A potential model of factors influencing alcoholism in American Indians
Krause, Traci M
Objectives and Methods: The impetus for this article was the need to compile information on American Indians and alcoholism. The objective of this paper was to conduct a review of the literature and examine which variables influence alcoholism in this population according to the published research. The second objective was to develop a model of possible factors that influence American Indians and alcoholism. The variables that were indicated as being significant in the review of the literature, were incorporated with the definition of alcoholism by the National Council on Alcoholism and Drug Dependence and the American Society of Addiction Medicine (Morse & Flavin, 1992).
Results and Conclusions:
The results are a brief synopsis of what was found during the literature review. In addition, a model was designed utilizing all the previously mentioned information. It is the hope of the author that this model might assist in guiding future research and interventions.
KEY WORDS Alcohol drinking; Alcoholism; Culture; Female; Indians, North American; Male; United States.
According to the U.S. Department of Health and Human Service, the United States federal government recognizes more than 500 American Indian and Alaska Native tribes. According to the 1990 census, approximately two million individuals classified themselves as American Indians and Alaska Natives (Cook & Petit de Mange, 1995).
PROBLEM AND PURPOSE
Alcoholism is a widespread problem among American Indians. Nationwide, American Indians suffered an accident mortality rate 2 + times higher than the US average. Much of this carnage can be attributed to alcohol impaired drivers- an estimated 75 percent of all accidental deaths within this population are alcohol related (Rhoades, Reyes, & Buzzard, 1987). The magnitude of actual causes of death that can be attributed to alcoholism can be difficult to measure. Alcohol-related deaths include such causes as cirrhosis of the liver, suicide, homicide, and diabetes mellitus, which are not classified as alcohol-related deaths in mortality statistics. According to the National Institute on Alcohol Abuse and Alcoholism, chronic liver disease and cirrhosis accounted for three times more deaths among American Indians than that found in the general population (Lamarine, 1989). This is a substantial number of people affected by alcoholism that could benefit from future nursing research and interventions.
The magnitude of alcoholism in the United States is cause for concern as, “Alcohol contributes to 100,000 deaths annually, making it the third leading cause of preventable mortality in the U.S., after tobacco and diet/ activity patterns” (McGinnis & Foege, 1993). The relationship between American Indians and alcoholism is very powerful. “95% of American Indian and Alaska Native families are either directly or indirectly affected by a family member’s abuse of alcohol” (U.S. DHHS, 1993). Alcoholism is a substantial public health threat to American Indians. Lamarine (1989) stated, “It is remarkable, in a morbid sense, that the segment of our population with the longest American lineage continues to enjoy some of the worst health in the nation.” The purpose of this paper is to present a model of factors influencing alcoholism in American Indians in order to provide a better understanding of the complexity of the problem.
DEFINITION OF ALCOHOLISM
It is can be a challenge for nurse to ascertain which theoretical model is a good fit with alcoholism and American Indians. The first required element is to determine a suitable definition for alcoholism. Alcoholism has been theoretically defined by a 1992, 23-member multidisciplinary committee of the National Council on Alcoholism and Drug Dependence and the American Society of Addiction Medicine. The committee conducted a 2-year study of the definition of alcoholism in the light of current concepts (Morse & Flavin, 1992). Their goal was to create by consensus a revised definition of alcoholism that was (1) scientifically valid, (2) clinically useful, and (3) understandable by the general public. The definition is as follows:
Alcoholism is a primary, chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. The disease is often progressive and fatal. It is characterized by continuous or periodic: impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking, most notably denial. (Morse & Flavin, 1992) The revised definition recognizes alcoholism as a heterogeneous disease (that is, biopsychosocial factors are implicated in the causes, signs and symptoms, complications, and treatment of alcoholism). It also acknowledges a genetic vulnerability in the evolution of alcoholism in many alcoholics; and, for the first time, formally incorporates denial as a major concept (Morse & Flavin, 1992).
FACTORS INFLUENCING ALCOHOLISM IN AMERICAN INDIANS
After a thorough review of the literature, it became apparent that certain variables frequently emerged as having a possible relationship to alcoholism. Interestingly, the area of genetics as it relates to American Indians and alcoholism has been all but ignored. A”Medline” search from 1966 to present elicited zero articles using the combined keywords of alcoholism, genetics, American Indians or Native Americans. A search of “CINAHL” subsequently had the same results. Three articles were found in a “HealthSTAR” search from 1975 to present. One article discussed the possible relationship between alcohol dehydrogenase (ADH) polymorphisms among 95 Mission American Indians. The study found that 12 American Indians were heterozygous for ADH2*3, an allele previously identified only in persons of African descent, although none of the study participants had African ancestry. The final point of the article was the need for additional research into these genes to provide an increased understanding of the likely polygenic contributions to alcohol-related disorders in the American Indian population (Wall, Garcia-Andrade, Thomasson, Can, & Ehlers, 1997).
