Neurosensory disturbances after immediate loading of implants in the anterior mandible : an initial questionnaire approach followed by a psychophysical assessment The aim of the study was to assess past and present neurosensory disturbances using a questionnaire and a psychophysical approach in patients treated with immediate loaded implants in the edentulous anterior mandible . A group of 65 patients -LRB- age range 30 -- 84 years , mean 58 years , 30 women -RRB- was enrolled . All were treated by means of three immediately loaded implants -LRB- Branemark Novum System ® -RRB- . A self-designed questionnaire was used for data collection . The response rate was 89 % . Of the 58 responders , 33 % -LRB- n = 19 -RRB- reported neurosensory disturbances after implant surgery . Nine of these patients -LRB- mean age 56 years , seven women -RRB- participated in an objective evaluation and were subjected to a psychological and several psychophysical tests . At the moment of the evaluation none of the nine patients still had clinical complaints . Psychological testing revealed no statistical differences between the patients , who had previously experienced subjective complaints , and the control group . Two-point discrimination and thermal sensation tests revealed no sensory lesions . The light touch sensation test at the lower lip indicated a more frequent reduction of tactility for the test group -LRB- p ≤ 0.03 -RRB- . Neurosensory disturbances can occur in the anterior region of the mandible after implant surgery . Introduction Nerve injury and specifically trigeminal nerve injury is known as a potential risk of many surgical procedures in the oral cavity in general -LSB- 17 , 23 , 30 -RSB- . Usually after oral implant rehabilitation , the patient expects and experiences significant improvements , not only regarding jaw function , but also in relation to dental , facial , and even overall body image -LSB- 22 -RSB- . One can perfectly understand that the patient does not accept neural side effects , which might compromise his well-being . Following the definitions of the Subcommittee on Taxonomy of the International Association for the Study of Pain 1986 , the types of sensorial disturbances are principally anesthesia , paresthesia , or dysesthesia . These changes can be persistent according to the degree of damage of the nerve -LSB- 31 -RSB- . Sensory disturbances in the maxillofacial region could be associated with different surgical procedures , like placement of endosseous implants -LSB- 3 , 36 , 37 -RSB- . With regard to immediately loaded implants , the presence of postoperative sensory disturbances was not documented . Branemark et al. -LSB- 5 -RSB- developed a new approach for immediate loading using fixed prosthesis of prefabricated standard components in the edentulous mandible . This technique involves a flattening of the jaw crest , followed by the placement of the implants by means of prefabricated and thus not individualized surgical guides . Thus the distances -LRB- but not the depth of drilling -RRB- between the implants were always the same , considerably reducing the variation of the surgical procedure . Sometimes the distal implants were positioned near the mental foramen -LSB- 5 -RSB- . Damage to the mental nerve may result in loss of tactility and thus biting on the tongue or lip , drooling , painful sensations , and also interference with several jaw functions such as mastication , speech , hygiene maintenance , and social or psychosexual well-being -LSB- 15 -RSB- . Different methods were used to evaluate such sensory disturbances after the placement of dental implants . Ellies -LSB- 11 -RSB- in 1992 and Ellies and Hawker -LSB- 12 -RSB- in 1993 published two retrospectives studies based on the analysis of questionnaires . Wismeijer et al. -LSB- 36 -RSB- applied in a prospective study a self-administrated questionnaire and the somatic questionnaire , the Hopkins Symptoms Checklist -LRB- HSCL -RRB- . The latter is a questionnaire routinely used in psychology to estimate a patient 's psychoneurological and/or psychosomatic discomfort . The somatic score of the HSCL was oriented on physical complaints and shows the level of a patient 's perception of his/her physical state . The higher the somatic score -LRB- i.e. , 25 % in the study of Wismeijer et al. -LSB- 36 -RSB- -RRB- , the more the patient tends to exaggerate physical complaints , but the risk of a sensory disturbance of the lower lip is a possible complication after implant surgery -LSB- 38 -RSB- . Bartling et al. -LSB- 3 -RSB- analyzed the neurosensory disturbances in a population of patients after oral implant placement , using a combination of psychophysical methods like soft brush , two-point discrimination , pain perception , and temperature sensitivity . A small number -LRB- 8/94 -RRB- of patients experience altered sensation after the placement of mandibular endosseous implants , but no permanent alteration was found . Walton -LSB- 37 -RSB- published a prospective study of 75 subjects using one objective -LRB- the light touch sensation -RRB- test , associated with a subjective analysis -LRB- questionnaire -RRB- ; both methods were used before and after placement of two implants in the anterior mandible . In this study , 24 % of subjects reported neurosensory disturbances in the short term after implant surgery in the anterior mandible , but the problem appears to be a transient one with only about 1 % experiencing sensation changes 1 year after implant surgery -LSB- 37 -RSB- . After reviewing the related