Mental health promotion and substance misuse prevention among adolescents living on or near the Cherokee Nation Reservation: Investigation of protective factors Restricted; Files Only

Abstract

This dissertation uses a strengths-based approach to investigate mental health and substance misuse among adolescents living on or near the Cherokee Nation Reservation, which is of critical concern given the elevated rates of suicide and drug overdose among rural and Indigenous youth in the United States. The research is structured around three scientific papers (Chapters 2-4), each using theory to contribute unique insights to different aspects of the issue and interventions with potential to prevent escalating problems.

The first paper explores the implementation of Youth Mental Health First Aid (YMHFA) in rural area schools. Guided by the Consolidated Framework for Implementation Research (CFIR) and Relational Worldview Model, semi-structured interviews with YMHFA-certified instructors revealed 14 key themes and eight recommendations to improve implementation. Findings highlight the importance of strong community partnerships and recommend policy and operational changes to support future school-based implementation.

The second paper examines the role of social support and social norms in influencing adolescent substance use (n=919). Informed by the Theory of Triadic Influence and Integrated Behavior Model, the study found a complex interplay between social influences on alcohol and marijuana use, with variations by source. In Part A, regressions were used to test theory-informed hypotheses. In Part B, traditional regression (generalized estimating equations, GEEs) and targeted maximum likelihood estimation with ensemble machine learning (TMLE with SuperLearner) were used to estimate norm-stratified effects, plus t-tests to compare estimates.

The third paper uses Self-Determination Theory (SDT) to investigate motivations behind non-use of substances and the trajectories of subsequent use among adolescents with low to no reported substance use (n=360). Results showed that having positive people in one’s life as a motivation for non-use predicted reduced marijuana use and vaping at follow-up, and its protective effect on vaping diminished over time. Conversely, feeling bad predicted increased marijuana use at follow-up.

Overall, findings underscore the importance of strengthening community partnerships and positive social influences to enhance evidence-based interventions like YMHFA and the computer-based program. The selected theories provided valuable insights into the social context affecting rural and Indigenous youth, and implications for prevention are discussed.

Table of Contents

Chapter 1. Introduction 1

1.1. Overview and objectives 1

1.2. Deaths due to drug overdose and suicide among rural and Indigenous adolescents 5

1.3. Social determinants of adolescent mental and behavioral health 9

1.4. Theoretical orientation for risk and protective factors and levels of intervention 14

1.5. Advancing research to prevent substance misuse and promote mental health 18

1.6. Youth Mental Health First Aid as a promising intervention strategy 20

1.7. Social support and social norms 28

1.8. Trajectories of adolescent substance use and motivations for non-use 36

1.9. Rationale 43

1.10. References 45

Chapter 2. Youth Mental Health First Aid implementation in rural schools 73

2.1. Introduction 73

2.2. Methods 77

2.3. Results 79

2.4. Recommendations 94

2.5. Discussion 99

2.6. References 103

Chapter 3. Social support, norms, and substance use: Regression vs. TMLE with SuperLearner 110

3.1. Introduction 110

3.2. Methods 115

3.3. Results 121

3.4. Discussion 132

3.5. References 139

Chapter 4. Adolescent motivations for substance non-use and usage trajectories 150

4.1. Introduction 150

4.2. Methods 155

4.3. Results 159

4.4. Discussion  162

3.6. References 165

Chapter 5. Conclusion 171

5.1. Summary of findings 172

5.3. Strengths 181

5.4. Limitations 183

5.5. Implications for research, theory and intervention development, and policy and practice 184

5.6. Conclusion 186

5.6. References 188

Appendix I 194

Appendix II 197

Appendix III 213

About this Dissertation

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School	Laney Graduate School
Department	Behavioral Sciences and Health Education
Degree	Ph.D.
Submission	Dissertation
Language	English
Research Field	Health Sciences, Public Health Health Sciences, Mental Health
Keyword	adolescents prevention substance misuse Cherokee Nation rural communities mental health
Committee Chair / Thesis Advisor	Kelli A. Komro, MPH, PhD, Emory University
Committee Members	Ashley I. Naimi, PhD, Emory University Juli R. Skinner, MSW, Cherokee Nation Behavioral Health Melvin D. Livingston, PhD, Emory University Elizabeth Reisinger Walker, PhD, MPH, MAT, Emory University

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