Mental health, family functioning, and sleep in cultural context among American Indian/Alaska Native urban youth: A mixed methods analysis

https://doi.org/10.1016/j.socscimed.2021.114582Get rights and content

Highlights

  • Narratives show family cohesion through family traditional practice.

  • Narratives show role family cohesion plays in sleep, e.g., stable sleep environment.

  • Better family functioning had direct effect on less depression and anxiety.

  • Better family functioning had indirect effects through lower sleep disturbance.

  • Cultural identity was not a significant moderator in the tested pathways.

Abstract

Mental health problems contribute significantly to the global burden of disease. Driven in part by family stressors and insufficient sleep, mental health disproportionately affects low SES urban adolescents. In the United States, American Indian/Alaska Native (AI/AN) youth exhibit excessively high rates of mental health problems. Family functioning is strongly associated with adolescent mental health, and sleep problems may serve as a pathway between family functioning and mental health. Using mixed methods we examine the associations among family functioning, subjective- and actigraphy-measured sleep, mental health (depressive and anxiety symptoms), and cultural identity in a sample of urban AI/AN youth. All participants (N = 142) completed surveys; a random subsample (n = 26) completed qualitative interviews to assess family and cultural dynamics related to sleep, which informed hypothesized direct and indirect effects that were tested using survey data. Narratives identified mechanisms of family cohesion (e.g., daily interactions that build perceived family togetherness and family-centered traditional activities) and the role that family cohesion plays in sleep (e.g., ensuring stability of sleep environments). Path analysis showed direct effects of improved family functioning on fewer depressive and anxiety symptoms, and indirect effects through lower self-reported sleep disturbance (but not through greater actigraphy-measured sleep duration or efficiency). Cultural identity did not moderate effects in quantitative tests. Our findings illustrate the complex associations among family functioning, sleep, and mental health in AI/AN youth. Family-based interventions to improve adolescent mental health should address modifiable intervention targets such as sleep, and address sources of both risk and resilience relevant to urban AI/AN families, including extended family and cultural practices.

Introduction

Mental health problems contribute significantly to the global burden of disease (Reijneveld, 2005), with half of all mental health conditions beginning in adolescence (Kessler et al., 2007). Insufficient sleep is a core driver of adolescent mental health, often underrecognized as a public health epidemic, but with serious health and social consequences (Chattu et al., 2018). Evidence suggests that, worldwide, adolescent urban dwellers are at an increased risk for sleep and mental health problems, accentuated by poverty, low social capital, and other characteristics of urban environments that are experienced in the home environment and family context (Murphy et al., 2020; Rudolph et al., 2019). To address such problems, there have been calls for family-focused public health efforts, acknowledging the role of family context for many health outcomes (Hanson et al., 2019). There may be important lessons to learn about critical opportunities to intervene to effect change in mental health outcomes among vulnerable urban populations.

In the United States, urban American Indian/Alaska Native (AI/AN) youth experience disproportionately high rates of mental health symptoms. For example, compared to other racial/ethnic minorities and non-Hispanic White adolescents, AI/AN adolescents report more depressive symptoms and generalized anxiety (Serfaini et al., 2017). Furthermore, the suicide rate among AI/AN youth and young adults is 1.5 times higher than the national average (Centers for Disease Control, 2017). These disparities are related to European contact, forced relocation, and cultural genocide, leading to widespread traumatic experiences and unresolved grief across generations (Brave Heart and DeBruyn, 1998). Moreover, approximately 70% of all AI/ANs reside in urban locations far from reservations or tribal lands, and face additional psychosocial and environmental stressors, such as lack of social cohesion and exposure to poverty, that may put them at further risk for mental health problems (U.S. Census Bureau, 2010).

In the current paper, we focus on two distinct but related dynamics that are associated with adolescent mental health. First, family functioning – that is, family interactions and relationships, including conflict, cohesion, structure, and communication (Lewandowski et al., 2010); adolescents in well-functioning families report better mental health outcomes, including less depression and anxiety (Scavenius et al., 2019). Second, sleep problems often occur during adolescence due to irregular sleep-wake schedules (Carskadon, 2011), and are a significant contributor to adolescent mental health (Zhang et al., 2018; Hysing et al., 2020). Moreover, poorer family functioning (Schmeer et al., 2019; Blackham et al., 2019) and lower quality parent-adolescent relationships (Haines et al., 2016) are also associated with sleep problems. Despite high rates of mental health problems among AI/AN youth, no studies to date have examined sleep as a potential mediator of the impact of family functioning on mental health.