literature , it is clear that the proportion of patients with sensory disturbances varies among publications . It is therefore essential to assess if neurosensory changes take place after the immediate loading of oral osseointegrated implants in the edentulous mandible in patients who received a fixed prosthetic construction on the day of implant insertion or the next day . Distinguishing between dysesthesia , an unpleasant abnormal tactile sensation , and paresthesia , an abnormal -LRB- not painful -RRB- and often decreased sensation , is the first step in defining the character of the neurosensory disturbance reported by a patient . Further differentiation between paresthesia and hypoesthesia , which is a reduction in the level of sensation , and finally anesthesia , the complete absence of any sensation , is important from all viewpoints . In the presence of dysesthesia , the differentiation must be established between spontaneous and a stimulus-induced unpleasant sensation . The clinical approach and sometimes legal implications of these different conditions are evident -LSB- 6 -RSB- . Besides clinical evaluation , it must be understood that evaluation of nerve injuries such as demyelinization due to compression -LRB- neuropraxia -RRB- , distal Wallerian degeneration with intact cell tubes -LRB- axonotmesis -RRB- , or proximal and distal Wallerian degeneration with disparate Schwann cell tubes -LRB- neurotmesis -RRB- is an impossible mission for the clinician . Nevertheless , if no spontaneous return of tactile sensibility is noted within 3 -- 6 months , the permanent loss of continuity of some or all the elements of the nerve trunk should be expected -LSB- 11 , 27 -RSB- . Some observations indicate that the return to normal tactile sensibility may even occur after 2 to 3 years -LSB- 12 -RSB- . The differences between laboratory and clinical results are obvious . In some studies , questionnaires were used to evaluate the presence of sensory disturbances . Such methodology is clinically helpful and is a good basis for more detailed and objective evaluations . Immediate loading of oral implants was proposed as an alternative protocol in the rehabilitation of partially or fully edentulous patients -LSB- 8 -RSB- . Surprisingly enough , no study has yet referred to the possible different neural sensibility when loading is imposed immediately after or together with the placement of the implants . This tactile sense aspect is relevant especially if we consider that the prosthetic rehabilitation -LRB- implying by example a full occlusal contact -RRB- is functional within one or a few hours after the implant placement . Thus , the patient 's awareness of the load imposed on the implants can be a key issue to avoid undue load transfer on the implant -- bone interface . The overall aim of the present research is to objectively evaluate the neurosensory disturbances and/or function occurring after placement of oral implants in the anterior region of the mandible . Materials and methods This study comprised a total of 65 patients -LRB- age range 30 -- 84 years , mean age 58 years ; 30 women -RRB- . All patients were treated by means of immediately loaded implants in the anterior mandible with the Brånemark Novum ® system approach . Surgery took place at the Department of Periodontology , Catholic University Leuven -LRB- 55 patients , 3 surgeons -RRB- , and at the Department of Oral and Maxillofacial Surgery , Erasmus Hospital , Free University of Brussels -LRB- 10 patients , 2 surgeons -RRB- . Selection criteria included -LRB- 1 -RRB- placement of implants in the anterior mandible using Brånemark Novum System ® -LRB- NobelBiocare AB , Gothenburg , Sweden -RRB- ; and -LRB- 2 -RRB- no history of neurological disorder . An ad hoc multiple choice questionnaire -LRB- 13 questions -RRB- was designed to record past and present neurosensory disturbances in these patients . The clinical history of the patient was used , and according to the selection criteria , a self-administered questionnaire was sent out to the 65 patients . The questionnaire was sent by mail to the patients with the request to complete it and return it to the clinic . The questionnaire was designed by experienced periodontologists , prosthodontists , and one psychologist -LRB- see Appendix for the questionnaire -RRB- . The answers to the questions were analyzed and data were collected by this same team . An objective evaluation took place after analysis of the questionnaire . During this evaluation psychological and psychophysical tests took place . The clinical evaluation of trigeminal nerve injuries suggested by Zuniga and Essick -LSB- 39 -RSB- in 1992 was used as basis in the test and control population . A psychological test : the SCL-90-R ® -LRB- Symptom Checklist-90-Revised -RRB- was applied . The SCL-90-R ® measures the psychoneurotic-somatic nonwellness -LRB- Psychoneuroticism -RRB- of patients -LSB- 10 -RSB- . The SCL-90-R ® is different from the HSCL because it considers a broader area of psychopathology . The scale of psychoneuroticism in patients is assessed . It reveals the global level of recent psychological and also physical dysfunction . In the present study , the intensity of somatic complaints was considered important . The SCL-90-R ® scale reveals complaints , loaded with a general feeling of physical dysfunction , as a result from functional problems . After completion of the questionnaire , each patient was interviewed using a standardized series of `` key questions '' on altered feeling in the