James R. Moran
Phillip A. May
This chapter provides a guide to the literature dealing with the prevention of alcohol
and other drug (AOD) abuse among American Indians. As a guide, rather than a critical
review, the chapter provides an overview of potentially useful approaches. This strategy
was chosen because the heterogeneity of the American Indian population requires that
social work professionals explore many options and tailor their prevention approaches to
specific communities. Thus, a broad review covering many approaches is more useful than an
in-depth critical review of fewer strategies.
It should be noted that although this chapter focuses on preventing AOD abuse, most of
the literature regarding American Indians primarily addresses alcohol. However, drugs
other than alcohol also present problems in American Indian communities. Recent works by
Beauvais (1992b); Mail and Johnson (1993); Okwumabua and Duryea (1987); and Swaim,
Oetting, Edwards, and Beauvais (1989) provide good overviews of the range of drug and
related problems experienced by American Indians. For example, inhalants are frequently
abused by American Indian youths, especially by young adolescents before they gain access
to alcohol (Beauvais, Oetting, & Edwards, 1985b; Wingert, 1982); use of marijuana is
highly variable across different American Indian groups, but it appears to be higher among
American Indian youths than among non-Indian youths (Mail & Johnson, 1993); heroin use
is low among American Indian people (Bachman et al., 1991); and cocaine use is similar for
American Indians and non-Indians (Beauvais et al., 1985b). After reviewing the evidence
from several national studies, Mail and Johnson (1993) concluded that the availability and
predictability of results have made and continue to make alcohol the drug of choice among
American Indian people.
A consequence of alcohol being the preferred drug is that alcohol abuse represents a
major problem for many American Indian communities. For example, as a group, American
Indians and Alaska natives experience high rates of diseases of the heart, cancer,
diabetes, and injuries or death as a result of accidents (Indian Health Service [IHS],
1991; May, 1995). An important observation is that alcohol abuse plays a significant role
in these problems. Alcohol is a major factor in five of the 10 leading causes of mortality
for American Indians (IHS, 1992). Morbidity data also indicate that alcohol abuse is a
major factor contributing to health problems among this population. Both inpatient and
outpatient data of the Indian Health Service (IHS) show alcohol-related trauma and
diseases to be frequent reasons for health care and disability (Hisnanick & Erickson,
1993; IHS, 1993). More recently, Walker, Howard, Anderson, and Lambert (1994) found that
among people newly discharged from Veterans Affairs hospitals, American Indian veterans
had twice the rate (45 percent) of alcohol dependence that non-Indian veterans had.
Because of the magnitude of the problems related to alcohol, most of the literature (and
hence this chapter) focuses mainly on issues related to prevention programs that targeted
alcohol abuse among American Indians.
This chapter begins with an overview of characteristics of the American Indian
population that provides important background information for social workers planning to
work with this population. Next, the extent of the problem of alcohol abuse is described,
particularly as it is reflected in American Indian mortality data. This text also explores
some of the common myths concerning American Indians and alcohol. Also included is a guide
to the literature on preventing alcohol-related problems among the American Indian
populations and a set of recommendations that can enhance the operation of prevention
programs within American Indian communities.
The American Indian Population
The term American Indian, rather than Native American, is used throughout
this chapter. The reason for this choice is that Native American, in addition to referring
to indigenous peoples, can also refer to descendants of immigrants from other nations.
Thus, the term Indian or American Indian is now more common in everyday
usage and in literature addressing this population. Furthermore, for this chapter, the
term Indian or American Indian is inclusive of Alaska natives.
The 1990 census counted 1,959,873 American Indians in the United States (U.S. Bureau of
the Census, 1991). This group of people is characterized by its heterogeneity rather than
its homogeneity. For example, as of 1993, there were 341 federally recognized tribes as
well as another 111 tribal groups seeking federal recognition (Hirschfelder & Montano,
1993). Although some similarities exist across tribal groups, a great deal of cultural
variation exists. For example, there are 17 distinct cultural areas (Manson, Shore,
Barron, Ackerson, & Neligh, 1992) and more than 200 different American Indian
languages currently spoken (Fleming, 1992).
In addition to tribal differences, American Indians differ greatly by degree of
American Indian ancestry; this is important because American Indians are the only ethnic
group in the United States that is legally defined by degree of ancestry. The degree of
American Indian ancestry is referred to as blood quantum, with 25 percent American Indian
blood being the most commonly accepted minimum threshold for tribal membership. Throughout
the 20th century, mixed-blood American Indians have outnumbered full-blood American
Indians (Wilson, 1992). This point draws attention to the social versus biological
definition of who is an American Indian and calls the genetics-based explanations of
American Indian drinking into question.
