Health Survey of Two-Spirited Native Americans

This application, in response to PA-01-096, is for a FIRST TIME R01 by a NEW INVESTIGATOR. Building upon solid preliminary data, it proposes three innovative and significant aims. First, we will conduct structured survey interviews with 400 two-spirits drawn from six sites across the U.S. With these interview data, we will test a theoretical model of stress and coping specific to this population. Sub-aims are to (a) establish preliminary prevalence rates of trauma and health outcomes (i.e., HIV sexual risk behaviors, alcohol and other drug use, and mental health indicators); (b) test the direct associations between trauma and health outcomes; (c) determine how cultural and spiritual coping factors moderate the effect of trauma on health outcomes; and (d) examine the mediating role of substance use on the trauma-HIV sexual risk behavior and trauma- mental health relationships. The second aim is to test the feasibility of an innovative non-probability sampling methodology that combines targeted, partial network, and respondent-driven sampling procedures in order to approximate a representative national sample of two-spirits. Additionally, we will test the feasibility of two different mechanisms (agency based vs. census based) by which we execute this sampling method. Our results will contribute toward the refinement of a sampling strategy useful in studying other hidden and stigmatized populations. Our third and final aim is to conduct a qualitative study involving 12 focus groups and 60 key informant interviews in order to identify emergent themes regarding stressors and coping strategies specific to two-spirits. Through the course of this project, we aim to develop the research infrastructure at the six community agencies comprising our participant recruitment sites. With this structure in place, we can fulfill our post-project goals of devising interventions to address the needs of two-spirits, testing them with R21-funded projects at the individual sites, with the eventual aim of conducting multi-site R01-funded trials interventions based on the cumulative knowledge from this line of research. To ensure the successful fulfillment of each aim, the PI has drawn upon the excellent research resources and facilities of the University of Washington and assembled a team of mainly AI national experts to serve as co-investigators and consultants, each with expertise in at least one aspect of the project and many with experience specifically with AI populations.

Specific Aims

1. To test a theoretical stress-coping model of the relationships among trauma, coping, and health outcomes via a survey study of 400 urban two-spirits systematically recruited from six sites across the U.S. Specifically, we will examine trauma (i.e., historical trauma, discrimination, traumatic life events, physical and sexual assault in childhood and adulthood) and coping practices that include cultural (i.e., identity attitudes, enculturation) and spiritual components (i.e., spiritual coping, traditional healing practices). The health outcomes we will study include HIV sexual risk behaviors (i.e., consistency of condom use, unsafe sex with high risk partners); substance use (i.e., alcohol, injection drugs, club drugs, other illicit substances, alcohol-sex expectancies); and mental health (i.e., PTSD, anxiety, depression). Specifically, using the survey data, we aim:

a. To establish preliminary prevalence rates of trauma and health outcomes.
b. To examine the direct associations between trauma and health outcomes.
c. To examine how coping factors moderate the effect of trauma on mental health outcomes.
d. To examine the mediating role of substance use on the trauma-mental health relationship and the trauma-HIV sexual risk behavior relationship.

2. Test the feasibility of a mixed sampling methodology utilizing targeted, partial network, and respondent driven sampling strategies in order to approximate a somewhat representative sample of two-spirits in the U.S. Our results will contribute toward the refinement of a sampling strategy that will be an important tool for the study of other hidden and stigmatized populations. We will test the feasibility of conducting a census strategy at one site as well.

3. To conduct a qualitative study involving 12 focus groups and 60 key informant interviews with two-spirits in order to examine coping strategies, resilience, racial and two-spirit identity statuses, stigma management, and disclosure, as well as other themes pertinent to two-spirit HIV risk prevention, substance use and mental health. The focus groups will provide qualitative information on the cultural equivalence of standardized measures and will be used for pilot testing and refining the relatively new measures of historical trauma and discrimination