathers in the relation of abusive childhood experiences and later parenting outcomes, indicating both are candidates for interventions. Strong effects ofsocial support offer avenues for interventions to parents. The prevalence of substance use disorders and their role as a mediator of two parenting outcomes in the Northern Plains should focus special attention on substance use treatment, especially among those who experienced childhood victimization. These factors offer direct ways in which childhood victims of abuse can be helped to avoid negative attributes of parenting that could put their own children at risk of violence.

Alcohol use is cited as a risk factor for exposure to HIV infection through risky sexual behavior, especially among adolescents. From Social Cognitive Theory, positive outcome expectancies about the use of alcohol have often been presented as a critical aspect of alcohol use. Yet little is known about how they might be related to different aspects of HIV risk. Using latent growth curve modeling with data from 292 American Indian youth across seven years, both alcohol use and positive expectancies increased significantly; a lower-risk group showed significantly slower increases in both. Changes in alcohol use and outcome expectancies were significantly interrelated, providing support for reciprocal influence between the two constructs. Positive alcohol outcome expectancies may provide a preventive intervention point worthy of further consideration as influencing alcohol use and lowering HIV sexual risk among adolescents.

The purpose of this study was to identify factors associated with 4 clusters of obstacles (self-reliance, privacy issues, quality of care, and communication and trust) to mental health and substance abuse treatment in 3 treatment sectors for residents of 3 reservations in the United States. Participants (N = 3,084) disclosed whether they had sought treatment for emotional, drug, or alcohol problems in the past year and, if so, whether they had faced obstacles in obtaining care from Indian Health Services, tribal services, and other public or private systems. Correlates of these obstacles included negative social support, instrumental social support, utility of counselors, utility of family doctors, treatment sector, treatment type, diagnosis of an anxiety disorder, and tribe.

Contracting a sexually transmitted disease (STD) is one of the most serious public health issues for adolescents and young adults; rates of STDs among American Indian youth are among the highest of any racial or ethnic group in the United States. Although it is one of the key risk factors for spreading STDs, little is known about individual development of multiple sexual partners in any ethnic group. Drawing from social cognitive theory, this study used latent growth curve modeling with a sample of 518 American Indian adolescents and young adults to delineate the relationship across 4 years between youths' confidence in resisting risk and the number of sexual partners they had. The development of resistive efficacy was similar across genders: Although women reported higher levels at all time points, both genders increased across time. Men reported relatively stable levels of sexual partners; women had fewer sexual partners initially, but the number increased significantly and then decelerated. Further, the 2 trajectories had significant interdependence: Both intercepts and slopes were negatively related to each other across construct, suggesting that increasing resistive efficacy was related to decreasing number of sexual partners. (Contains 4 tables and 2 figures.)

This study examined the prevalence of suicidal behaviors among 1,638 Northern Plains American Indians ages 15?57. Age and gender patterns were investigated as was comorbidity with psychiatric and substance use disorders. Data from a population-based survey indicated that suicidal behaviors were more frequently reported among females than males and among younger respondents than older respondents. In addition, suicidal behaviors were associated with depressive disorders, PTSD, substance abuse/dependence, and violent ideation/aggression. Results underscore the importance of effective and acceptable alcohol, drug, and mental health services in reducing the rates of suicidal behaviors in American Indian communities.

Data from self-reports of high school students (N=1,353) representing three culturally distinct American Indian tribes were analyzed for tribal differences in factors associated with suicidal ideation. No single correlate was common to all three tribes; the correlates were consistent with each tribe's social structure, conceptualization of individual and gender roles, support systems, and conceptualization of death. (Author/MKA)