Geographically, American Indian populations tend to cluster in the western states, with
66 percent of all American Indians living in 10 states. Eight of these 10 are in the West
or Midwest (Hodgkinson, Outtz, & Obarakpor, 1990; Snipp, 1989). Although American
Indians are often thought of as living mainly on reservations, only about 35 percent
actually do (U.S. Bureau of the Census, 1991). Finally, as a result of a birth rate that
has consistently been twice that of the U.S. average, the American Indian population is
young. The median age of the American Indian population was 24.2 years in 1990, compared
with 34.4 years for U.S. whites (IHS, 1993).
Extent of the Problem
Alcohol takes a disproportionate toll among American Indians. An overall indicator of
this toll is that American Indians have a higher rate of alcohol-related death than the
general U.S. population (May, in press). This is especially true in the under-45 age
group. For example, in the age group 2534, American Indian men die 2.8 times more
frequently than non-Indian men from motor vehicle crashes, 2.7 times more from other
accidents, 2.0 times more from suicide, 1.9 times more from homicide, and 6.8 times more
frequently from alcoholism (alcohol dependence syndrome, alcoholic psychosis, and chronic
liver disease and alcoholic cirrhosis) (May, 1996).
More evidence of the problem is seen in the percentage of all American Indian deaths
that involved alcohol. For 19861988, motor vehicle crashes, other accidents, suicide,
homicide, and alcoholism caused a total of 5,781 American Indian deaths. On the basis of
an approximation of alcohol involvement developed by May (1989a), a total of 3,656 of
these deaths are estimated to have involved alcohol. This represents 16.7 percent of the
21,943 American Indian deaths from all causes in these years. The percentages of
alcohol-involved deaths by gender were 26.5 percent for men and 13.2 percent for women
(May 1989a, in press).
This difference in alcohol-involved deaths by gender is important. Although American
Indian men have higher rates of death than American Indian women for all types of
alcohol-involved causes and in all age groups, alcohol has major negative consequences for
American Indian women. For example, American Indian women ages 2534 die 1.4 to 12 times
more frequently of alcohol-involved causes than non-Indian women (May, in press).
These data seem to support the common view that Leland (1976) described in her book Firewater
Myths. Leland said that many people believe that American Indians are inclined to
develop an excessive craving for alcohol and to lose control of their behavior when they
drink. Most often this view is couched in terms of a genetic predisposition to alcohol
(Mail & McDonald, 1980). Of particular concern from a prevention perspective is that
many American Indian people also accept the myth or stereotype of the "drunken
Indian," that is, the idea that American Indians are somehow different from
non-Indians in their susceptibility to alcohol. For example, most (63 percent) Navajo
people believe that American Indians have a special physiological weakness to the effects
of alcohol (May & Smith, 1988). Sage and Burns (1993) found that American Indian
adolescents, particularly men, attributed American Indian drinking problems to being
"in the blood." These adolescents tended to use the heredity or genetic
explanation of American Indian drinking as an excuse for their own abuse of alcohol.
Despite its common acceptance, many components of the myth are inaccurate (Leland, 1976;
Westermeyer, 1974), and no major deficit in the rate of alcohol metabolism or any other
particular physiological predisposition to alcohol abuse has been documented in the
scientific literature (Mail & Johnson, 1993; May, 1989a; Reed, 1985; Schaefer, 1981).
However, from the mortality data presented earlier, it is evident that alcohol wreaks
destruction among American Indians: American Indian men have a greater problem with
alcohol-involved death than American Indian women; alcohol-involved mortality data are
worse for both American Indian men and women than the overall U.S. averages; and the
disparity between American Indians and the U.S. general population is greatest in the
younger age groups (May 1986, 1989a).
Given that little scientific support exists for the belief that American Indians are
genetically predisposed to alcohol, what explains the severe alcohol problems experienced
by American Indian communities as reflected in the higher rates of mortality? The answer
comes from understanding the variation in alcohol use among American Indians. Just as
heterogeneity exists along other dimensions, a great deal of diversity is seen in the
manner in which alcohol is used by American Indian people. One measure of this variation
is presented by May (1982) in a report on studies that examined the prevalence of alcohol
use in different American Indian communities. Compared with the overall U.S. prevalence of
67 percent to 68 percent (National Institute on Alcohol Abuse and Alcoholism, 1981), the
Navajo of the Southwest had a rate of only 30 percent (Levy & Kunitz, 1974). The
Standing Rock Sioux of South Dakota were at about the same as the U.S. figure, at 69
percent (Whittacker, 1962, 1982), whereas the Ute of Southern Colorado (Jessor, Graves,
Hanson, & Jessor, 1968) and the Ojibwa of the Brokenhead Reserve in Canada (Longclaws,
Barnes, Grieve, & Dumoff, 1980) were both higher at about 80 percent. From these
studies, it is seen that not all American Indian people use alcohol; in fact, some groups
such as the Navajo abstain from any alcohol use at twice the rate of the general U.S.
population.
Perhaps more to the point regarding variation in alcohol use among American Indians is
the literature that examines drinking styles (Levy & Kunitz, 1974; Weisner,
Weibel-Orlando, & Long, 1984). The most frequently described styles are abstinence,
recreational, anxiety, and moderated social drinking (Ferguson, 1968; May, 1982, 1989a).