Two additional articles focused on the relationship between the possible genetic connection of family history to alcoholism in American Indians in Colorado and California (Gill, Elk, & Deitrich, 1997; Wall, Garcia-Andrade, Thomasson, Cole, & Ehlers, 1996). Gill et al. (1997) found that 60.6% of their American Indian study participants had at least one alcoholic parent and only 11.1% had no primary or secondary alcoholic family members. A second study on the topic of familial associations suggests that given the high prevalence and family history of alcoholism among American Indian populations, evaluation of alcohol metabolism and genotypes of the alcohol-metabolizing enzymes in this population merits further study (Wall, Garcia-Andrade, Thomasson, Cole, Ehlers, 1997).
Analysis of a number of articles about American Indians and alcoholism suggested that various demographic variables including sex, age, household composition, marital status, employment, ability to speak the tribal language, and tribal affiliation were important in their relationship to alcoholism (Barker & Kramer,1996; Lowe, Long, Wallace, & Welty,1997; Robin, Chester, Rasmussen, Jaranson, & Goldman, 1997). Cheadle, Pearson, Wagner, Psaty, Diehr, and Koepsell (1994) looked at several demographic variables: age, sex, employment, marital status, education, and income and their relationship to health behaviors, which included alcoholism, in the form of questions about drinking and driving, and role models use of alcohol. They found that “alcohol abuse can only be partly explained by the relative poverty, unemployment, and lack of education among American Indians living on reservations” (Cheadle et al., 1994).
Grossman, Krieger, Sugarman, & Forquera (1994) looked at ethnicity and alcohol consumption and found 20.1% of urban American Indians consumed alcohol on a regular basis compared to 6.2% of the white population and 11.0% of the African American population. This was compared to 16.2% for rural American Indians (Grossman, Krieger, et al., 1994). Gilliland, Becker, Samet, & Key (1995) found that in New Mexico, a sample of American Indians had the highest rates of alcohol-related mortality for both sexes.
Gender was found to be significant in its relationship to alcoholism (Barker & Kramer,1996). More women than men and more people 60-plus years of age abstained from alcohol (Barker & Kramer, 1996). Robin et al. (1997) found that gender played a role in alcoholism and treatment as 41.1% of the males and 18.8% of the females reported treatment for substance abuse in a Southwestern United States American Indian sample. 81.8% of the males were found to be heavy alcohol users compared to 61.4% for females in an American Indian group from rural South Dakota (Lowe et al., 1997).
Much of the literature referred to relationships between alcohol intoxication among American Indian drivers and motor-vehicle crashes. A number of studies focused on alcohol use and its relationship to automobile accidents (CamposOutcalt, Prybylski, Watkins, Rothfus, & Dellapenna, 1997; Chang, Lapham, Barton,1995; Grossman, Sugarman, Fox, & Moran, 1997; Landen, 1997; Sugarman, Warren, Oge, & Helgerson, 1992).
In Grossman et al. (1997) the relationship between being American Indian or non-American Indian and driver impairment was looked at in relationship to a number of variables including location of crash: rural vs. urban. This study found that rural motor-vehicle crashes were more likely to have driver impairment in American Indian populations (Grossman et al., 1997). This is a significant finding when considering interventions for a rural population, and may have a relationship to the “unique legal environment of the Indian reservation” (Grossman et al., 1997). This theme was also apparent in another study that looked at tribal alcohol legislation and alcohol-related mortality and attempted to answer the question, “Are alcohol-related mortality rates lower on reservations where alcohol was legal than where it was prohibited” (Landen, 1997). The article did not find a concrete answer of the better option between the two alcohol policies, but the study was limited by confounders such as the level of enforcement of tribal alcohol legislation which made drawing any concrete conclusions difficult (Landen, 1997).