chin , lips , tongue , and cheek . Each time a distinction was made between the right and left sides of the face . Typical questions were as follows : How would you describe the altered feeling?Do you notice the altered feeling constantly or only when touching the area , or chewing , or talking?Is it painful ? Where ? Transient or constant?Does it start spontaneously or is it evoked by touching , chewing , or speaking?What exacerbates the pain?What relieves the pain ? After thorough questioning about the patient 's general and oral medical history , an extra - and intraoral clinical examination took place , including palpation and/or percussion , to detect eventual provoked pain at the site of injury . Finally , inspection of the oral cavity was performed to find eventual evidence of nerve injury , self-induced trauma , etc. . In the present study three psychophysical tests were selected : two-point perception at the lower lip , both left and right side -LRB- Fig. 1 -RRB- ; thermal sensitivity at the lower lip and gingiva of the anterior lower jaw , both left and right side -LRB- Fig. 2 -RRB- ; and light touch sensation at the lower lip and gingiva of lower jaw , both left and right side -LRB- Fig. 3 -RRB- . Fig. 1Two-point discrimination instrumentFig . 2Thermal sensitivity instrumentFig . 3Light touch sensation -LRB- Semmes-Weinstein Aesthesiometer ® -RRB- instrument Psychophysical tests demand a thorough consciousness and active participation of the patients and a quiet environment -LSB- 20 -RSB- . A combination of both psychophysical tests with testing tools adapted to the intraoral and perioral sites were used . The light touch sensation on the other hand was tested using the original Semmes-Weinstein Aesthesiometer ® -LRB- Stoeling Company , Wood Dale , USA -RRB- device . To determine the threshold level the staircase method was applied . In the light touch sensation and static two-point discrimination , eight maximum and eight minimum values were recorded . Finally , in the thermal sensitivity test , all subjects were tested with ten trials . For a more detailed methodology of the procedures for sensory testing , see Jacobs et al. -LSB- 21 -RSB- . The collected data were statistically analyzed using the Statistica for Windows 5.1 ® -LRB- Stat Soft , Tulsa , OK , USA -RRB- . A Mann -- Whitney U test was applied to the threshold levels in the test and the control groups . Results Fifty-eight of the 65 patients -LRB- 89 % -RRB- completed the questionnaire and returned it to the hospital . Systemic diseases like cardiac , respiratory , endocrine , and renal diseases , allergic reactions , and psychological -LRB- depression -RRB- problems were detected in 46 % -LRB- n = 30 -RRB- of the patients . The mean time between the placement of the implants and the reception of the questionnaire was 20 months -LRB- range 8 -- 40 months -RRB- . The analysis of the questionnaire showed that 33 % -LRB- n = 19 -RRB- of patients reported a kind of neurosensory disturbance after the placement of the implants -LRB- range 8 -- 24 months -RRB- . The age range of this subpopulation was between 30 and 71 years -LRB- mean age 56 , 13 women -RRB- . This data are not different from the remaining group . The duration of this postsurgical neurosensory disturbance after the implant surgery was less than 3 months in 58 % -LRB- n = 11 -RRB- of the patients . However , eight patients were still suffering from a disturbance . For them the problem persisted for a period between 8 and 21 months . The most commonly affected sites in the 19 patients were the gingiva only -LRB- 6 patients -RRB- , the inferior lip only -LRB- 4 patients -RRB- , and the chin -LRB- 4 patients -RRB- . One of the patients did not remember or could not determine the affected zone . Speaking and drinking -LRB- five patients -RRB- were the oral activities most commonly impaired by the altered sensations . An important part of the affected population group -LRB- 12 patients -RRB- did n't complain about problems with oral function or daily activity . The most common reported sensation was numbness -LRB- nine patients -RRB- , followed by cutting , beating , and itching reported by two patients . Only one patient considered that the benefits of a fixed prosthesis did not outweigh the disadvantages that she had experienced as a result of disturbances in sensation of the lower jaw . She considered that she would not have done this surgery again , if she had been informed beforehand about the potential sensory changes in the orofacial region . From the 19 patients , 9 volunteered to participate in the objective evaluation -LRB- test group -RRB- . The test group was 30 -- 71 years old -LRB- mean age 56 years , seven women -RRB- . A control group of volunteers -LRB- N = 9 -RRB- was also enrolled . Their age ranged from 49 to 71 years -LRB- mean age 63 years , all women -RRB- . The mean observation time in this group since the surgery -LRB- two implants placed in the anterior mandible after a two-stage protocol -RRB- was 18 months -LRB- range 11 -- 22 months -RRB- . As psychological test , the SCL-90-R ® test was applied for symptom measurement of patient treatment outcomes and their degree of somatization of the symptoms . The psychophysical tests included three neurosensory evaluations : two-point discrimination , thermal sensitivity , and light touch sensation . The staircase method of limits was applied to determine the tactile threshold . An age - and gender-matched group of patients who had undergone similar surgery -LRB- two implants in