Of these four, only the recreational and the anxiety styles are linked to the problems
outlined here. In other words, abstinence, common among many tribes (see May 1989a),
particularly among middle-aged and older people, obviously causes no alcohol-related
problems. Similarly, many American Indians tend to drink as do others in the strata of
society to which they are attached (see Levy & Kunitz, 1974; Liban & Smart, 1982).
Many American Indians, therefore, tend to practice a moderated or light social drinking
style, which produces few or no problems related to morbidity, mortality, arrest, or other
health or social problems.
However, Ferguson (1968) described the subgroups of recreational and anxiety drinkers
that are also common among most American Indian communities. The recreational drinker is
typically a young man who drinks with friends (predominantly men, but also in mixed
groups) on weekends and for parties, special occasions, and other social events. As with
other groups of young people, drinking and intoxication are important for social cohesion
and are generally highly valued. Recreational drinking among American Indian groups of
many tribes may be different from some other groups in the United States only in matters
of degree and cultural meaning. As described by many authors, American Indian recreational
drinking is more rapid and more forced, and the "bouts" are extended over long
nights, weekends, and for other lengthy periods (Dozier, 1966; Hughes & Dodder, 1984;
Lurie, 1971; Savard, 1968; Weisner et al., 1984). High blood alcohol concentrations are
commonly found in American Indians who practice this style of drinking.
Anxiety drinkers tend to be older and they drink chronically, are more solitary, and
are generally physically addicted to alcohol. They generally drink cheap wine and beer and
supplement with hard liquor, but they will consume almost any alcoholic beverage
available. They also use nonbeverage items that contain alcohol, such as hair spray,
aftershave, and disinfectant. Anxiety drinkers are mostly unemployed, live in border towns
and skid row areas, and are not usually associated with the mainstream society of their
tribe or of Western society. Most anxiety drinkers are ostracized to a great degree,
whereas the recreational drinkers may be in the mainstream of society and associated with
abusive peer clusters only when drinking.
These two patterns, the recreational and anxiety drinking, represent the types of
alcohol-abusing or alcohol problemgenerating styles that account for most of the
problems related to alcohol in American Indian communities. It is from these two groups
that the stereotype of the "drunken Indian" gains meaning. The people involved
in these two styles of drinking do not include all American Indian people. However, the
problems encountered by these drinkers are a significant issue (for example, higher
mortality rates) for American Indian communities.
From these data, the need for programs for preventing alcohol-involved problems is
evident. However, differences by tribal group, cultural orientation, degree of American
Indian ancestry, and residency (that is, reservation versus urban) make it difficult to
prescribe what prevention efforts should be. Considering this heterogeneity, what then
does the literature tell us about alcohol abuse prevention among American Indians?
The Literature on Prevention
The criterion for inclusion of articles in this chapter was an assessment of their use
for alcohol-related prevention activities. In some cases, the works are more concerned
with etiology than application, and others describe specific strategies of prevention.
Nevertheless, the basic insights in the articles reviewed hold promise for reducing
alcohol-related problems. As stated previously, this chapter is a guide to the literature
to help develop prevention efforts with this population, not a critical review of the
research literature. It should also be stressed again that the heterogeneity of the
American Indian population makes it difficult to generalize specific interventions.
This chapter should be useful to social workers pursuing applied programs of alcohol
abuse prevention. An attempt has been made to focus on ideas and alcohol programs that are
primarily prevention oriented, rather than treatment oriented. The emphasis is on
tertiary, secondary, and primary prevention, including comprehensive programs that address
more than one level. Because some programs have diverse elements that address multiple
levels, categorization in this chapter is intended to reflect the predominant theme of the
programs.
Overview Articles
Several articles identifying key issues related to the prevention of AOD abuse among
American Indians have been published. Most of this literature focuses on young people.
Alcohol, marijuana, and inhalants are the three drugs most commonly abused by American
Indian youths. American Indian youths generally report they use alcohol as frequently or
more frequently than other youths in the United States. For example, by the 12th grade,
lifetime prevalence of alcohol use is quite high: 96 percent for American Indian men, and
92 percent for women (Oetting & Beauvais, 1989). However, the major difference between
American Indian youth data and U.S. youth averages is found in measures dealing with age
at first involvement and degree of involvement.
The age at first involvement with alcohol is younger for American Indian youths, the
frequency and amount of drinking are greater, and the negative consequences are more
common (Beauvais, Oetting, & Edwards, 1985a; Forslund & Cranston, 1975; Forslund
& Meyers, 1974; Hughes & Dodder, 1984; Oetting, Beauvais, & Edwards, 1988).
