Jebose O. Okwumabua, Ph.D. Elias J. Duryea, Ph.D.

In recent years, investigators have documented evidence supporting the effectiveness of school-based interventions which emphasize social skills in facilitating adolescents’ resistance to pressures to use drugs and alcohol (Pentz, 1983; McAlister, Perry, & Maccoby, 1979; Evans et al, 1978; Duryea, 1984; McGuire, 1962). Competence in decision making, for example, has been considered an important prerequisite in adolescent health promotion efforts (Strait, 1974; Duryea, Kreuter, & Braza, 1981; Duryea & Okwumabua, 1985; Schinke & Blythe, 1981).

Although investigators continue to formulate strategies that would help adolescents to make health-enhancing decisions, there exists a complete absence of data concerning health choices and resistance skills among American Indian adolescents. American Indian youth are frequently delineated, however, as a high risk group for engaging in health-compromising behaviors. For example, drug use is higher in all categories of mood altering drugs (e.g., marijuana, inhalants, and cocaine) among American Indian youth than for their counterparts in the mainstream population (Beauvais & LaBoueff, 1985). Moreover, the morbidity and mortality rates due to accidents (a by-product of risky health behaviors) among American Indian youth is four times higher than the national average (Rhoades, 1982).

In light of these findings and the postulated relationship between decisionmaking skill and health-promoting behavior, it is crucial to investigate the connection between these variables in American Indian adolescents. Essentially, the research reported here was a pilot study to investigate the relationship between decision-making skill and health-promoting behavior among American Indian youth. Specifically, the study assessed the extent to which a sample of American Indian seventh-grade students could learn a four-step decision-making process and subsequently apply this sequence to an array of health-related situations. Such information would be beneficial for school health curriculum planners, health-behavior researchers, and related disciplines that interact regularly with American Indian adolescents in education and medical settings (e.g., schools, pediatrics).

The subject sample was comprised of 44 seventh-graders (mean chronological age = 12.6; range = 11 to 13 years) of American Indian descent. There were approximately equal numbers of males (N = 23) and females (N = 21) in the sample. All of the participants attended a boarding school exclusively for American Indian youth. The school is located in a major metropolitan city in the Southwest but serves American Indians from throughout the United States. Student body representation was primarily from the 19 Pueblo tribes with a significant number of Navajo, Hopi, and Jicarilla Apache Indians. There were also students from the Blackfoot, Caddo, Cheyenne, Choctaw, Comanche, Kiowa, Sioux, and Ute tribes. Specifically, eighty-four percent of the study sample was representative of the Pueblo Indian tribes, while sixteen percent was representative of students from the Navajo, Hopi, and Jicarilla Apache Indian tribes.

Contrary to descriptions of boarding schools for Indians provided elsewhere (Schottstaedt & Bjork, 1977), the school was operated by the All Indian Pueblo Council, Incorporated, not the Bureau of Indian Affairs (BIA). The All Indian Pueblo Council, Incorporated was the first Indian organization to contract and operate its own school under the Indian Self-Determination Act (P. L. 93-638). The school was not intended for children with emotional, psychological, or social problems. Respect for American Indian culture and tradition as well as excellence in academia are strongly emphasized by the school.

Informed consent was obtained from parents and students through the school’s superintendent. The school utilizes a blanket consent from parents for the administration of informal tests and questionnaires.

A modified version of the Decision-Making Instrument (Centers for Disease Control, 1984) was used to assess students’ baseline decision-making skill level. The instrument allows for the examination of student understanding of the general decision-making process.

The Decision-Making Instrument consists of a series of scenarios describing a young person in the act of making a decision. For each scenario, selected steps of the decision-making process (e.g., defining the decision; identifying alternative courses of action; weighing costs/benefits of alternatives; making a decision) are provided either in the scenario and/or in a series of choices that follow each scenario. Students are required to read the scenario, determine which steps, if any, in the decision-making process have been taken, and select, from possible alternatives, the next step the individual described in the scenario should take in order to make a "wise" decision.

The scoring key for this instrument employs the following method of annotation in analyzing students’ responses to the scenarios: (1) Skipped step (a response that describes one of the decision-making steps that occurs after the correct step); (2) Repeated step (a response that describes one of the decision-making steps that has already occurred); (3) Ineffective implementation of a step (a response that describes a decision-making step but is clearly inconsistent with one or more of the steps’ characteristics); (4) Deflective action (a response that is unrelated to effective decision making and may deflect the decision maker from taking necessary action). The instrument has been found by the Centers for Disease Control to be reliable and valid in assessing adolescents’ decision-making skill.