Geographical region was also investigated and its relationship to drinking and driving, defined as a person who reports driving after perhaps having too much to drink (Sugarman et al., 1992). This study found that the Plains states had the highest percentage of drinking and driving among American Indians (Sugarman et al., 1992). Sugarman et al. (1992) also found that seatbelt non-use was highest among American Indians in the Plains states, as well as heavy drinking (5 or more drinks on at least one occasion during the preceding 4-week period).
A number of studies examined the relationship between American Indians and blood alcohol concentrations (CamposOutcalt et al., 1997; Chang et al., 1995; Lapham, Skipper, Owen, Kleyboecker, Teaf, Thompson, & Simpson, 1995; Sugarman & Grossman,1996). Sugarman & Grossman (1996) focused on American Indian admissions to a Level I trauma center in King County, Washington. This retrospective analysis found that 72.3% of the American Indian trauma admissions tested at the hospital had blood alcohol levels exceeding 0.1%. Chang et al. (1995) found that American Indian offenders, arrested for driving while intoxicated (DWI), had high blood alcohol concentrations with 50% of male offenders exceeding 0.16 g/dL. Lapham et al. (1995) reported that American Indian DWI offenders generally had higher test scores on alcoholism screening instruments. Campos-Outcalt et al. (1997) found that in Arizona among motor vehicle crash fatalities, American Indian occupants and pedestrians had the highest levels of blood alcohol concentration at >.20 g/dL, ranging from 41.4% for American Indian occupants vs. 15.4% for non-Indian occupants, and 60.2% for American Indian pedestrians vs. 20.9% for non-Indian pedestrians.
When considering interventions and research with an American Indian population cultural factors must be taken into consideration. “Nurses need to consider the traditional beliefs of Native Americans and other indigenous populations when planning care, especially in the treatment of alcoholism” (Wing & Thompson, 1995). This article also makes the point that, “A challenge facing nurses is how to provide culturally sensitive care when clients’ and nurses’ beliefs about the cause of alcoholism may be in conflict” (Wmg & Thompson, 1995). The need for culturally sensitive research is imperative to a successful working environment with American Indian populations. “Some of the cultural factors to be considered are: health beliefs; spirituality; social, gender, and age roles; tribal organizational differences; and difference in conceptualization of time. Also potentially problematic are differences in language, dialect, and interpersonal communication styles” (Cook & Petit de Mange, 1995).
MODEL FOR EXAMINING RELATIONSHIPS BETWEEN ALCOHOLISM AND AMERICAN INDIANS
In this area, it is interesting to note that there seems to be no theoretical model to address the association of possible factors related to alcoholism in American Indians (Model 1). Because of this gap in the knowledge the need to develop a preliminary model was apparent. This preliminary model may be used as a guide to facilitate future research into the subject area. The model was designed to incorporate the variables found to be important during the review of the literature with the definition of alcoholism (Morse & Flavin, 1992).
All the variables found to be statistically significant during the review of the literature were placed in the model. The variables are connected to “ALCOHOLISM” by solid lines, which indicate that there is a possible relationship. The variables are also connected to each other with solid lines to indicate possible relationships among the variables. These variables are placed under four broad categories. Three of the categories are from the definition of alcoholism: genetic, psychosocial, and environmental (Morse & Flavin, 1992). The fourth broad category of culture was added, as this is highly relevant to the study of alcoholism in American Indians. The variables are arranged under the four broad categories to indicate that they may fall under one or more of the broad categories. An example of this is the variable “Ability to Speak Native Language,” which may be both “Environmental,” and related to “Culture.” The precise relationships between the variables and the four broad categories are for future research to discover.
Also incorporated into the model were the three continuous or periodic outcomes of alcoholism mentioned in the alcoholism definition (Morse & Flavin, 1992). These outcomes include impaired control over drinking, preoccupation with the drug alcohol despite adverse consequences, and distortions in thinking, most notably denial (Morse & Flavin, 1992). The solid arrow lines from the word “ALCOHOLISM” to the three outcomes indicate possible outcomes of alcoholism on American Indians.
Taking into consideration all the previously mentioned factors, the end result was the “Model of Possible Factors Influencing American Indians and Alcoholism.” This model should be considered a work in progress and speaks only to possible relationships and possible outcomes as suggested by the literature and the 1992 definition of alcoholism (Morse dc Flavin).