Oetting, Swaim, Edwards, and Beauvais (1989) have found that at all ages and grades, a
greater percentage of American Indian youths are more heavily involved with alcohol than
non-Indians are. Several studies indicate that alcohol use is both encouraged and expected
among many peer groups as the "Indian thing to do" (Winfree & Griffiths,
1983b). By 12th grade, 80 percent of American Indian youths are current drinkers, but
variation exists from reservation to reservation (May, 1982). Severity measures show that
American Indian youths who drink are more likely to report having been drunk and to have
"blacked out" (Oetting & Beauvais, 1989).
The American Indian patterns are similar to general U.S. high school data, which show
an increase in drinking and marijuana use through 1980 and subsequent declines after 1980.
That is, American Indian youths have reported reduced AOD use in recent years (Oetting
& Beauvais, 1989; Winfree & Griffiths, 1983a). However, the subgroup of American
Indian youths who indicate heavy use has not declined but rather has remained steady at 17
percent to 20 percent (Beauvais, 1992b).
The youths most likely to abuse alcohol are those tied to AOD-abusing "peer
clusters." Also, American Indian youths who do not do well in school, who do not
strongly identify with American Indian culture, and who come from families who also abuse
alcohol (Guyette, 1982) are more likely to abuse AOD. The findings of Oetting and Beauvais
(1989) further characterize AOD abusers as having poor school adjustment, weak religious
and spiritual foundations, poor family and peer group associations, and little hope for
the future. However, American Indian youths with strong attachments to families in which
culture and school are valued and abusive drinking is neither common nor positively valued
tend to be less likely to get seriously involved with AOD.
Low self-esteem, depression, anxiety, and other negative emotional states—taken
independently—are not highly influential or discriminating in alcohol abuse among
American Indian youths (Oetting & Beauvais, 1989; Oetting et al., 1988). Biculturalism
(the ability to function well in both tribal, American Indian society and the modern,
Western world) tends to have a low association with AOD abuse or other predisposing
variables (Moran, Fleming, Somervell, & Manson, in press; Oetting & Beauvais,
19901991). In their most recent works, Swaim, Oetting, Thurman, Beauvais, and Edwards
(1993) emphasize resocialization (the learning or relearning of modes of adjustment to
life that are AOD free) in the family, schools, peer groups, and religious institutions as
preventive of AOD abuse among American Indian youths (Beauvais, 1992a; Swaim et al.,
1993). With these overview articles as background, this chapter now turns to specific
prevention approaches. May, Miller, and Wallerstein (1993) describe seven steps that are
useful in developing appropriate community-based prevention programs: (1) listen; (2)
develop a relationship and rapport; (3) promote dialogue; (4) avoid polarization; (5)
maintain ongoing dialogue and roll with any resistance; (6) provide a menu of options; and
(7) help the community initiate options on its own. The following text covers tertiary,
secondary, and primary programs because this order represents a progression from a more
traditional and somewhat limited view of prevention to broader approaches that hold more
promise for American Indian communities.
Tertiary Prevention Programs
Tertiary prevention consists of measures taken to reduce existing impairments and
disabilities and to minimize suffering caused by severe alcohol abuse or alcohol
dependence (Last, 1983). Programs that emphasize tertiary strategies with American Indian
alcohol abuse are listed in Table 1-1. The first three listings, Shore and Von Fumetti
(1972), Wilson and Shore (1975), and Weibel-Orlando (1989) described the typical methods
used in American Indian alcohol treatment programs and also the tertiary prevention issues
that are important to consider with adult American Indians who abuse alcohol. For example,
Weibel-Orlando (1989) reports on a survey of 26 federally funded rural and urban treatment
programs. She compared them across factors such as ethnicity of staff, strength of
Alcoholics Anonymous (AA) affiliation, cooperation with tribal healers, and treatment
effectiveness. Most programs were staffed mostly by American Indian people, and this was
positive because non-Indian counselors often faced reactions from overt hostility to
sullen resistance. Most programs had a strong AA affiliation, which was seen as related to
the AA background of most of the counselors.
Most programs were accommodating to cultural practices—at least to a limited
extent—through display of American Indian posters and handicrafts. Several programs
included such practices as sweats and praying with a sacred pipe. However, traditional
American Indian healers played only a minor role in the 26 programs. Weibel-Orlando stated
that several medicine men whom she interviewed expressed doubt that traditional healing
practices are appropriate in typical treatment settings. Furthermore, they indicated that
most traditional healing is tribe specific and not available to outsiders. Documenting
treatment effectiveness proved elusive in this study. Program directors could provide only
anecdotal accounts of posttreatment abstinence from drinking. In effect, no program had
evaluated its outcomes. She concludes by calling for both more local focus on treatment
programs to enable increased cultural involvement and more systematic evaluation to
document treatment outcomes.