the symphyseal region -RRB- in the same area , but without reporting sensory disturbances , served as control . Results of the psychological and psychophysical tests As mentioned above , each of the 19 patients of the self-declared affected population was invited for a clinical evaluation and 9 of the 19 patients accepted to participate . The time span between surgery and psychophysical evaluation was on average 29 months -LRB- range 19 -- 49 months -RRB- . During the clinical interview , before the actual objective testing took place , none of the nine patients had remaining complaints or clinical symptoms such as drooling or tongue bite wounds that could indicate a sensory disturbance . However , at the reception of the questionnaire , which had to be mailed after the examination session , five of the nine patients with self-declared neurosensory disturbances still reported having them . In the remaining four patients the subjective neurosensory disturbances were completely resolved . No major complaints were recorded after the evaluation of the SCL-90-R ® . The scores of the SCL-90-R ® of the test -LRB- N = 9 -RRB- and control group -LRB- N = 10 -RRB- revealed no statistic differences , neither on the global scale of neuroticism , nor on the dimension of somatic complaints . This means that the level of complaints of both groups was similar . After clinical examination and considering the negative interview for unpleasant dysesthesia and pain , it was concluded that only potential signs of paresthesia were currently present in the affected patients . Two-point discrimination , thermal sensation , and light touch sensation at the gingival level show no significant difference between test and control groups -LRB- Table 1 -RRB- -LSB- 14 , 16 , 26 , 28 -RSB- . Table 1Overview of psychophysical tests scores between test group , control group , and reference valuesType test/RegionTest groupControl groupReference valuesReference numberT ° S/LLLS0 .8 -LRB- CR -RRB- 0.9 -LRB- CR -RRB- 0.8 -LRB- CR -RRB- 18T ° S/LLRS0 .9 -LRB- CR -RRB- 0.9 -LRB- CR -RRB- 0.8 -LRB- CR -RRB- 18T ° S/LGLS0 .8 -LRB- CR -RRB- 0.8 -LRB- CR -RRB- 0.8 -LRB- CR -RRB- 18T ° S/LGRS0 .8 -LRB- CR -RRB- 0.8 -LRB- CR -RRB- 0.8 -LRB- CR -RRB- 182PD/LLLS3 .4 mm4 .5 mm6 .1 ± 3.1 mm193 .3 ± 1.6 mm202 ± 4 mm21 , 222PD/LLRS3 .4 mm4 .8 mm6 .1 ± 3.1 mm193 .3 ± 1.6 mm202 ± 4 mm21 ,22 LTS/LGLS7 NFa6 NFa4 -LRB- 2.83 -RRB- NF 19LTS/LGRS7 NFa7 NFa4 -LRB- 2.83 -RRB- NF19T ° S Thermal sensation , LLLS lower lip left side , LLRS lower lip right side , LGRS lower gingiva right side , LGLS lower gingiva left side , CR correct ratio , 2PD two-point discrimination , mm millimeters , LTS light touch sensation , and NF the number of the filamentaMean value of von Frey hair The light touch sensation of the lower lip was significantly impaired in the test group -LRB- Mann -- Whitney U test -RRB- . There was a statistical difference for both sides -LRB- p ≤ 0.03 -RRB- between test and control groups . Systemic diseases have a significant effect on the outcome of the light touch testing at the lower lip . The light touch sensation of the lower lip revealed a statistical difference -LRB- p ≤ 0.04 -RRB- for both sides . Discussion The anterior region of the mandible was always considered as a `` safe zone '' for the use of oral implants . This is particularly true concerning the high success rate of oral osseointegrated implants -LSB- 25 -RSB- . Nevertheless , there is an important difference between the reported implant success rate with specific surgical technique and the postsurgical changes to function , sensory mechanisms , and the physiological integration in the human body . Anatomical considerations in the anterior region of the mandible and the skills and experience of the surgeon are also important -LSB- 24 -RSB- . It is surprising to note that the present methodology allowed us to observe a very high percentage of subjective postoperative complaints . These results are in agreement with others , i.e , Ellies -LSB- 11 -RSB- with 37 % and Ellies and Hawker -LSB- 12 -RSB- with 36 % . This high degree of concordance for the percentages of incidence is interesting , considering the different surgical techniques used and cultural and sometimes ethnic differences between the three involved populations -LRB- Canada , Australia , and Belgium -RRB- . It was not possible , based on the subjective data , to establish any correlation between the systemic diseases presented in the study population and the reported sensory disturbances -LRB- i.e. , impairment of perception in a patient with diabetes -RRB- -LSB- 2 , 4 -RSB- . It is interesting to know that eight patients had the impression to be affected by some kind of persistent neurosensory disturbance , most probably paresthesia or hypoesthesia , more than 12 months after the surgery . Nevertheless , besides these results , a majority of these affected patients considered that the benefits outweigh this kind of transient or permanent disadvantages , and consider that they would accepted an implant surgery again even if they knew about the present complication . Normal somatic sensation reflects a continuous day and night monitoring process . Little of this activity reaches consciousness under ordinary conditions . Disordered sensation is alarming and dominates the sufferer 's attention . As expected from the neuroanatomical knowledge recently collected , neurosensory disturbances regularly occur in the anterior region of the mandible after surgery . Anatomical factors like the presence of an