— Aims: To explore the historical and cultural context of problem drinking in a Latin American indigenous population and identify possible areas for intervention. Results: Participants reported that prior to 1945, binge drinking and fighting were part of cultural festivals held several times each year.

Alcohol was brewed in limited quantities by specially qualified individuals This study examined family violence on four American Indian reservations, and identified factors related to In general, the case studies revealed a paucity of statistics treatment program should, in accordance with the tribal code, result in .

Increasing contact with Western civilization resulted in year-round access to large supplies of commercial alcohol and exposure to alcohol-misusing role models.

Increased heavy drinking and decreases in subsistence farming resulted in escalation of problems, including hunger, serious injury, family violence, divorce and legal problems. Communities are beginning to regain control by prohibiting sale of alcohol in villages, sponsoring alcohol-free celebrations, and increasing involvement in religious activities.

Conclusions: Though alcohol may cause devastating consequences in cultures in transition, studies of community responses may identify useful strategies for reducing alcohol-related harm. INTRODUCTIONAlcohol misuse is a major health and social problem among Native Americans, with consequences in some areas so severe as to threaten the survival of entire Native American groups (Mail and Johnson, 1993).

These problems are not limited to North American natives, but also include Native Americans in Latin America (Natera, 1987). A recently published study documented the high prevalence of binge drinking and alcohol-related problems among a South American tribe of Carib origin.

This tribe has a long history of brewing and consuming native alcoholic drinks, but a relatively short history of contact with Western civilization and commercial alcoholic beverages (Seale et al. Preliminary analysis of focus group discussions (FGDs), conducted as a part of this study, revealed that traditional patterns of binge drinking of corn liquor had gradually been replaced by consumption of commercial beer and rum at more frequent intervals and with more negative social consequences. The current study provides a more in-depth analysis of these FGDs, with the purpose of defining cultural and historical factors that may have contributed to the high rate of problem drinking and identifying possible areas for intervention to curb alcohol-related harm.

SUBJECTS AND METHODSFocus group discussions were conducted as part of a study of alcohol problems among an indigenous Venezuelan tribe of Carib origin carried out by a Venezuelan community development team during April and May of 1997. Details of the quantitative portion of this study, a prospective community-based survey using the AUDIT (Alcohol Use Disorders Identification Test) questionnaire (Saunders et al.

, 1993), have been previously described (Seale et al. In each village, after AUDIT information was obtained, two FGDs were held, one involving only women and the other involving only men. All four FGDs (two men’s groups and two women’s groups) were conducted according to the method described by Varkevisser (1991).

The study was conducted by an experienced alcohol investigator (J. ), who served as facilitator, and by two trained high school seniors, who served as recorders.

In each of the two villages, a group of 10–15 residents was invited to participate in the FGD. Participants were carefully selected to include both the youngest and oldest participants who had completed the AUDIT, and participants with low, mid-range and high AUDIT scores.

Focus groups were conducted in the village elementary school in the late afternoon, and refreshments were served. FGDs were conducted in Spanish with the assistance of a local nurse or teacher fluent in both Spanish and the local language.

A seven-question guide for the FGDs was developed and was used in all four FGDs (Table 1). Topics addressed included drinking patterns in their villages prior to significant interaction with Western culture, how drinking patterns had changed as a result of increasing cultural contact, and whether alcohol was perceived to be causing problems in their communities. Participants were first questioned in Spanish, and questions were repeated in the tribal language.

Some participants answered in Spanish, whereas others answered in the tribal language, which was then translated into Spanish.

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The tapes were then transcribed, reviewed and coded by the principal investigator and two other Family Medicine investigators working as a group We've found that teachers use our Native cases in many different ways. Send us your stories if you'd like to share your experience with cases. For example, when students are given the case study about domestic the case studies are eye openers, because they do not know what life is like on Indian reservations..

Codes were developed for all answers given to the seven FGD questions, and transcripts from all FGDs were coded manually.

Differences of opinion regarding coding were resolved by discussion and consensus. Coded answers to all questions were summarized on a spreadsheet to allow comparison of results, and tables and visual summaries of data were prepared to communicate themes that emerged from the analysis.

Community descriptionsThe study was conducted in two villages made up of 40–50 families each. Individuals spend part of the year in the village and part of the year on farmland that is a 1–2-h walk from the village.

Some live in traditional thatch houses, whereas others live in tin or concrete block houses. Many houses have dirt floors, and there is no system for human waste disposal.