The articles by Ferguson (1968, 1970, 1976) and Savard (1968) describe the use of
Antabuse (disulfiram), arrest diversion, milieus change, and other tertiary methods of
prevention and intervention for people who chronically abuse alcohol. Ferguson (1970)
reports on a Navajo treatment program involving detoxification, court-ordered use of
disulfiram, staff monitoring and assistance in taking the disulfiram, counseling with the
assistance of interpreters, and employment and welfare aid. A key outcome used for this
study was cessation of destructive drinking as measured by a decrease in drinking-related
arrests. During the 18-month treatment period, arrests fell by 78 percent, with about
one-third of the 115 people in treatment having no arrests.
The subjects of this study were extreme examples of alcohol abuse. However, given that
this type of subject accounts for much of the official American Indian alcohol arrest
data, the positive results from the use of disulfiram along with social supports are
important. It was also found that those who had stronger ties to more traditional culture
fared better than those with weaker traditional ties.
Ferguson (1976) elaborates on this latter point in a second article, in which she
applies "stake theory" to the Navajo subjects in the chronic alcoholic study.
Stake theory holds that those who have a stake in society will conform to society's norms
and demonstrate less deviance such as alcohol abuse. Applying this lens to the subjects
who chronically abuse alcohol produced the following results: those with a stake in the
Navajo society or a stake in Western society responded better than those with a stake in
neither. However, those with a stake in both Navajo society and Western society had the
most success in terms of the 24-month outcome. This is an important finding and one that
corresponds with the findings of Oetting and Beauvais (19901991) and Moran and
colleagues (in press) regarding bicultural competence. These authors found increased
levels of psychological well-being, such as higher self-esteem and more internal locus of
control, and fewer problem behaviors among American Indian adolescents who identified
strongly with both their American Indian culture and Western culture versus those who
identified with only one or with neither. The implication here is that programs at all
prevention levels can probably benefit by consciously addressing issues of culture in a
manner that fosters stronger identification and thus enhances participants' stake in both
their American Indian society and Western society.
Westermeyer and Peake's (1983) study is unique in that it consists of a 10-year
treatment follow-up interview with 45 American Indians who abuse alcohol. At the time of
the 10-year interview, seven had improved, seven remained unchanged in their alcohol use,
19 were doing worse, nine had died, and three could not be located. Factors associated
with doing better were stable employment, good economic and living conditions, strong
interpersonal relationships, and little depression. These factors were not present for
those doing worse. Although not a causal argument, these data point to the importance of
some components of primary prevention efforts described later in this chapter.
Also included in the tertiary level literature are three articles describing the
therapeutic efficacy of using the values, beliefs, structure, and rituals of the Native
American church to treat and prevent further problems from alcoholism. Albaugh and
Anderson (1974), Blum and colleagues (1977), and Pascarosa and Futterman (1976) describe
Native American church practices and peyote as therapeutic agents that can treat problems
with alcoholism. The latter two articles, however, emphasize the pharmacology more than
Albaugh and Anderson, who emphasize the social and behavioral aspects.
The final article in Table 1-1, Masis and May (1991), describes a fetal alcohol
syndrome (FAS) prevention program in Arizona that is focused on women who chronically
abuse alcohol. The tertiary goals are to prevent alcohol damage (FAS or lesser
alcohol-related birth defects) among children yet to be born to mothers who have already
had one damaged child or are drinking heavily while pregnant. The program provides
extensive case management using counseling, social support, birth control, and treatment
for alcoholism.
Secondary Prevention Programs
Secondary prevention uses measures available to individuals and populations for early
detection within high-risk groups and prompt and effective intervention to correct or
minimize alcohol abuse in the earliest years of onset (Last, 1983). The secondary
prevention resources presented here focus on groups and individuals within those groups,
rather than on the entire community, environment, or structural conditions.
Alcohol and Mental Health Programs
The articles in Table 1-2 concern secondary AOD abuse prevention conducted within the
context of mental health programs. Many, if not most, of the people in mental health
programs have problems that involve comorbidity with AOD consumption (May, 1982).
Therefore, AOD abuse prevention has often been developed in mental health programs. Of the
eight articles of this nature, six are in a mental health or suicide prevention context,
one is in an alcoholism treatment context (Silk-Walker, Walker, & Kivlahan, 1988), and
two are in the context of a community mental health initiative (Parker, Jamons, Marek,
& Camacho, 1991; Shore & Kofoed, 1984). These articles underscore the many
possibilities for initiating prevention in all mental health and alcoholism programs. For
example, Silk-Walker and colleagues (1988) describe the necessity for prevention of
alcohol problems to be undertaken within families.
Stabilization of at-risk families through skills training of spouses and broader
community ties should reduce drinking in American Indian communities. Furthermore, centers
for social detoxification and halfway houses are described as prevention possibilities for
American Indian communities (Silk-Walker et al., 1988). Shore and Kofoed (1984) advocate
programs for identifying and diverting alcohol-impaired drivers as well as programs for
the public inebriate and a greater emphasis on outpatient and social detoxification. The
article by Parker and colleagues (1991) takes the problem of youth AOD abuse as it is
affected by a poor self-concept and lack of understanding of traditional culture and
traditions. They describe a program of alcohol education and alcohol abuse resistance
through the use of an alcohol abuse education curriculum and active participation in
traditional tribal activities such as artwork, crafts, songs, and lore.