THE MEASUREMENT INSTRUMENTS FOR ALCOHOLISM IN AMERICAN INDIANS
The most effective way to screen for alcoholism is through the use of an instrument. Four commonly used screening instruments for alcoholism: the CAGE, the Michigan Alcoholism Screening Test (MAST), the Self-Administered Alcoholism Screening Test (SAAST), and the Short Michigan Alcoholism Screening Test (SMAST) are often cited in the literature (Davis, Hurt, Morse, & O’Brien, 1987; Mayfield, Mcleod, & Hall, 1974; Selzer, Vinokur, & van Rooijen, 1975; Zung, & Charalampous, 1975). It is important to have some basic background knowledge of these oft-used instruments and to take a brief look at how effectively they measure the components of the model. Caution must be taken when examining the instruments and their fit to the “Model of Possible Factors Influencing American Indians and Alcoholism,” as the components of the model measured by the instruments is only this author’s opinion, and have not been tested.
The CAGE is a 4-item instrument developed in 1970 by J. A. Ewing and B. A. Rouse (Mayfield, McLeod, & Hall, 1974). The phi coefficient of correlation for a true dichotomy was used for a correlation coefficient of 0.89 for a 2 out of 4item positive response (Bush, Shaw, Cleary, Delbanco, & Aronson, 1987). Two affirmative answers should alert the interviewer to a high likelihood of the presence of alcoholism (Ewing, 1984). When applying the CAGE screening tool to the model the tool predominantly measures variables in the broad categories of genetic and psychosocial. The CAGE does not address areas under the categories of environmental and culture. The CAGE also measures alcoholism variables that would fit under the first two continuous or periodic outcomes of the model: impaired control over drinking and preoccupation with the drug alcohol despite adverse consequences. The instrument does not address the third outcome: distortions in thinking, most notably denial.
The Michigan Alcoholism Screening Test
M. L. Selzer developed the Michigan Alcoholism Screening Test (MAST) in 1967 (Zung & Charalampous, 1975). The test consists of a 25-item weighted scoring criterion, with a score of 7 or more indicating alcoholism (Zung & Charalampous, 1975). The MAST has a reliability coefficient alpha of 0.95 (Zung & Charalampous, 1975). The MAST screening tool predominantly measures items in three of the four broad categories of the model: environmental, genetic, and psychosocial. To a limited degree the MAST also measures some factors under the category of culture. The MAST addresses culture with such questions as: have you ever attended a meeting of Alcoholics Anonymous (AA) and have you ever gone to anyone for help about your drinking (Selzer, Vinokur, & van Rooijen, individuals belief systems to some extent. Like the CAGE, the MAST measures the first two continuous or periodic outcomes, but does not address the third outcome.
The Self-Administered Alcoholism Screening Test
W. M. Swenson and R. M. Morse developed the SelfAdministered Alcoholism Screening Test (SAAST) in 1972 as a modification of the Michigan Alcoholism Screening Test (MAST) at Mayo Clinic (Hurt, Morse, & Swenson, 1980). This instrument is a 35-item yes-no format used to assess the presence of alcoholism (Davis et al., 1987). The KuderRichardson no. 20 for dichotomous items yielded a reliability coefficient of 0.81 for a total sample and 0.84 for an alcoholic sample (Swenson & Morse, 1975). The SAAST screening tool measures variables in three of the four broad categories of the model: environmental, genetic, and psychosocial. The SAAST does not address areas under the broad category of culture. Similar to the CAGE and the MAST, the SAAST measures alcoholism items that would fit under the first two outcomes of the model. It does not address the third outcome.
The Short Michigan Alcoholism Screening Test
All four instruments were looked for during the review of the literature with the search terms American Indian and Native American. The only instrument that the review of the literature cited for measuring alcoholism in an American Indian population was the Short Michigan Alcoholism Screening Test (SMAST) developed in 1972 by A. D. Pokorny, B. A. Miller, and H. B. Kaplan (Lowe, Long, Wallace, & Welty, 1997). In Lowe et al., the SMAST was used with an American Indian population. The SMAST is a shortened version of the Michigan Alcoholism Screening Test (MAST). A stepwise regression procedure was employed to select only those MAST items that significantly improved the prediction of the variable alcoholic or nonalcoholic (Selzer et al., 1975). A set of 10 items was selected by this statistical procedure (Selzer et al., 1975). The SMAST reliability coefficient alpha is 0.93 (Selzer et al., 1975).
Like the MAST, the SMAST screening tool predominantly measures items in three of the four broad categories of the model: environmental, genetic, and psychosocial. The SMAST, like the MAST, also measures some factors under the category of culture. The SMAST addresses the broad category of culture with the same questions as the MAST. The SMAST measures alcoholism items that fit under the first two outcomes of the model. The SMAST does not address the third outcome.
