The Importance of Understanding Social Context in the Reduction of AEP Risk among Native Women

Jessica Hanson, Cassaundra Mohawk, Umit Shrestha, Marie Gross, Marcia O’Leary, Michelle Sarche

Research output: Contribution to journalComment/debatepeer-review

1 Scopus citations
Original languageEnglish (US)
Pages (from-to)2154-2157
Number of pages4
JournalAlcoholism: Clinical and Experimental Research
Issue number11
StatePublished - Nov 2020

Bibliographical note

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The goal of this commentary is to outline important paths for addressing AEP prevention in Native (e.g., American Indian, Alaska Native, Native Hawaiian, Indigenous, and First Nations) women that holistically takes into account the views of the women and communities participating in these interventions. Reducing alcohol consumption to below bingeing levels is a focus of Healthy People 2020, which sets data-driven national objectives to improve health in the United States. For women, risky drinking includes either binge (i.e. 4 or more drinks on an occasion) or heavy (i.e. 8 or more drinks per week) drinking (National Institute on Alcohol Abuse and Alcoholism, no date), with recommendations for complete abstinence from alcohol during pregnancy. In Native communities, binge drinking remains a critical public health issue. While Native women are more likely to abstain from alcohol compared with other racial/ethnic groups, among those who drink binge drinking is more likely (Ye et al., 2020). Considering the relational and situational contexts of drinking, Native women in the United States who drink are more likely to do so in a home setting rather than in bars and restaurants (May and Gossage, 2001, Hanson et al., 2017) and are more likely to binge drink on weekends in a group to be sociable, to celebrate a special occasion, because others are drinking, or to be part of a group (May and Gossage, 2001). Reduction in binge drinking includes the need to address risk for alcohol-exposed pregnancy (AEP). A cohort study with Northern Plains American Indian women found that 52% consumed alcohol during pregnancy, with 41% engaged in prenatal binge drinking (Ye et al., 2020). AEP prevention efforts that have specifically targeted the preconception period focused on behavior change before women become pregnant by either encouraging the reduction or elimination of risky alcohol use and/or effective contraceptive use among women who could become pregnant. Data from the South Dakota Tribal Pregnancy Risk Assessment Monitoring System (PRAMS) found that 55% of Native women from Great Plains Area tribes were binge drinking in the 3 months prior to pregnancy (Great Plains Tribal Chairmen’s Health Board, 2017). Among this same sample, 82% were sexually active, not trying to get pregnant, and were not using any birth control at conception. In the past, many efforts have been undertaken to reduce risk for AEP in tribal communities. Previous AEP prevention projects within these populations have focused on nonpregnant women of childbearing age, pregnant women, and the public with a variety of universal, selective, and indicated AEP prevention activities (Symons et al., 2018). One such AEP prevention project is the CHOICES (Changing High-risk alcohOl use and Increasing Contraception Effectiveness Study) Program, an evidence-based intervention to reduce AEP risk by decreasing risky drinking and increasing effective contraceptive use among women at risk for an AEP (Project CHOICES Intervention Research Group, 2003). The heart of the intervention is its use of motivational interviewing (MI), which focuses on the individual’s own perspectives about changing behaviors, and helping the person set goals and develop personalized plans for change (Project CHOICES Intervention Research Group, 2003). A previous implementation of CHOICES with a tribal community, adapted by and for the tribal community, showed a significant decrease in risk for alcohol-exposed pregnancy (Hanson et al., 2017). CHOICES, while not originally designed for Native communities, has been adapted by and implemented with several tribal nations in the United States and Canada. These evidence-based and community-led AEP prevention efforts are important in reducing risk for AEP within Native communities. However, there is a missing component—social networks and social support—often overlooked when implementing interventions such as CHOICES, but one that can be considered in future AEP prevention endeavors. The role of the social network in decisions to abstain from alcohol is not limited to Native communities. In particular, the social networks of family and peers surface as a constant theme impacting women’s drinking, consistent with previous work indicating that social influences are pivotal for women’s alcohol consumption in general (Brady and Randall, 1999, Meurk et al., 2014). Addressing social support and social networks in AEP prevention programs with Native communities must be led by community partners due to the unique cultural connection to family and community within many Native communities. Historically, kinship in tribal settings was not strictly linked with biology, and “children were trained to see themselves as related to virtually all with whom they had regular contact” (Brendtro et al., 2002, p. 46). There was a strong sense of belonging with the community, which public health theorists and others dictate as important: A strong ecological balance through the interpersonal and community realms ensures a balance in the individual (Bronfenbrenner, 1979). In her seminal book Decolonizing Methodologies: Research and Indigenous Peoples, Smith writes, “to be connected is to be whole” and this idea of connection must be included in research with Indigenous communities (Smith, 1999, p. 148). Indeed, research with Native communities has shown that this sense of connectedness is a protective factor against binge drinking and can aid in reducing risky drinking (Mohatt et al., 2004; Mohatt et al., 2011). Unfortunately, this idea of multigenerational and community-wide connection is often lacking within current AEP prevention efforts. As a result, AEP interventions designed to reduce binge drinking may not fully account for the ways in which binge drinking occurs alongside the building or maintenance of social connections. Interventions may therefore unintentionally cause a disconnect between those whose behavior is changed by the intervention and their social networks. As noted above, a previous implementation of the CHOICES intervention with a tribal community showed a significant decrease in risk for alcohol-exposed pregnancy based on behavioral variables such as reduced risky drinking and increased contraceptive use (Hanson et al., 2017). However, this research did not evaluate or estimate the potential social or emotional consequences of reducing or changing alcohol use. Previous research with Native women at risk for AEP did explore the effects of depression on risky