School-Based Programs
The articles in Table 1-3 are school-based programs. Most prevention programs aimed at
American Indians in recent years have been school-based initiatives that emphasize
information about the effects and consequences of AOD abuse. Programs such as "Here's
Looking at You," "Project Charley," and "Babes" have been used in
many American Indian communities, both on and off reservations. However, the effectiveness
of such programs has been infrequently studied and published. The 15 articles listed in
Table 1-3 represent the published evaluations of programs in American Indian community
schools. IHS documents describe the most frequently used school-based prevention efforts
(IHS, 1986, 1987).
The consistent themes in school-based AOD abuse prevention programs are building
bicultural competence (LaFromboise & Rowe, 1983), increasing self-esteem and
self-efficacy (IHS, 1987), improving resistance to peer pressure and overall
discriminatory and judgment skills (Duryea & Matzek, 1990; Gilchrist, Schinke,
Trimble, & Cvetkovich, 1987; Schinke et al., 1988; Schinke, Mancher, Holden, Botvin,
& Orlandi, 1989), and increasing the perception of the riskiness of AOD abuse
(Bernstein & Woodall, 1987). The current etiological literature supports these
thematic efforts if undertaken in the proper context. That is, building self-esteem alone
will not solve the AOD use and abuse problems, yet building new perceptions, values,
skills, and support systems along with self-esteem may be essential. Therefore, these
programs must also affect the social and cultural aspects of life and mitigate the effects
of abusive peer clusters in the lives of these youths (Newcomb & Bentler, 1989).
Whether this is accomplished by direct or indirect influence, the sociocultural aspects
must be addressed along with the mental health and psychological issues (Oetting &
Beauvais, 1989).
The articles that document school-based prevention can be used as guides and models for
health promotion. Long-term follow-up of the adolescents who participated in these
programs should be pursued aggressively, particularly after they leave school and enter
adulthood. Studies of health promotion among American Indian youths will have to use
long-term outcome evaluation that pinpoints factors associated with low AOD abuse and
overall health and success in life (Neumann, Mason, Chase, & Albaugh, 1991).
Primary Prevention
Primary prevention is the promotion of health and elimination of alcohol abuse and its
consequences through communitywide efforts, such as improving knowledge; altering the
environment; and changing the social structure, norms, and values (Last, 1983). General
approaches and overview articles are presented in Table 1-4. The rationale and philosophy
of primary prevention among American Indian people are described in these articles.
Rhoades, Mason, Eddy, Smith, and Burns (1988) and the IHS (1986) call for broad programs
of health promotion, particularly those that emphasize community change. May (1986)
stresses primary prevention through social policy, environmental change, and broad-based
action for normative change. The Office of Substance Abuse Prevention (1990) focuses on
both mental health and AOD abuse programs for prevention and concludes with an emphasis on
comprehensive prevention. Mail (1985) lays out a rationale and some specific
considerations for primary prevention initiatives in American Indian communities, and Mail
and Wright (1989) indicate that successful prevention programs will have to come from the
communities themselves.
Marum (1988) describes the community-generated prevention process with one program in
Alaska. Public education on AOD abuse was undertaken to increase the pool of knowledgeable
and skilled people who would be working on preventing AOD abuse. Specifically, the Alaskan
efforts emphasized community mobilization and empowerment through volunteer networks to
increase knowledge of AOD abuse and interventions, communitywide awareness of AOD abuse,
AOD education for youths, problem solving at the local level, and increased involvement
and empowerment of the elders.
Beauvais (1992a) pinpoints socioeconomic conditions as the major factors that have
contributed greatly to AOD abuse among the youths of most American Indian communities. He
therefore proposes a four-level integrated model of prevention. True prevention of many
AOD problems will come from improvement in social structure (economic, family structure,
and cultural integrity), socialization (family caring, sanctions, and religiosity),
psychological factors (self-esteem and reduced alienation), and peer clusters (peer
encouragement and sanctions against promoting AOD). Ultimately, this improvement will lead
to lower levels of AOD use. This approach is similar to the one advocated by Beauvais and
LaBoueff (1985) in an earlier article, an approach that should be implemented in a
collaborative manner from within the community rather than from the top down.
Maynard and Twiss (1970) describe a pilot model community mental health program at Pine
Ridge, South Dakota, in the 1970s. Research was generated on social and environmental
conditions that were related to mental health, AOD abuse, and other health and behavioral
health conditions. Their monograph summarizes those studies. It details the historical,
demographic, economic, social, and cultural conditions among the Oglala Lakota (Sioux) at
Pine Ridge and analyzes their significance for behavioral health. A large part of the
concern is related to AOD abuse. Each section of the monograph concludes with suggestions
for prevention, most of them geared to primary prevention. Most solutions involve
communitywide, structural issues. Maynard and Twiss (1970) advocate a major social and
economic development program that eliminates dependent poverty through providing
culturally approved employment opportunities on the reservation, upgrading the educational
system, and fostering leadership through strengthening the authority and dignity of the
tribal leadership and tribal council.