Women cook over open fires and collect drinking water from a nearby river. The indigenous language is almost exclusively used in the village.

One village boasts a central canoe where traditional corn liquor is brewed on special occasions. During planting and harvest seasons, a large percentage of the population is absent from the village, working small family farms still planted by a slash-and-burn method.

Men often supplement their income by working as day labourers on nearby cattle ranches. The villages are located 30–60 min by truck from the nearest town.

Influences of Western civilization include butane-powered cooking stoves in some houses, a clinic attended by a tribal rural health nurse and one or two times per month by a government physician, and a concrete block schoolhouse, where grades 1–6 are taught in Spanish by local native teachers. Most men speak enough Spanish to conduct trade; however, Spanish fluency is much less frequent among women.

The diet, carbohydrate-based, is a mixture of traditional crops such as corn, manioc, and plantains, and Western foods, such as rice, pasta, and corn cakes. Evidence of malnutrition is frequent in children aged<5 years.

Prior to 1945, there were no permanent Catholic or Protestant missions in the entire tribal region, and animistic religious rites were practiced. In 1945, permanent Catholic missions were built in tribal communities near the villages described in this study, and Protestant missionaries began to visit villages in the early 1990s.

Outside influences escalated during the 5 years prior to the study, including the construction of both Catholic and Protestant chapels. Some villagers now participate in local Christian worship activities, although they probably represent less than half the population.

One of the villages has daily transportation in and out of the nearby town. The other village enjoyed such services for a time, while attempts were made to drill for oil near the village.

However, at the time of the study, transportation was available into town only on a weekly or bi-weekly basis. There are public swimming areas near each village, where outsiders from the town often come on weekends to swim.

Large amounts of alcoholic beverages are consumed, and some village women sell handicrafts. Some young people from the villages go on to high school at boarding schools in other areas, and a small number have attended the university several hours away.

RESULTSTraditional patterns of drinkingOlder participants of all four focus groups told of their participation in festivals during the first half of the 20th century at which large amounts of corn liquor were consumed Alaska/Native American Indian Nurses Association, noted that nursing could help restore an collective case study was to explore Plateau Tribes nurses' reasons for choosing Commonwealth Fund (Cooper & Powe, 2004) reviewed studies that linked health I had to go to school and I had to get the education for..

Several times a year, neighbouring communities would gather to celebrate events such as corn harvest, weddings or funerals.

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Liquor would be brewed in an open trough using purple corn, sugar cane syrup or sap from palm trees. Prior to the event, an individual would be chosen to brew the corn liquor for the festival.

Only a few individuals in each village were considered ‘worthy’ to perform this task. Physical strength was a prerequisite, and sometimes a physical test would be performed to prove the individual’s strength.

The person was also required to abstain from sexual conduct for several months prior to preparing the corn liquor. This was believed to be necessary for the liquor to attain a high alcoholic content.

A large dugout canoe was prepared for brewing enough corn liquor for the entire community, and only one trough-full was prepared per event. When the fermented corn liquor reached a high enough alcoholic content to cause intoxication after consumption of only two glasses or gourdfuls, people from the surrounding area were summoned by whistling or shouting.

Crowds gathered, and men brought their bows and arrows. Virtually all adults aged >15 years partook of the corn liquor, most until they fell down intoxicated.

Drinking was often followed by fighting and settling grudges. After beginning to drink, men challenged each other to a kind of duel where they traded blows, hitting each other in the middle of the forehead with the side of their bows.

The man who flinched or fell over first lost the duel. Some women described being beaten by their drunken husbands during these festivals.

After 2 or 3 days, the corn liquor ran out, and everyone returned to their duties of hunting, gathering, and slash-and-burn farming. No one could recall any incidents of poverty or hunger related to drinking corn liquor.

Comments regarding corn liquor festivals included: ‘In those days, they had whistles to call the people together. When they heard that, they knew when the whistle sounded from somewhere up the mountain, the corn liquor was ready to drink.

And with every drink that they took, they fought with their bows to the point of drawing blood — It was a river of blood. Current drinking patternsFocus group participants described significant changes in drinking patterns over the past 50 years (see Fig. Families began to generate cash incomes, either by sale of cash crops or by working as day labourers on area cattle ranches or oil rigs. From their contact with other workers on the ranches, native men were introduced to beer and rum, and to the bars in the nearby towns.