Conclusions regarding Instruments
All four screening instruments must be used with caution in an American Indian population. Testing of these instruments with an American Indian population to see which components of the model are actually measured by the instrument is necessary. Caution must also be taken with these instruments, as the area of culture tends to be ignored. The applicability of the third outcome of denial must also be measured to verify its suitability with an American Indian population.
Areas of Future Need
The lack of instruments to measure alcoholism in the American Indian population is an important future consideration. The existing tools highlighted previously need to be tested with diverse ethnic groups before their utility with minority populations can be established.
An additional area of concern is the lack of a clear-cut theory on alcoholism to guide practice in this field. This is especially evident as one looks specifically at the population of American Indians and discovers that there is no theoretical foundation to apply to this group. The aforementioned definition of alcoholism is also lacking a strong theoretical foundation (Morse & Flavin, 1992).
As previously mentioned, the area of genetics and alcoholism in American Indians requires research. One can theorize a connection between genetics and American Indians, but until such time as there is research to support this, it is nothing more than an unsubstantiated theory.
It is important to get a view of the bigger picture of alcoholism and American Indians. The newly developed model could serve as a starting point for development of additional research into this subject area. The model potentially gives direction to future research questions as one looks at the possible relationships and outcomes. Measurement tools and interventions could be designed utilizing various aspects of the model, which is based on a thorough review of the literature. The model has its limitations as it shows associations with alcohol, but these relationships have not been tested in an American Indian population. It is a complex issue in need of additional research.
Future Research in the Area of American Indians and Alcoholism
One article stated that “major aspects of the broader picture have yet to be investigated: abstainers, moderate drinkers, and women. One suspects there are valuable lessons waiting to be learned from Indian communities, if only the scope of the inquiry were broadened and different questions were asked” (Mail & Wright, 1989).
For nurse researchers as well as nurses working with an American Indian population it is important to keep in mind that the single most important obstacle in gaining entry to the American Indian community is the lack of a trusting relationship. Nurses working with American Indian populations must identify factors that facilitate trust in interactions with American Indians affiliated with various tribes (Cook & Petit de Mange, 1995). With this in mind, it is imperative that the nurse or researcher has a broad knowledge base of issues that are important to American Indians. “Alcoholism is viewed by both Native American and non-native service providers as the single greatest health problem on the reservation” (Cook & Petit de Mange, 1995). It is for the reasons detailed above that the area of alcoholism and American Indians warrants further study.
Barker, J. C., & Kramer, B. J. (1996). Alcohol consumption among older urban American Indians. Journal of Studies on Alcohol, 57,119-124.
Bush, B., Shaw, S., Cleary, P., Delbanco, T. L., & Aronson, M. D. (1987). Screening for alcohol abuse using the CAGE questionnaire. The American Journal of Medicine, 82, 231-235.
Campos-Outcalt, D., Prybylski, D., Watkins, A. J., Rothfus,
G., & Dellapenna, A. (1997). Motor-vehicle crash fatalities among American Indians and Non-Indians in Arizona, 1979 through 1988. American Journal of Public Health, 87, 282-285.
Chang, I., Lapham, S. C., & Barton, K. J. (1995). Drinking environment and sociodemographic factors among DWI offenders. Journal of Studies on Alcohol, 57, 659-668. Cheadle, A., Pearson, D., Wagner, E., Psaty, B. M., Diehr, P., & Koepsell, T. (1994). Relationship between socioeconomic status, health status, and lifestyle practices of American Indians: Evidence from a Plains reservation population. Public Health Reports, 109, 405-413. Cook, L. S., & Petit de Mange, B. (1995). Gaining access to Native American cultures by Non-Native American nursing researchers. Nursing Forum, 30, 5-10.
Davis, L. J., Hurt, R. D., Morse, R. M., & O’Brien, P. C. (1987). Discriminant analysis of the self-administered alcoholism screening test. Alcoholism: Clinical and Experimental Research, Il, 269-272.
Ewing, J. A. (1984). Detecting alcoholism the CAGE questionnaire. The Journal of the American Medical Association, 252, 1905-1907.
Gill, K., Elk, M. E., Deitrich, R. A. (1997). A description of alcohol/drug use and family history of alcoholism among urban American Indians. American Indian and Alaska Native Mental Health Research, 8, 41-52. Gilliland, ft D., Becker, T. M., Samet, J. M., & Key, C. R.