Alcohol-Related Injury Programs
The four articles listed in Table 1-5 relate to the prevention or control of
alcohol-related injury. The May (1989b) article is a literature review that documents the
close tie between alcohol and deaths and injuries, that result from motor vehicle
accidents, and outlines a variety of suggestions for prevention. May advocates the
following primary prevention efforts: social and economic improvement; traffic safety
education and highway improvement; public education; and new tribal alcohol policies,
laws, norms, and values. Improving alcohol education in schools, working to break abusive
drinking subgroups and peer clusters, and increasing use of safety belts and infant car
seats for injury reduction were advocated as secondary prevention level efforts. Tertiary
prevention efforts included improving emergency medical systems, medical care, and alcohol
abuse treatment programs.
Similarly, the Smith (1991) and IHS (1990) documents outline specific strategies for
the prevention of injury and present detailed data to guide and support these efforts. The
IHS initiatives emphasize surveillance to pinpoint problem topics and environments in need
of prevention, as well as increased community awareness of injuries and their
alcohol-related nature. Recommended prevention activities include multiple-media
"None for the Road" campaigns, training of local community experts and
advocates, and infant car seat and adult safety belt usage programs to prevent serious
injury and death despite alcohol-related crashes.
Finally, the Macedo (1988) article provides a primary prevention perspective on whole
communities that are "injured" and traumatized by modern forces, particularly
alcohol abuse, and offers a paradigm for recovery. Macedo emphasizes the concept that
these communities must first work through their collective trauma and then begin to
develop their own internal interventions.
Fetal Alcohol Syndrome Programs
FAS has been upheld by many as a perfect motivation for primary prevention among American
Indians (May, 1986). Indeed, some would say that American Indian communities and some
American Indian organizations are leading the way in the area of FAS prevention. The three
articles on FAS prevention in Table 1-6 are all examples of using public education,
awareness, research, and some diagnostic clinic work to change perceptions and behaviors
around this issue. These American Indian FAS prevention efforts have been unique in that
they have been initiated in conjunction with clinical screening efforts that were designed
to elicit the nature, prevalence, and epidemiological characteristics of the problem
before initiating full-scale prevention programs (May & Hymbaugh, 1983). They
represent targeted approaches based on the clinical and epidemiological findings on the
mothers and infants. Furthermore, the baseline prevalence of the problem as established by
the screening will allow for eventual determination of prevention program success (May
& Hymbaugh, 1983, 1989). In the coming years, it will be vital to evaluate the
long-term effects of health promotion programs in some of the communities that
participated in the first FAS prevention efforts described in these articles.
Policies and Laws
The final primary prevention area is that of alcohol control policy and laws. Table 1-7
lists the major articles in this area. The principal policy regarding American Indians and
alcohol has been prohibition (Mail & McDonald, 1980). In 1832 the U.S. Congress
prohibited the sale of liquor to any American Indian. This law remained in effect until
1953, when each reservation was given the power to regulate alcohol within its own borders
(May, 1976). Because only about 30 percent of all reservations have passed laws making
alcohol legal, more than two-thirds continue to operate under a policy of prohibition
(May, 1992). However, it is clear from the information presented in this chapter that this
policy has not been effective. Bootleggers and the off-reservation purchase of alcohol
have largely circumvented this policy. In fact, some see the policy as encouraging such
alcohol-abusive behavior as passing a bottle among group members and drinking quickly
until the alcohol is gone (Bach & Bornstein, 1981; Dozier, 1966; Mail & McDonald,
1980). Some scholars have suggested new laws to allow legalization and control of alcohol
sales on reservations (Dozier, 1966; Stewart, 1964).
Other policy options discussed in the literature include the following:
- Increase the price of alcohol through taxation (Moore & Gerstein, 1981). Many
western states have relatively low tax rates on alcohol. It is estimated that a 33.6
percent increase in price would result in an 11 percent to 32 percent decline in alcohol
consumption (U.S. Surgeon General, 1989). However, reducing availability of alcohol
through price can also have the unintended result of increasing the use of alternative and
more toxic substances such as hair sprays, solvents, and inhalants (Beauvais et al.,
1985b; Oetting & Beauvais, 1989).
- Reduce the number of establishments licensed to sell alcohol and regulate the type and
location of licenses issued. For example, alcohol sold in bars has generally been found to
produce more cases of alcohol-impaired driving, yet alcohol sold in grocery stores results
in the lowest level of drinking and driving (O'Donnell, 1985).
- Ban or limit alcohol advertising. For many years, beer companies advertised heavily at
events such as powwows. Many American Indian communities are now refusing advertising from
beer companies, and powwows have generally become alcohol-free events.