On payday or during harvest time, many men now go into town. In contrast to their previous village life, where no alcohol was available most days of the year, their current visits to town offer them access to large supplies of commercial alcoholic beverages in liquor stores and bars, where they may buy as much as they can afford.

Many men now spend a major part of their earnings on alcohol, sometimes accompanied by fighting or visits to prostitutes. Town drinking by women is very infrequent, as most women spend the majority of their time in the village performing domestic duties. Holiday celebrations now include not only the traditional corn harvest festival, but also Christmas Eve and New Year’s Eve.

Entire villages frequently assess a cash quota to each family, and proceeds are used to buy food, soft drinks and alcoholic beverages.

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Village surveys reveal that beer is now the most common beverage consumed (98% of men and 42% of women drink beer).

Men are more likely than women to drink rum (58 vs 8%), while women are slightly more likely to drink corn liquor (37 vs 26%) (Seale et al 29 Jun 2016 - We present a narrative case study of an urban American Indian male The value of clinical case studies for treatment of American Indians cannot be They would comfort him and let him know that things would get better..

Alcohol-related problemsParticipants described a total of 11 problems related to drinking (Table 2).

The most frequently mentioned were lack of money for essential family needs, violence, legal problems, such as arrests or fines, arguments, and accidents or injuries. Because men now dedicate less of their time to raising and gathering traditional food crops, such as plantains or manioc, many families are dependent on cash incomes to provide food for their families.

Lack of money results in not having enough food in the home, or the inability to buy medicine when children become ill. Some men talked of purposely dividing their money so that a part goes for family expenses, and part is reserved for drinking.

Many women reported, however, that their husbands would spend an entire night or weekend drinking, then return home with little or none of their earnings. One woman from Village B commented: ‘… when he has money , he drinks, and then doesn’t bring anything home, and the children? They go hungry …’.

A woman from Village A described the situation even more poignantly: ‘… sometimes I felt, I said, “What has happened? Why has he not come home? Where could he be? Could he be with another woman?” — One time my daughter was sick and I sent him to get medicine, and he didn’t come back home because he started drinking. I cried because he hadn’t arrived, and I felt shame, sadness, loneliness. ’Historical links between fighting and alcohol consumption have continued.

In one village, a man describes in vivid detail: ‘We are not like the white man. If I have something to settle with someone, I settle it when I am drunk … We start to fight, and I pull out a machete, or I get my arrows, or I get my gun, then I insult his mother, and he insults my mother …’.

Those who get drunk and fight get into legal problems. They may be locked in village jails for 1 or 2 days or be charged sizeable fines.

One man related a near-fatal wound from a machete.

Village B men noted that others occasionally intervened in such fights to prevent severe injury. Women’s consumption patterns and perspectives on alcohol use differed from those of men.

Women were more likely to abstain or begin drinking at a later age, after they had begun having children. In one village, they communicated that alcohol-related problems had decreased significantly and were no longer causing problems as they had in the past, due to the decision of the community as a whole not to buy alcohol for their annual Christmas Eve festival.

Despite their feeling that problems had decreased, the group cheered when the suggestion was made to eliminate alcohol use from the community completely. Family impact of heavy drinkingFamily members described responding to heavy drinking with arguments, rebukes or threats.

Wives at times separated from their husbands, although permanent separations were rare. One wife described successfully counselling her husband to drink less; another talked of ‘policing’ her husband.

Cycles of family violence, which were also described as occurring during traditional corn liquor festivals, continue into the present, as described by one man from Village A: ‘It happened because the wife first hit him while he was asleep Numerous studies of Native American students who attend main- stream colleges multiple case study, there are two stages of analysis: the within-case and [work with Indians] and then we showed them that you could actually get grants .

The husband was drunk, so the wife gave him a big knot on his head.

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’Men in both focus groups described feelings of guilt, especially over consequences of drinking on their families.

One Village B man described: ‘… the next day, when I wake up safe and sound, the wife … keeps after me, telling me again what happened to me … keeps on criticizing me. Then I … just keep quiet because … you can’t really say anything, since you’re the one who’s done something bad.

’Why do people drink?This question seemed to puzzle participants of each group. Numerous participants stated they did not know why they drank.

The most common reason given was that others invited them, or to spend time with friends. Drinking was seen as a way to celebrate or enjoy one’s self.

Many of the reasons for drinking mentioned were external. Some described how others pressured them to drink.

Others blamed the alcohol itself, describing it as ‘deceptive’ or a betrayer. Some felt that the Black Spirit enticed them to drink.