anterior loop , handling of the mental nerve during surgery , or the perforation of the incisive nerve canal can all provoke such disturbances . As mentioned above , the Brånemark Novum ® technique involves a flattening of the jawbone . This procedure can be considered rather invasive and can damage , in severely resorbed jaws , the incisive canal or the mental nerve emerging at the crestal level . The relationship between a reduction of the crestal jawbone and neurosensory disturbances could not be traced in the literature . However , bone chin grafting procedures present some similarities . von Arx et al. -LSB- 35 -RSB- recently reported 8.1 % of neurosensory disturbances after 6 months in patients who underwent such procedures . For some systemic conditions , it was reported that persons can be more prone to sensory disturbances . Peripheral neuropathy in people with scleroderma is thought to be rare , however , nerve conduction studies showed abnormalities in patients with a mean disease duration of 10 years or longer -LSB- 29 -RSB- . Polyneuropathies in mild or severe diabetic patients often cause subclinical damage of the trigeminal nerve . Moreover , their sensory complaints in the perioral area often remain unnoticed and the dysfunction undiagnosed -LSB- 9 -RSB- . Age by itself also has an influence , especially when repair is concerned . The younger the subject , the greater the degenerative response but the quicker and more complete the overall recovery -LSB- 7 -RSB- . Tactile threshold assessment reveals that detection of monofilaments up to 0.023 g -LRB- monofilament number 2 -RRB- can be considered normal in the orofacial region -LSB- 14 , 37 -RSB- . Neurophysiological recordings of the masseter reflex , the mental nerve blink reflex , or evoked potentials are all useful in evaluating trigeminal nerve damage . This was specifically shown for damage of the inferior alveolar nerve -LSB- 19 , 32 , 33 -RSB- . However , evaluation of nerve damage in the symphyseal region was not reported in the literature . The number of nerves innervating this region , the vicinity of interfering structures -LRB- e.g. , tongue , saliva , and labial muscles -RRB- , and anatomical variations make this a difficult but challenging task . In humans , several reports show that during the stimulation of peripheral sensory limb nerve examined after surgical repair -LRB- time span between 5 and 20 years -RRB- , the sensory function remained deficient and often included abnormal sensory disorders -LSB- 1 -RSB- . It must also be considered that the loss of tactile sensitivity after surgery is not always reflected in abnormal psychophysical test results -LSB- 13 -RSB- . Furthermore , it is also possible , as shown by the collected data in this study , that an abnormal test result , particularly the light touch sensation test , does not reflect clinical reality . In other words , the patient does not always detect the loss of sensitivity . It should be stressed that the selection of a control group of patients treated by means of two implants in the symphyseal region was principally motivated by the intent to have an age - and gender-matched group . The selection of a control group among patients treated with the Novum ® system but without neurosensory complaints would not have allowed this . It must also be considered that sometimes thresholds of the psychophysical test are not easy to reach in the oral cavity ; the devices were not originally designed for this region , particularly light touch sensation -LSB- 33 -RSB- . Not less important is the fact that 95 % -LRB- n = 17 -RRB- of the affected population considers that the treatment benefits outweigh the transient disadvantages , and that 18/19 of the patients consider that they would follow an implant surgery again if they knew beforehand the changes in sensation after the surgery . There are no data in literature to compare neurosensory disturbances after immediate loading with those after the two-stage protocol . It is clear that it is difficult for the patient to distinguish between postoperative inconveniences , early functional adaptation , and real neurosensory dysfunction . Only a differential objective diagnosis can do so . A meticulous preoperative planning of the surgery , even in an improperly so-called safe region of the jaws , like the symphyseal region , might avoid many neural disturbances -LSB- 18 -RSB- . In this perspective , the use of cross-sectional images and the transfer of the planning to the operative field may be considered -LSB- 34 -RSB- . Conclusions The use of a questionnaire to determine the presence or absence of a problem after a medical procedure is easy and inexpensive ; but to clarify the type , magnitude , extension , and eventual persistence of the neurosensory disturbance , the use of objective methods -LRB- i.e. , psychophysical methods -RRB- in the evaluation of a population affected by any sensory disturbance , when complaints are detected , is highly recommended . The objective follow-up revealed that patients are often not impaired by , and even not aware of , neurosensory dysfunctions after implant surgery in the anterior mandible . Objective tests indicate however that tactile threshold levels may be elevated after such surgery . None of the patients suffering from this impaired tactile function seems to have functional deficits resulting from it . Based on these data , proper preoperative planning using cross-sectional imaging can be advised even for surgical procedures in the symphyseal region .