The Centers for Disease Control (CDC) Decision-Making Instrument was modified in the present investigation to be culturally relevant and comprehensible to a sample of American Indian youth. That is, realistic aspects of American Indian culture and social environment were depicted in each scenario. For example, there were references to familiar Indian reservations, activities and celebrations (e.g., pow-wow). Curriculum specialists and participating teachers at the study school collaborated in evaluating the comprehensibility as well as the ethnic propriety of each scenario. Figure 1 presents a sample scenario and accompanying choices.

The instrument was additionally modified to assess students’ decision-making skill level based on a four-step paradigm rather than the conventional five-step decision-making process (Janis & Mann, 1977). The terminal fifth step--self-evaluation of the decision--was omitted for the purpose of this study. The four-step paradigm was employed for these students due to the fact that school officials considered a four-step decision-making steps (i.e., define the decision/identify alternatives/weighing costs, benefits/making the decision) to be the most appropriate format. Moreover, the four decision-making steps were considered the core components of the basic decision-making process (Kolbe et al., 1981; Renaud-Salis, 1980).

Reliability of instrument was assessed at .81 by employing a test-retest procedure. Face validity was judged significant by a panel of experts from the University of New Mexico, local American Indian curriculum specialists as well as participating teachers at the study school.

CHECK ONLY ONE:

Figure 1. A Sample Scenario with a Health-Decision Focus

A total of ten decision scenarios were developed by the author, school officials and the participating teachers. Five of these scenarios involved a socialdecision focus (e.g., deciding how to avoid a conflict with a sibling) and five involved a health-decision focus (e.g., deciding whether or not to ride with a drinking driver). Scenarios with social-decision focus were used to train experimental subjects in the sequential four-step decision-making process. In essence, the social-decision scenarios allowed for examination of the experimental subject’s understanding of the decision-making process. Figure 2 presents a sample scenario with a social-decision focus and accompanying choices.

Subsequently, scenarios with health-decision focus were used to later assess whether or not students could apply the newly acquired decision-making skill to everyday risky health situations. Figure 1 illustrates a health-related decision-making situation.

Each scenario had all but one step of the decision-making process depicted. For example, scenario #1 illustrated all but step #2 (identifying alternative course of action); scenario #2 illustrated all but step #1 (identifying the decision to be made); scenario #3 excluded step #4 (making a decision) and so on.

The study students were randomly assigned via computer, in approximately equal numbers, to day and evening classes by the school administration. The experimental group comprised those students attending day classes (N = 23), while the control group comprised those students attending evening classes (N = 21). Both groups were pretested to determine their baseline level of decision-making skill. Results of this baseline assessment are reported elsewhere (Okwumabua, Okwumabua, & Duryea, 1987).

The data reported in this study were collected in the Fall, 1985. The scenarios were administered to the students by their teachers during their regularly scheduled health class. All information collected was assured confidential.

CHECK ONLY ONE:

Figure 2. A Sample Scenario with a Social-Decision Focus

Treatment exposure time for the experimental group involved a duration of five weeks, including two days of in-service training for the participating teacher.

Treatment was comprised of three components: Component #1 (slide show, formal instructions) familiarized experimental subjects with the four-step decision-making process and its utility; Component #2 (question-answer panel, role play) showed experimental subjects how to evaluate the costs/ benefits in making specific decisions; Component #3 (role play, film) showed experimental subjects how to apply the learned decision-making process to everyday situations involving health choices.

Students’ responses to the decision scenarios were assessed using the Chisquare statistical procedure. The intent of this analysis was to evaluate whether or not the distribution of correct responses (at pre- and post-training) to the scenarios was the same in the experimental and control conditions.

Data analysis was based on .05 level of statistical significance. Essentially, for a student’s performance to be considered successful, he/she would have to select at least four (4) correct choices out of five (5) scenarios for learning the process of sequential decision making, and for applying the decision making process to health-related situations.

The findings of the study present a comparison of differences in the proportion of correct responses between experimental and control groups as well as for the differences in the proportion of correct responses within each group at pre- and post-training conditions.