(1995). Trends in alcohol-related mortality among New Mexico’s American Indians, Hispanics, and non-Hispanic whites. Alcoholism, Clinical and Experimental Research, 19, 1572-1577.
Grossman, D. C., Krieger, J. W., Sugarman, J. R., & Forquera, R. A. (1994). Health status of urban American Indians and Alaska Natives: A population-based study. The Journal of the American Medical Association, 271, 845-850. Grossman, D. C., Sugarman, J.R., Fox, C., & Moran, J. (1997). Motor-vehicle crash-injury risk factors among American Indians. Accident Analysis & Prevention, 29,313-319. Hurt, R. D., Morse, R. M., & Swenson, W. M. (1980). Diagnosis of alcoholism with a self-administered alcoholism screening test. Mayo Clinic Proceedings, 55, 365-370. Lamarine, R. (1989). The dilemma of Native American health.
Health Education, 20, 15-18.
Landen, M. G. (1997). Alcohol-related mortality and tribal alcohol legislation. The Journal of Rural Health, 13, 38-44. Lapham, S. C., Skipper, B. J., Owen, J. P., Kleyboecker, K., Teaf, D., Thompson, B., & Simpson, G. (1995). Alcohol abuse screening instruments: Normative test data collected from a first DWI offender screening program. Journal of Studies on Alcohol, 56, 51-59. Lowe, L. P., Long, C. R., Wallace, R. B., & Welty, T. K. (1997). Epidemiology of alcohol use in a group of older American Indians. Annals of Epidemiology, 7, 241-248. Mail, P. D., & Wright, L. J. (1989). Point of view: Indian sobriety must come from Indian solutions. Health Education, 20, 19-22.
Mayfield, D., McLeod, G., & Hall, P. (1974). The CAGE questionnaire: Validation of a new alcoholism screening instrument. American Journal of Psychiatry,131,11211123.
McGinnis, & Foege, W. (1993). Actual causes of death in the United States. The Journal of the American Medical Association, 270, 2208.
Morse, R. M., dE Flavin, D. K. (1992). The definition of alcoholism. The Journal of the American Medical Association, 268, 1012-1014.
Regional differences in Indian health, (1993). Washington, DC: US Dept. of Health & Human Services. Rhoades, E. R., Reyes, L. L., & Buzzard, G. D. (1987). The organization of health services for Indian people. Public Health Reports, 102, 352-356.
Robin, R. W., Chester, B., Rasmussen, J. K., Jaranson, J. M.,
& Goldman, D. (1997). Factors influencing utilization of mental health and substance abuse services by American Indian men and women. Psychiatric Services, 48, 826-832.
Selzer, M. L., Vinokur, A., & van Rooijen, L. (1975). A selfadministered short Michigan alcoholism screening test (SMAST). Journal of Studies on Alcohol, 36, 117-125. Sugarman, J. R., & Grossman, D. C. (1996). Trauma among American Indians in an urban county. Public Health Reports, 111, 321- 327.
Sugarman, J. R., Warren, C. W., Oge, L., & Helgerson, S. D. (1992). Using the behavioral risk factor surveillance system to monitor year 2000 objectives among American Indians. Public Health Reports, 107, 449-456. Swenson, W. M., & Morse, R. M. (1975). The use of a self
administered alcoholism screening test (SAAST) in a medical center. Mayo Clinic Proceedings, 50, 204-208. Wall, T. L., Garcia-Andrade, C., Thomasson, H. R., Carr, L. G., & Ehlers, C. L. (1997). Alcohol dehydrogenase polymorphisms in Native Americans: Identification of the ADH2*3 allele. Alcohol and Alcoholism, 32, 129-132. Wall, T. L., Garcia-Andrade, C., Thomasson, H. R., Cole, M., & Ehlers, C. L. (1996). Alcohol elimination in Native American Mission Indians: An investigation of interindividual variation. Alcoholism, Clinical and Experimental Research, 20, 1159-1164. Wing, D.M., & Thompson, T. (1995). Causes of alcoholism: A qualitative study of traditional Muscogee (Creek) Indians. Public Health Nursing, 12, 417-423. Zung, B. J., & Charalampous, K. D. (1975). Item analysis of the Michigan alcoholism screening test. Journal of Studies on Alcohol, 36, 127-132.
Traci M. Krause, RN, BSN, MSN/MPH Degree Candidate, The Johns Hopkins University, Baltimore, Maryland.
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