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O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O 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O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O

oral implants
neurosensory disturbances
mental nerve
psychophysical tests


Mental Health and Substance Abuse Services Preferences among American Indian People of the Northern Midwest ABSTRACT INTRODUCTION A 2001 supplemental report on mental health to the Surgeon General describes the current United States public health perspective as a `` population-based approach -LRB- that -RRB- is concerned with the health of the entire population , including its link to the physical , psychological , cultural , and social environments in which people live , work , and go to school -LRB- Dept of Health and Human Services -LRB- DHHS -RRB- , 2001 -RRB- . '' This statement reflects a concept of holistic healing in a time of growing acceptance and utilization of alternative or complimentary health services beyond those available within professional medical systems . Rodenhauser -LRB- 1994 -RRB- notes that although psychiatry as a specific medical field shows increasing cultural awareness regarding clinical sensitivity within the academic literature , there has been little to no evidence of cultural factors found within mainstream journals for health administrators . In addition , very little research is available concerning the co-utilization of `` alternative '' and western medical approaches , let alone an examination of this overlap within specific cultures -LRB- Gurley et al. , 2001 ; Rhoades & Rhoades , 2000 ; but see Novins , Beals , Moore , Spicer , & Manson , 2004 -RRB- . An understanding of these services may be especially important within an American Indian cultural context where traditions often involve complex ceremonies and beliefs that require consideration far beyond that of mainstream religion -LRB- Rhoades & Rhoades , 2000 -RRB- . The purpose of this study is to examine factors that influence the choice between traditional cultural and western mental health and substance use associated care among American Indians from reservations in the northern Midwest . Specifically , we examine preference in terms of perceived effectiveness and actual utilization of traditional vs. Western-based service outlets . Barriers to Health Services American Indians and Alaskan Natives have been found to report highest rates -LRB- 12.9 % -RRB- of frequent mental distress among all ethnic groups , including Hispanics -LRB- 10.3 % -RRB- , African Americans -LRB- 9.7 % -RRB- , Whites -LRB- 8.3 % -RRB- , and Asian/Pacific Islanders -LRB- 6.1 % -RRB- -LRB- Centers for Disease Control -LRB- CDC -RRB- , 1998 -RRB- . The 2000 -- 2001 National Household Survey on Drug Abuse found American Indians/Alaskan Natives to be second only to multi-ethnic individuals to have received mental health treatment in the past year . At the same time , American Indian/Alaska Native respondents were second highest among all ethnic groups who had not received mental health care to report perceived unmet service needs -LRB- Barker et al. , 2004 -RRB- . A similar pattern is found for substance abuse where again , American Indians/Alaskan Natives are second to multi-ethnic persons in terms of prevalence of illicit drug or alcohol dependence -LRB- Substance Abuse and Mental Health Services Administration -LRB- SAMHSA -RRB- , 2002 -RRB- . A majority of Indian people within the United States receive physical and mental healthcare from Indian Health Services -LRB- IHS -RRB- -LRB- Gone , 2004 -RRB- . IHS 's Indian Health Care System served around 1.6 million American Indians/Alaska Natives residing on or near reservations in 2003 -LRB- IHS , 2003 -RRB- . Over one-third of service utilization within this system involves mental health and social service related concerns -LRB- IHS , 2002 -RRB- . Although Indian Health Services is meant `` to raise the physical , mental , social , and spiritual health of American Indiana and Alaska Natives to the highest level '' -LRB- IHS , 2002 -RRB- , a variety of barriers may impede American Indians ' ability to receive adequate health care . Specific to mental health care delivery , and often overlapping with the characteristics of healthcare in general , Rodenhauser -LRB- 1994 -RRB- characterizes barriers into two major groups : -LRB- 1 -RRB- those within the current medical system , including under-funding and staffing issues , inconsistent services , insensitivities , fear of litigation and non-compliance with organizational requirements , and staff burnout ; and -LRB- 2 -RRB- those inherent to American Indian/Alaska Native cultures , such as fear , high rates of accidents/violence , intrinsic conditions -LRB- i.e. denial , helplessness and hopelessness -RRB- , and mistrust of government agencies . Traditional Help Seeking Research and anecdotal evidence suggests that many American Indians report health related help-seeking via culturally traditional outlets . For example , Marbella , Harris , Diehr , Ignace , and Ignace -LRB- 1998 -RRB- surveyed 150 American Indian adult patients at the Milwaukee Indian Health Center and found that 38 % had sought help from a traditional healer in addition to physician-administered care . Furthermore , 86 % of those interviewed said that they would consider seeking a traditional healer in the future . In instances where traditional healer 's and physician 's advice differed , patients said they would rely on their healer 's advice 61.4 % of the time . In a separate study