Interventions for Health Promotion and Disease Prevention in Native American Populations (R01)
Research Project Grant
Specific Research Objectives and Scope by Institute
Each institute has specific areas of research interest. Investigators are required to view the following website http://cancercontrol.cancer.gov/nativeamericanintervention to identify topics of interest to each institute and encouraged to contact the program director before submission. Contact information is provided in the Agency Contacts section of the website. A brief summary of each institute’s interest is below.
National Cancer Institute (NCI)
Native American populations have the lowest 5-year cancer survival rate and highest percentage of disseminated and ill-defined cancers of any subpopulation in the U.S. Poorer cancer survival rates have been attributed to many factors, among them inadequate access to health care, geographic isolation, later stage of detection, underutilization of treatment, poverty, and social and cultural barriers.
The National Cancer Institute (NCI) is interested in applications that focus on both individual and community interventions relating to primary and secondary (screening) cancer prevention. It is important that researchers consider the context in which people live and develop interventions that can improve overall health and result in better health outcomes as they relate to cancer.
National Heart, Lung, and Blood Institute (NHLBI)
The National Heart, Lung, and Blood Institute (NHLBI) is interested in applications that evaluate interventions of health risk factors that contribute to cardiovascular and pulmonary morbidity and mortality including smoking, poor dietary intake, sedentary behavior, and hypertension and cholesterol screening and management. Evaluation of interventions that address multiple cardiovascular risk factors in a comprehensive program, especially in those at risk for cardiovascular disease, are particularly encouraged.
National Institute on Alcohol Abuse and Alcoholism (NIAAA)
The Burden of Alcohol use among Native Americans
In spite of estimates from 2007 that only about 50% of Native Americans (American Indians and Alaska Natives) report using any alcohol at all, they had the highest prevalence (12.1%) of heavy drinking (i.e., five or more drinks on the same occasion for 5 or more of the past 30 days) and binge drinking (29.6%). Estimates based on the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) showed that both male and female Native Americans had the highest rate of weekly heavy drinking. When considering only young people ages 18-24 who participated in NESARC, 70.7% exceeded the recommended daily level of drinking and 27.4% exceeded the weekly drinking limits. Exploration of age of onset of drinking from NESARC data found that more Native Americans (16.43%) reported starting drinking before age 15. The CDC (2008) reported that from 2001 to 2005, alcohol attributed deaths accounted for 11.7% of Native American deaths. Thus, when considering Native Americans as a whole, without examining within group differences, the epidemiologic data suggests a pattern of risky alcohol use including heavy, binging and early onset drinking.
It is important to note reports of distinct drinking patterns among Native Americans from different tribes and geographic backgrounds. Lifetime rates of alcohol dependence varied from 2-30% for females and 1-56% for males in the Ten Tribes Study. Others have found difference in both past year (4.5 versus 9.8%) and lifetime (9.8 versus 16.6%) alcohol dependence among Southwest Indians versus Northern Plains Indians. There are comparatively fewer reports of the prevalence of alcohol use disorders among Alaska Natives and Native Hawaiian, possibly due to sampling difficulties involving spread out but small populations. Nevertheless, there is considerable concern that overall they also might experience significant problems with alcohol use and abuse. These data have lead to increased interest on the part of the NIAAA as well as tribal and other Native American communities to address the health risks associated with heavy alcohol use and explore how to moderate the overall and individual patterns of drinking. NIAAA is interested in prevention and treatment intervention research that focuses on:
- Reducing high risk drinking and alcohol
- Promoting moderate drinking
- Postponing onset of heavy drinking among youth
- Avoiding any alcohol use among pregnant women
- Identifying culturally based risk and resilience factors that affect adoption of moderate alcohol use or abstinence
- Implementing and evaluating effective pharmacologic agents and behavioral therapies for the treatment of alcohol addictions
National Institute on Drug Abuse (NIDA)
The National Institute on Drug Abuse (NIDA) supports interventions to prevent the onset of drug use, prevent the escalation from drug use to abuse and dependence, and prevent the occurrence of drug-related HIV-risk behavior among American Indian, Alaska Native, and Hawai’i Native populations. Investigators should specifically aim to prevent drug use, drug abuse, and (as relevant) associated comorbid conditions including, but not limited to, HIV/sexually transmitted infections, child abuse and neglect, injuries, violence, and suicide. Drug abuse prevention research involving these outcomes and/or outcomes reflecting positive adjustment, such as educational achievement, is of interest to NIDA.