A test of homogeneity of variance at pre-training revealed no difference between the experimental and control groups. At post-training, however, the experimental subjects demonstrated a significantly higher level of knowledge of the four-step decision-making process than the control subjects who were not exposed to the training (X2 = 11.17 p < .03). [In original document the 2 in X2 is superscripted.] This is reflected in Table 1 by the number of individual correct responses to decision-making process scenarios at pre- and post-training conditions.

Similarly, the experimental subjects at post-training demonstrated the ability to apply the learned decision-making process to health-related situations at a significantly higher level than the control subjects (X2 = 18.51, p < .001). As Table 2 shows, experimental subjects at post-test reported a greater number of correct responses for decision-making ability at post-training than control subjects.

TABLE 1
Number and Percent of Individuals for Each Category
of Correct Response for Decision-Making Process Ability
(Between Group) at Pre- and Post-Training

TABLE 2
Number and Percent of Individuals for Each Category
of Correct Response for Decision-Making Application Ability
(Between Group) at Pre- and Post-Training

Data produced by the control subjects did not yield statistically significant difference in the distribution of scores from pre- to post-training on decision-making process or application abilities.

A similar within group analysis performed for experimental subjects indicated significant differences in the distribution of scores from pre-training to post-training on process and application abilities (X2 = 19.49, p < .001; X2 = 13.64, p < .01, respectively).

Findings from this study of American Indian students indicated that after training, experimental subjects demonstrated a significantly superior knowledge of the four-step decision-making process than the control subjects who were not exposed to the training. Similarly, the experimental subjects demonstrated a significantly superior ability to apply the learned-decision process to health-related situations than the control subjects. Although these results suggest that American Indian adolescents can learn and apply a four-step decision-making process, findings must be tempered due to the small sample size. Considerable caution must also be exercised in generalizing the study outcomes to other Indian tribes, since the majority of the study sample (84%) was representative of students from the Pueblo Indian tribes. Despite these limitations, however, results suggest that the experimental subjects learned a cognitive skill which should give them a potential tool to effectively manage health-decision situations involving risky health behavior.

A follow-up interview with the experimental students and the participating health teacher at the study school indicated that the role play simulations and question-answer panel discussion sessions were the most effective components in generating student participation, open communication as well as facilitating students’ understanding of the sequential decision-making process. For example, during the role-play simulations and question-answer panel discussion sessions the students pointed out some cultural implications in risky health behavior patterns among American Indian adolescents. It was revealed that the most frequent health-compromising decision-making situation confronting most students involved parent(s)/older adult relatives. According to American Indian culture, it is considered disrespectful for a younger person to challenge or refute instructions from his or her parent(s) or older adult relatives (Primeaus, 1977). Health-comprormising behavior (e.g., riding with a drinking driver) predicated upon this cultural belief could pose a major barrier in health-promotion efforts among American Indian adolescents. In addition, the issue of the availability of transportation on the Indian reservation was brought out by the students and discussed relative to the potential risks of riding with a drinking driver. In other words, due to the scarcity of transportation on the reservation, people (including adolescents) are exposed to the risk of riding with anyone who provides transportation regardless of the health risk involved (i.e. riding with a drunk driver). Peer-centered, health-related decision-making situations were also shown to be a frequent concern of students.

In view of these issues, it is evident that drug education/prevention programming for American Indian adolescent populations should not be limited to the classroom setting but should include parents and older adults in the community. In essence, a comprehensive drug education/prevention program that jointly incorporates the school system and the community will possess the most salient potential for generating a more positive and lasting health status for American Indian adolescents. This approach is particularly critical due to the fact that culturally-rooted behavior is most resilient to change (Sobralske, 1985; Wauneka, 1969). Modification in such behaviors can be facilitated when parents and older adults are involved in the process. The present study was not intended to integrate these critical elements.

Future studies are needed to clarify important theoretical and methodological issues in health decision-making dynamics among American Indian adolescents. For instance, issues such as content of thinking during decisions, consistency of thinking, transfer, and retention of learning need to be systematically investigated within specific tribal populations. Additionally, future replication and extension of the research reported here should consider utilizing geographically separate but homogeneous (matched) Indian schools--one for experimental (treatment) and another for control. These modifications will increase the sample sizes as well as ameliorate possible "contamination" elements. It is hoped that future investigations will delineate the kind of health decision-making training which ultimately translates into reduced health risk in the American Indian adolescent population.

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