including respondents from 2 different American Indian tribes , Novins , Beals , Moore , Spicer , and Manson -LRB- 2004 -RRB- found traditional healing options to be prevalent and important to both tribes , whether used alone or in combination with biomedical services . Although traditional beliefs and practices can guide some American Indians through mental and physical illnesses and healing , there is disagreement concerning the degree of connection between traditional and professional medical services at an institutional level . A number of researchers discuss a gap wherein the processes of traditional and mainstream professional healing should be linked -LRB- Marbella et al. , 1998 ; Mohatt & Varvin , 1998 ; Novins , Beals , Sack , & Manson , 2000 ; Novins , Fleming , Beals , & Manson , 2000 -RRB- . Conversely , others feel that formal funding for traditional practices is difficult and perhaps inappropriate . Payment to a traditional healer by a patient may be compromised in a situation where billing must occur via a third party . Issues surrounding payment are complicated further considering the need to establish credentials for employees of government funded agencies like IHS -LRB- Rhoades & Rhoades , 2000 -RRB- . It is also important to consider the heterogeneity of the over 300 different tribal or language groups from which American Indian individuals belong -LRB- Beauvais , 1998 -RRB- . Tribal differences extend to various opinions regarding an integration of the two health care systems -LRB- Rhoades & Rhoades , 2000 ; see also Novins et al. , 2004 -RRB- . Despite some documentation on the preference of traditional vs. western medical treatment among American Indians who receive both , we found little empirical evidence that directly tests the factors that affect this choice -LRB- but see Gurley et al. , 2001 ; Novins et al. , 2004 ; Robin , Chester , Rasmussen , Jaranson , & Goldman , 1997 -RRB- . In addition , there is a lack of empirical research surrounding American Indian mental health/substance use related services utilization -LRB- Manson , 2000 -RRB- , and what work has been done typically focuses on Indian children -LRB- i.e. Novins , Harman , Mitchell , & Manson , 1996 ; Costello , Farmer , Angold , Burns , & Erkanli , 1997 ; Novins et al. , 2000 -RRB- . This research begins to address such gaps in the literature by examining predictors of service preferences among a sample of American Indian adults . Hypotheses In a review of the literature , Manson -LRB- 2000 -RRB- includes differences related to culture -LRB- i.e. acculturation vs. enculturation -RRB- as important predictors of formal mental health service utilization . Elsewhere , higher levels of social support -LRB- here measured as community support -RRB- have been shown to be related to receiving a treatment recommendation for substance use problems -LRB- Novins et al. , 1996 -RRB- ; in turn , being recommended for treatment may increase actual service utilization . In addition , rates of mental health treatment have been found to be higher for adults with a lower perceived health status -LRB- Barker et al. , 2004 -RRB- . Based on these findings and coupled with the barriers to care discussed earlier , we hypothesize that higher levels of enculturation , experiencing discrimination , and living on a reservation will be positively related to perceived effectiveness or preferences for informal services and negatively related to formal services . In addition , self-reported physical health is hypothesized to be negatively related to preferences of both service types -LRB- Barker et al. , 2004 -RRB- . We also predict that higher levels of social support will be positively related to use of both informal and formal service outlets . Lastly , we control for the effects of age , gender , education , and employment on service utilization preferences . METHODS Sample These data were collected as part of the `` Healing Pathways Project , '' a 3-year lagged sequential study currently underway on four American Indian reservations in the Northern Midwest and five Canadian First Nation reserves . Because of national differences in health care systems , the data presented here includes only that from U.S. reservations . The data are from wave one of the study collected on two U.S. reservations from February through October 2002 , and wave one on a second pair of U.S. reservations collected from February through October 2003 . The reservations share a common cultural tradition and language with minor regional variations in dialects . The sample represents one the most populous Native cultures in the United States and Canada . The project was designed in partnership with the participating reservations and reserves . Prior to the application funding , the research team was invited to work on these reservations , and tribal resolutions were obtained . As part of this agreement , the researchers promised that participating reservation names would be kept confidential in published reports . An advisory board was appointed by the tribal council at each participating reservation and is responsible for advising on difficult personnel problems , questionnaire development , reading reports for respectful writing , and assuring that published reports protected the identity of the respondents and the culture . Upon advisory board approval of the questionnaires , the study procedures and questionnaires were submitted for review and approved by an Institutional Review Board . All participating staff on the reservations were approved by the advisory board and were