NIDA supports research across a broad range of disciplines to significantly improve prevention and inform policy. We encourage the development of novel, ground up prevention approaches and culturally adapted effective practices intended to support the prevention of drug use and its consequences. NIDA encourages research with regard to the unique prevention needs of individuals in urban and rural communities. Furthermore, NIDA encourages research that recognizes the distinctive prevention needs of individuals across the developmental spectrum as well as research that thoughtfully considers the role of sex and of the needs of LGBT populations in prevention interventions. Successful drug abuse prevention intervention efforts often target a variety of substances broadly; however, it is acceptable to address specific substances in cases where there are unique prevention strategies involved and/or specific community concerns. In either case theory-based approaches grounded in an understanding of community-level behavior change are essential.
National Institute of Environmental Health Sciences (NIEHS)
The National Institute of Environmental Health Sciences (NIEHS) is interested in interventions aimed to reduce the impact of environmental exposures on diseases and disorders among NA populations. In addition to testing impacts of interventions on exposure reduction, applicants also are encouraged to examine impacts on interim preclinical markers of disease when possible. Proposals may include, but are not limited to, projects focused on:
- Development and testing of culturally-sensitive health promotion strategies and interventions designed to educate tribal leaders and people about environmental hazards and encourage behavior change to reduce or eliminate exposure;
- Testing of existing low cost, sustainable methods for providing safe alternatives to contaminated drinking water and food and/or remediation of contaminated water, air and/or soil;
- Testing the impacts of policy-level decisions and interventions which are likely to influence environmental exposure levels and associated health outcomes;
- Development and testing of programs to train and build the capacity of community health workers and local health care professionals to assist tribal members in identifying unhealthy environments and/or environmentally-induced illness and ways to intervene.
National Institute of Mental Health (NIMH)
Burden of Mental Disorders and HIV/AIDS in Native American Communities
Mental Disorders: The CDC Health Disparities and Inequalities Report United States, 2011 indicates Native Americans (NA), experience disproportionately higher rates in comparison to the white population, on indicators such as psychological distress, death by suicide, and the percentage of adults who did not receive mental health counseling or medication treatments. In 2006, suicide was the second leading cause of death for American Indian/Alaska Natives (AI/AN) between the ages of 10 and 34; and violent deaths, unintentional injuries, homicide, and suicide accounted for 75% of all mortality in the second decade of life for Am/AN. Multiple factors contribute to the high rates of suicide among AI/AN populations, including individual-level factors (e.g., alcohol and substance misuse and mental illness), family or peer-level factors (e.g., family disruption or suicidal behavior of others), and societal-level factors (e.g., poverty, unemployment, discrimination, and historical trauma, which is defined as the cumulative emotional and psychological wounding across generations). There is a paucity of empirical data on the incidence and prevalence of mental disorders, pre-emptive and primary prevention tools, barriers to and facilitators of treatment-seeking, and course of treatment of mental disorders among the various NA populations, nationwide.
NIMH encourages research projects that: (1) Develop and test empirically informed preventive strategies and implementation approaches to support sustained use of science-based interventions; (2) Explore the expansion of science-based interventions that preempt or prevent mental disorders, including suicide; (3) Develop culturally appropriate interventions for increasing engagement in mental health services and linkage to care across Tribes and geographical regions; (4) Use mobile or IT interventions to increase use of evidence-based mental health care for individuals in hard-to-reach remote communities; (5) Explore which factors promote resilience and prevent mental disorders in persons at extreme social disadvantage to develop preventive intervention targets. NIMH strongly encourages the establishment of collaborative research partnerships which will provide the researchers of NA mental health, the capacity to investigate multiple units of analysis across domains/constructs that moderate intervention effects (e.g., stress, distress, cognition, social processes).