There is a rich literature regarding approaches to policy that may provide useful
examples for American Indian communities (Blose & Holder, 1987; Colon, Cutter, &
Jones, 1981; Gliksman & Rush, 1986; MacDonald & Whitehead, 1983; Mosher &
Jernigan, 1989). For example, authors writing about non-Indian populations call for
policies to be instituted in a comprehensive, community-generated way that affects norms
and values (Institute of Medicine, 1989). Beauchamp (1980, 1990) advocates for improved
understanding of the epidemiological nature of alcohol use patterns and problems to
initiate new norms that are encouraging and less tolerant of alcohol abuse. Holder and
Stoil (1988), Moore and Gerstein (1981), and Pittman and White (1991) have compiled and
written extensive literature on policy approaches to alcohol abuse, some of which have
been evaluated and found effective. Non-Indian literature on policy-oriented primary
prevention is extensive and may inform health promotion among American Indians as well.
New approaches to community definitions and policy need to be further integrated into both
research and application in American Indian communities.
Although the potential for communitywide policy and normative change is immense,
implementing such change is treacherous and slow. As Gordis (1991) has pointed out, going
from science to social policy is an "uncertain road," highly affected by the
type of scientific evidence, cultural and social influences, timing, and many other
factors. Similar, or even greater, pitfalls have been recorded in many American Indian and
Alaskan native communities (Foulks, 1989; Levy & Kunitz, 1981; Manson, 1989; Moran,
1995). For example, one edition of the journal American Indian and Alaska Native Mental
Health Research was devoted to the pitfalls of an alcohol research and prevention
initiative in an Alaskan community. In this community, research on alcohol use patterns
and plans for prevention created tremendous misunderstanding and turmoil perceived as
frustrating, painful, and destructive. The purpose of this volume of the journal was to
solicit and print commentaries by established researchers and prevention professionals who
describe how such problems could be avoided in the future (Manson 1989). The conclusion
reached by the contributors was that it is vital for professionals working in alcohol
problem prevention in American Indian communities to be patient, culturally sensitive, and
responsive to local leaders and citizens alike (Beauchamp, 1980; Beauvais & Trimble,
1992).
Summary and Conclusion
As a group, American Indians experience many health problems that are related to
alcohol abuse. Alcohol-involved mortality data are worse for American Indians than overall
U.S. averages. The age of first involvement with alcohol is younger, the frequency and
amount of drinking is greater, and negative consequences are more common for American
Indian than non-Indian youths. The literature summarized in this chapter shows that
programs do attempt to promote health in the face of the problem of alcohol abuse among
American Indians. A theme emerging from this literature is that programs that address
these issues must consider American Indian heterogeneity as it is reflected in tribal
affiliation, cultural groups, language, and blood quantum. Prevention programs must also
consider the young age composition of the American Indian population and the observation
that most American Indian people live off, rather than on, reservations.
Programs implemented in American Indian communities must be designed to allow the
content to be shaped and molded to fit the local culture. Furthermore, programs must
assist people in their efforts at empowerment (Beauvais & LaBoueff, 1985). Prevention
programs can be initiated by outside "experts" working with tribal leaders, but
the continuation and entrenchment of the activities must be carried on by individuals in
the local community (Moran, 1995; Office of Substance Abuse and Prevention, 1990). This
requirement does not imply that programs designed for one tribe cannot be transferred to
others. Programs should be made relevant to local norms, values, and conditions through
particular, culturally sensitive adaptations (May & Hymbaugh, 1989). A comprehensive,
community approach to health promotion and alcohol abuse prevention must always keep the
issue of adapting to the specific culture in mind. Such an approach should focus on a
public health perspective. In a public health approach, the goal is to apply comprehensive
strategies and programs to reduce the rates of affliction and early death among total
groups and aggregates of individuals (Beauchamp, 1980). The focus should be on communities
and particular geographic areas and not on individuals. No single type of alcohol abuse
prevention should be championed, but rather various programs and approaches should be fit
or bound together in a mutually supportive and beneficial manner (May, 1992). Different
levels of prevention dealing with alcohol-involved behaviors should be used and
coordinated (Bloom, 1981; Manson, Tatum, & Dinges, 1982). For example, prevention
efforts must have plans to involve and strengthen the community and family. American
Indian families that are strong and well integrated produce children with better
indicators of adjustment and, in most cases, fewer indicators of deviance (Jensen, Stauss,
& Harris, 1977). Conversely, disorganized, multiproblem families have higher alcohol
use and more health and deviance problems (Lujan, DeBruyn, May, & Bird, 1989; Spivey,
1977). The various programs described in this chapter, then, are not mutually exclusive
but can be mutually supportive if orchestrated by a comprehensive communitywide plan and
approach. Any community will have to have prevention programs and standard health and AOD
treatment programs. Once the problems and priorities of a community are identified from
research, data analysis, and local wisdom, proper programs and approaches can be
established that draw heavily on the literature presented in this chapter.
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