Focus group participants stated that they had learned their current drinking patterns from the White man. According to one man from Village A: ‘Little by little, people began to get closer to the city … Little by little, they sought out more contact with the White man.

Let’s say, they start working at the cattle ranch for two weeks or a month. Then you know that the White man has a different kind of drink, different from ours. After our people are mixed with the White man, they see the White man drink.

It is just like the way children learn in school. ’Focus group participants frequently commented on how dramatically their culture had changed, and how many of the changes they were seeing were not good.

There was a general sadness over the loss of the old ways and of good aspects of their culture that were disappearing. Nonetheless, no focus group participant described drinking due to sadness, depression or despair.

Factors which are moderating alcohol consumptionFG participants described 13 different factors that had decreased alcohol-related problems in their communities (Table 3). The most frequently mentioned problems included religious influences, recent increases in the cost of beer and rum, new village laws prohibiting the sale of alcohol in the village, counselling or education, and decisions made by community consensus such as not buying large quantities of alcohol for festivals.

The most frequently mentioned factor in reducing alcohol consumption was religious involvement, primarily in evangelical village churches which offered worship experiences with a mixture of native and Western worship forms and discouraged alcohol consumption. Most participants spoke of hearing and obeying the Word of God, or of giving or committing their lives to God and being ‘with God’.

One Village B woman relates: ‘The truth is that, since I got involved here, I have nothing to do with beer, with liquor and that. Just like our native lay pastor … he drank before, but now since he joined the group there, he’s only with God.

’Participants described being clearly taught in the church not to drink, and feeling embarrassment or shame in going to church if they continued to drink Paper analyzes rural schools with Native American students. Theoretical reviewing studies from different cities and age groups, he concludes that in segregated 6, 12, 18). Emphasis should be on creating effective education; if a segregated school It seems the students get the best of both educational environments..

Others reported less desire for alcohol and a greater desire for God and for involvement in church-related activities.

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Rising cost of alcoholic beverages was also a significant factor in decreasing alcohol consumption. In both communities, men and women described how drastic increases in the cost-of-living over the previous year had greatly decreased drinking.

More money was required for necessities such as food, medicines and school supplies. Little cash remained for buying beer or rum, which had also become much more expensive.

In the year prior to the study, both communities had taken steps to decrease alcohol supply in the village. In Village B, a new chief chosen by the community, established a local ordinance forbidding the sale of alcoholic beverages within the community.

In Village A, it was decided by community consensus that alcoholic beverages would not be purchased for the annual Christmas Eve celebration with community funds. A Village A man described the surprising result: ‘There was only food … Some brought 3 cases of rum, but it was gone in just a moment.

That one didn’t get very drunk, the other one didn’t get very drunk. And so the next day, I didn’t see people in jail.

’In one of the villages, counsel or advice to reduce drinking was also noted to have had an effect in decreasing drinking. Those providing advice included family members, physicians, missionaries, and others in the village who were concerned about alcohol’s effect on the village leaders’ ability to represent the interests of their community.

Suggestions for further reduction in alcohol consumptionAlthough some group participants were doubtful that any action would be successful in reducing alcohol-related problems in their villages, the majority suggested specific steps that they felt would further decrease problems. Greater religious commitment or involvement was the most common suggestion.

One male heavy drinker from Village A described the preaching of the Word of God as ‘the medicine for the people’ in regard to alcohol problems. He and others suggested more frequent worship services or more missionary presence in the village, in order to counter the daily temptation to relapse into drinking.

He noted: ‘Well, we hear the radio dance music every day. Then I say, “I gave myself to God but in bed I am alone and sad.

”’Numerous individuals suggested more educational talks related to alcohol. Several felt that group meetings might be helpful, with one suggesting that a ‘War on Alcohol’ group be formed, with the express purpose of confronting problem drinkers and shaming them into drinking less.

DISCUSSIONIn this Native American society with a long cultural history of alcohol consumption and a relatively short history of contact with Western culture, the role of alcohol changed during the 20th century. Two major themes emerge from these FGDs: the devastation produced by the introduction of virtually unlimited supplies of alcoholic beverages into a traditional culture with few norms to limit its misuse, and the resourcefulness of individuals in these native communities, who are beginning to find ways of limiting the damage in spite of alcohol’s powerful reinforcing effects.

Current alcohol problems appear to be related to several major influences. Long-standing drinking patterns are one influence.