drinking, but not the impact of changing one’s social setting to reduce or alter drinking patterns (Montag et al., 2015a, Montag et al., 2017). To address these limitations, AEP interventions must first conceptualize how and why Native women drink. Noted above, May & Gossage (2001) describe the social nature of drinking in many Native communities (to be sociable, to celebrate, and to be part of a group). As well, the individuals to whom these efforts are directed may define drinking in a more positive light. Qualitative data analysis from a previous tribal CHOICES program uncovered positive aspects of drinking (e.g., socializing and relaxing), some of which outweighed the negative consequences (Shrestha et al., 2018). For example, women believed that alcohol was beneficial within their circumstances despite its harmful health impact. Women generally knew that risky alcohol consumption could have negative health or social consequences, but alcohol helped them escape problems such as those related to finances, relationships, or mental/physical health (Shrestha et al., 2018). Identifying reasons (positive or otherwise) that Native women drink can help inform potential unintentional social consequences for Native women who are reducing their drinking. Previous formative data collected as part of developing new efforts on social support for women who are reducing their risk for AEP highlights some potential social situations that need to be acknowledged and addressed in prevention efforts with Native women. Data from key informant interviews highlighted the potential impact that reducing binge drinking can have for Native women. For example, reduced binge drinking as the result of participating in an intervention could cause many Native women to lose their only source of social support (e.g., the group with whom they previously drank). Women at risk for AEP may value the social support of their social network over the potential negative consequences from their risky drinking behaviors. Some women’s drinking groups may be the individuals living in their household, meaning that maintaining alcohol abstinence may be challenging if the woman is unable to find new housing to avoid the temptation to drink (unpublished data). What is described here is not a critique of alcohol reduction efforts with tribal communities. Instead, we have outlined opportunities to expand AEP prevention programs to better account for the social context in which drinking occurs. Many previous AEP prevention efforts with tribes were community-engaged projects where the tribal community was heavily involved in the development, implementation, and evaluation of the intervention. The critique is focused on the lack of attention paid to the dichotomy of potential harmful effects of these public health interventions, such as loss of social networks. Most, if not all, follow-up data points in the alcohol-exposed pregnancy prevention projects focused on alcohol-related behavior and did not include questions related to social support, overall well-being, and self-efficacy. We offer this call to recognnize the potential of public health interventions to negatively impact social networks, and to work with community partners to provide solutions that fully account for the context in which the target behavior(s) occur. We must better understand and consider the unintentional consequences of encouraging behavioral changes around substance use and work closely with tribes to develop and provide additional interventions or other support to participants. Support and building positive networks should be built into interventions and informed and led by the community. Building self-efficacy activities within an AEP prevention must be a goal, including increasing readiness to refuse or avoid drinking environments, providing tools to women interacting with individuals in their social network, and promoting skills in participants so that information provided in the intervention can be clearly shared with the overall community. As well, social networks may need to be redefined for each individual depending on their circumstances and the type of support (e.g., emotional, instrumental, information, or appraisal) that an individual needs, and also if that support is even available. Interventions to reduce alcohol have, in fact, been enacted at the social network level, although with varied success among women (Litt et al, 2015). If social networks cannot be easily reconfigured (e.g., changing social patterns in a positive way), they must be built. Many tribal communities have grassroots, community-led efforts that focus on promoting health and supplementing the tribal public health system. Alcohol interventions should be inclusive of linking Native women to available positive programming to create positive connections. In the case that positive programming does not exist, support groups can be developed at the community-level. For example, peer coaching has been successful in reducing substance use in Native communities by emphasizing social support, empathy, and therapeutic relationships (White, 2009). This approach emphasizes multiple levels of recovery that are important to Native communities, including the involvement of family and other social relationships and the role of culturally specific supports needed for recovery. In addition, mobile health (mHealth) interventions provide a viable approach in providing social support for women at risk for AEP. Therefore, while interventions such as CHOICES prepare women to make changes in their drinking, they may need additional support after the program ends. Providing social support for alcohol reduction or abstinence through supplemental services, such as peer coaching or social support via mHealth, provides them with the support, resources, and assistance to do so. Whatever the goal of an AEP prevention program, there are clear recommendations for developing interventions within Native communities. Wolfson et al (2019) outlined eight tenets for FASD prevention in partnership with Native communities: (1) centering prevention around indigenous knowledge and wellness; (2) using a social and structural determinants of health lens; (3) highlighting relationships; (4) (making efforts) community-based and community-driven; (5) provision of wraparound support and holistic services; (6) adopting a life course approach; (7) models supporting resiliency for women, families, and communities; and (8) ensuring long-term sustainable funding and research. The authors of the current paper outline suggestions for improving social support for Native women to reduce AEP risk, such as increasing self-efficacy, building social support networks, and intervening at multiple levels. Ultimately, the application of the eight tenets from Wolfson et al (2019) specific to these suggestions can only add to the breadth of knowledge and available programming within AEP prevention efforts in tribal communities.

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