In general, there are limited data on how challenges related to cultural disruption influence mental health among urban AI/AN families and youth (D'Amico et al., 2019). Urban AI/AN people emphasize that it is often very difficult to be culturally connected given the dispersion of the population and the limited resources (Kulis et al., 2016). Culture can be protective for sleep health (Worthman and Brown, 2007); however, no studies have assessed whether AI/AN culture may play a role in the relationship between family functioning and sleep, and ultimately on mental health. The current study adds to the literature by examining family functioning and sleep in relation to mental health among urban-dwelling AI/AN youth.

Section snippets

The role of biopsychosocial and contextual factors

One theoretical framework that is key to understanding the complex interplay between family functioning, sleep, cultural identity, and mental health and draws from a developmental psychopathology framework: the biopsychosocial and contextual paradigm (Becker et al., 2015; Porter, 2020). In this paradigm, domains of overall health, such as mental health and sleep, are intertwined (through reciprocal relationships) with a range of biological, psychological, social, and contextual factors (Becker

Overview

We analyzed data from 142 urban AI/AN youth using an integrative mixed methods approach (Palinkas et al., 2019) to examine pathways among family functioning, sleep, and behavioral health within a cultural context. In step one, we analyzed in-depth interviews and compared themes with our descriptive survey data on similar topics; this approach is known as complementary mixed methods analysis (Palinkas et al., 2019). In step two, we used narrative findings from qualitive interviews to formulate a

Stage 1: qualitative data analysis and complementary survey analysis

The first stage of analysis involved analyzing family functioning themes from our qualitative data and comparing these findings with similar questions from our survey data. First, we uploaded transcripts to Dedoose, a team-based collaborative software platform for qualitative data management, analysis and interpretation (Dedoose, 2019). Our qualitative analysis built on a previous study with the same data set (Palimaru et al., 2020). The previous study examined all aspects of sleep among AI/AN

Demographic characteristics and other descriptive information

Table 1 contains participant demographic characteristics for both qualitative and quantitative samples, showing that the two samples were comparable, except for sex: 54% of interviewees were male in the full sample versus 41% in the qualitative sample. Overall, youth were aged 12–16 (mean = 14.03 years, SD = 1.37 years). All parents identified their participating adolescent child as having AI/AN heritage, and 92% of youth identified as AI/AN, which is consistent with other work in this area (

Discussion

This study addresses several critical gaps in the literature by furthering our understanding of the role of family cohesion and conflict on mental health in urban AI/AN youth. We used an integrative mixed methods approach to examine family functioning and sleep in relation to mental health among urban-dwelling AI/AN youth in the context of cultural identity. To the best of our knowledge, this is the first study to examine these issues in AI/AN populations using both subjective and objective

Conclusions

This study provides an important look at the pathway between family functioning and mental health among AI/AN adolescents, and how sleep and cultural context contribute to these associations. In qualitative interviews, adolescents emphasized distinct aspects of family cohesion, including daily interactions that build a sense of family togetherness, discussions about AI/AN identity, and family-centered traditional activities. Our analysis indicated that better family functioning (i.e., greater

Credit author

Alina I. Palimaru, PhD MPP: formal qualitative and mixed methods analysis; Investigation; Writing – original draft; review and editing. Lu Dong, PhD: formal quantitative analysis; Investigation; Writing – original draft; review and editing. Ryan A. Brown, PhD MA: Formal analysis; Investigation; Methodology; Writing – original draft; review and editing. Elizabeth J. D'Amico, PhD MA: Conceptualization; Data curation; Funding acquisition; Project administration; Supervision; Investigation; review

Author note

This work was funded by a grant from the National Institute on Minority Health and Health Disparities (R01MD012190; MPIs: Troxel, D'Amico, and Dickerson). We thank Jennifer Parker, Keisha McDonald, and the RAND Survey Research Group for their help with this study.

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