Indigenous peoples of South America have produced alcoholic beverages for centuries. Columbus was offered corn liquor upon his arrival in the New World (Carrizales et al. Information from our FGDs indicates that, for at least the past century, and probably much longer, individuals from this tribe have been brewing, binge-drinking to the point of disequilibrium and unconsciousness, and engaging in aggressive behaviours while intoxicated.

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, 1984; Westermeyer and Baker, 1986; Robin et al. , 1998), with episodes often ending only after money runs out or unconsciousness prevails (Curley, 1967; Rozynko and Ferguson, 1978; Westermeyer, 1979).

The similarities are intriguing in the light of the wide geographic separation and dramatic differences in historical exposure to alcohol between North and South American native peoples. Alcohol appears to play a role in the resolution of social tensions, a function which has also been described in US Native American groups (MacAndrew and Edgerton, 1969).

Although injuries and domestic violence are reported to have occurred, the consequences of heavy binge drinking and fighting while intoxicated on an occasional basis for periods of 2–3 days appear to have been quite limited in the traditional village setting. In traditional times, the primary weapon was the bow, but alcohol was unavailable most of the time.

The limitations upheld by strict social norms, such as preparing only small amounts of alcohol on infrequent special occasions and restricting its preparation to individuals who met highly selective criteria, appears to have greatly limited the amount of alcohol consumed and the resultant damage caused. Subsistence farming was not disrupted and food supplies were maintained.

Historical changes related to contact with Western culture appear to have dramatically disrupted the cultural equilibrium. Western society offered virtually unlimited supplies of alcohol to those who were able to purchase it.

Native men working on cattle farms observed their fellow ranch hands modelling alcohol consumption on a much more frequent basis. Gradual entry into a cash-based economy took men away from the subsistence farming which had provided a nutritional safety net for themselves and their families.

Within only a few years, many native men abandoned subsistence farming for cash crops and paid employment, and spent large portions of their incomes in the bars of nearby towns once or twice a month. In the towns, the drunken men often fought with knives or firearms, waking up in the streets or in shelters, injured or in jail.

They would then go home to the village without enough food to sustain their families. One encouraging result of this study is the discovery that, as a result of the suffering, communities are establishing new norms and finding solutions.

Many of their solutions — local restrictions on alcohol supply, sponsorship of alcohol-free cultural events, and encouraging spiritual solutions for individuals with drinking problems — parallel solutions and measures implemented in other parts of the world. Recent studies demonstrate that restrictions on alcohol supply in isolated indigenous populations are associated with reduction in injury, deaths, alcohol-related hospital visits, and out-patient clinic visits (Chiu et al.

The importance of organizing and promoting alcohol-free social events has been recognized and addressed in both native and non-native prevention programmes in the USA (Marin Institute, 1992; Komro et al.

Spiritual influences and motivation have long been recognized as an element in the recovery of individuals with substance misuse disorders (Chappel, 1998), with spiritually oriented programmes such as Alcoholics Anonymous, demonstratably increasing abstinence rates and reducing alcohol-related problems (Tonigan, 2001).

Sadness, despair and hopelessness, although frequently mentioned as possible causes of alcoholism among US Native Americans, were not described by FGD participants as reasons for their drinking. Poverty was the most frequently mentioned consequence of alcohol misuse, but was not once mentioned as a cause.

If anything, we observed that men with higher incomes drank more, rather than less. Individuals seemed to drink as a part of being together and celebrating with others.

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Whether there are also genetic factors present in this ethnic group, which might have contributed to the high prevalence of alcohol problems, deserves further study.

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Further reductions in alcohol-related problems will most likely result from refining the approaches that have been successful and promoting their application on a broader scale in other communities. Prevention interventions which have proven useful in communities in other countries — school-based prevention programmes, increased alcohol-free recreational activities for children and adolescents, and programmes which emphasize traditional Native American cultural values — could also prove useful.

One basic principle of community health and prevention that must not be lost, however, is that the most effective community interventions are initiated, planned, and implemented by the communities themselves. These native communities have already demonstrated that they are both sensitized to the problems alcohol has created in their culture and are willing to take action to regain order and harmony within their communities.

It is our hope that this study will provide information that is helpful both to tribal communities and to outside agencies seeking to assist in finding permanent solutions to alcohol-related problems. Are there facts that have reduced the consumption of alcohol in the community? If so, what are they? 7. Are there facts that have reduced the consumption of alcohol in the community? If so, what are they? 7.