HIV/AIDS: Even though Native American (NA) HIV/AIDS cases comprise less than 1 percent of total cases in the U.S., NA communities are disproportionately impacted by the disease. NAs have a 40% higher rate of AIDS than non-Hispanic white Americans, and the AIDS rate among Native women is 2.8 times that of non-Hispanic white women. NA communities experience significant health disparities and face high rates of substance abuse and sexually transmitted infections, which increase the risk of HIV transmission. Several dimensions of the AIDS epidemic for NA groups are especially concerning including rapid progression from HIV infection to AIDS-defining illness and low survival rates after AIDS diagnosis is made. Additionally, many NAs, like other Americans, do not know that they are infected and are therefore more likely to spread the disease. Relevant factors that place these individuals at risk and present barriers to prevention include poverty, high rates of sexually transmitted diseases, substance abuse, violence, stigma, denial and concern about confidentiality in smaller reservation and rural communities.
Because HIV infection is a continuing health crisis in indigenous people, research on NAs has been identified as one of the overarching research priorities of the FY 2012 Trans-NIH Plan and Presidential By-Pass Budget, section on Reducing HIV-Related Disparities (http://www.oar.nih.gov/strategicplan/fy2012/index.asp). To reduce the impact of the HIV/AIDS epidemic among indigenous communities in the United States, NIMH/DAR-supported HIV/AIDS research in NA communities should have the following objectives: (1) Develop the HIV prevention intervention portfolio for gay men and other high-risk vulnerable individuals from indigenous communities; (2) Develop intervention programs based on mechanisms that explain HIV-related disparities (e.g., factors like stigma, social/sexual networks, access to and quality of health care, characteristics of health biology); (3) Identify core-elements of evidence-based interventions, develop and advance novel multilevel preventive interventions; examine promise of combination biomedical-behavioral interventions and treatment as prevention approaches; (4) Explore operations research to focus on barriers, facilitating factors, and outcomes of scaling-up HIV prevention interventions with known efficacy; and improve uptake and effectiveness of efficacious interventions. For these research objectives to be realized, it will be necessary to strengthen the workforce of HIV investigators from NA backgrounds through programs that develop a cadre of investigators in NIMH/DAR priorities (http://www.nimh.nih.gov/about/organization/dahbr/center-for-mental-health-research-on-aids/index.shtml), for indigenous scholars to nurture grant making skills in culturally-grounded HIV/AIDS research (e.g, Indigenous HIV/AIDS Research Training, IHART, http://depts.washington.edu/ihartp/index.php).
NIMH recommends, for both nonAIDS and AIDS, that applications that propose an adaptation to existing interventions should provide an empirical rationale for the need for and focus of the adaptation, consistent with NAMHC Workgroup Report recommendations on intervention adaptation (http://www.nimh.nih.gov/about/advisory-boards-and-groups/namhc/reports/fromdiscoverytocure.pdf) and consult with relevant Institute Program Staff.
National Institute of Nursing Research (NINR)
The National Institute of Nursing Research (NINR) is interested in interventions that promote and improve the health of individuals, families, communities, and populations. Specific topics that would be appropriate to this FOA and of interest to the NINR include, but are not limited to:
- Assess behavioral and social risk factors and responses to treatment, including the identification of biomarkers (e.g., neurohumoral markers for differential responses to behavioral interventions); identify susceptibility genes for such risk factors, and design interventions to moderate risk.
- Identify and develop individual and family interventions designed to sustain health-promoting behaviors over time (e.g., prevention of obesity; prevention of HIV/AIDS transmission).
- Design intervention studies using community-based approaches to facilitate health promotion/risk reduction behaviors (e.g., families with special needs, such as parents or caregivers of persons with chronic illness or developmental disabilities).
Elucidate mechanisms underlying health disparities and design interventions to eliminate them, with particular attention to issues of geography (rural and remote settings), minority status, underserved populations, and persons whose chronic or temporary disabilities limit their access to care.