either tribal members themselves or non-members who are spouses of tribal members . To ensure quality of data collection , all interviewers underwent special training for conducting pencil-and-paper and computer-assisted personal interviewing for diagnostic measures , including feedback sessions . In addition , all of the interviewers completed a required human subject 's protection training that emphasized the importance of confidentiality and taught procedures to maintain the confidentiality of data . Each tribe provided lists of families of enrolled children aged 10 -- 12 years who lived on or proximate to -LRB- within 50 miles -RRB- the reservation or reserve . We attempted to contact all families with a target child within the specified age range . Families were recruited via personal visits from Native interviewers during which they were given an explanation of the project , a gift of wild rice , and an invitation to participate . After agreement to participate and later completion of interviews , each participating family member received $ 40 for their time . This recruitment procedure resulted in an overall response rate of 79.4 % . Sample Characteristics The sample for this analysis is made up individuals from the U.S. reservations only and consisted of 865 parents/caretakers -LRB- 264 males and 601 females -RRB- of tribally enrolled children aged 10 -- 12 years . Fathers/male caretakers ranged in age from 21 to 70 years with an average age of 42 years ; mothers/female caretakers ranged in age from 17 to 78 years with an average of 39 years . Measurement To assess the perceived effectiveness of health service providers , respondents were given a series of questions asking them how effective various service outlets would be if ever there were to have -LRB- 1 -RRB- an emotional problem , or -LRB- 2 -RRB- a substance abuse problem . The response categories range from not at all effective to extremely effective . Traditional/informal services include family , talking to an elder , sweat lodge , pipe ceremony , offering tobacco , traditional healer , traditional ceremony , and healing circle . Formal services include Indian Health Service -LRB- IHS -RRB- , doctor , psychologist , social worker , counselor , psychiatrist , chemical dependency counselor , and nurse . Respondents were asked to evaluate the perceived effectiveness of formal services both on and off the reservation . For multivariate analysis a mean effectiveness score was computed for three categories of services : -LRB- 1 -RRB- traditional , -LRB- 2 -RRB- formal on reservation , and -LRB- 3 -RRB- formal off reservation , all within each realm of service need -LRB- emotional and substance abuse -RRB- . Each mean score has a range from 1 to 5 , with higher scores indicating greater perceived effectiveness . Enculturation is a latent construct assessed by three basic elements : -LRB- 1 -RRB- participation in traditional activities , -LRB- 2 -RRB- identification with American Indian culture , and -LRB- 3 -RRB- traditional spirituality -LRB- see Costello et al. , 1997 ; Whitbeck , McMorris , Hoyt , Stubben , & LaFromboise , 2002 -RRB- . The enculturation scale has high internal consistency -LRB- Cronbach 's α = .79 -RRB- , and the standardized version of the scale is used in these analyses . Perceived discrimination is measured with an 11-item scale designed to tap a range of potential types and sources of discrimination . Respondents were asked to report how often they had experienced specific instances of discrimination . Those items included in the scale were ; how often someone said something derogatory or insulting because of your race ; how often a store owner , sales clerk or person working at a business has treated you in a disrespectful way because of your race ; how often the police have hassled you because of your race ; how often you have been ignored or exclude from an activity because of your race ; how often someone has yelled a racial slur or racial insult at you ; how often someone threatened physical harm because of your race ; how often someone suspected you of doing something wrong because of your race ; how often you have been treated unfairly because of your race ; how often you have encountered whites who did n't expect you to do well because of your race ; how often someone discouraged you from trying to achieve an important goal because of your race ; and how often you have been treated unfairly in the courts because of your race . The four response categories range from never to always , with the mean of all 11 items used in these analyses . The scale has a high internal reliability with Cronbach 's α of .90 . Social support is measured with a 17-item scale in which respondents were read statements regarding community and neighborly cohesiveness and conflict . Statements include : this is a close knit community ; people around here are willing to help their neighbors ; there are adults in this community that children can look up to ; there are long standing family grudges in the community ; the community is split by politics ; the community is split by alcohol or drugs ; and so on . Respondents were asked to answer true or false to each statement . Items indicative of community conflict were reverse coded , and then all items were summed so that higher values represent higher community support . Cronbach 's α for this scale is .86 . Health status was assessed by response to the question `` In general , how well would you say your health is ? '' Response categories ranged from excellent -LRB- 5 -RRB- to poor -LRB- 1 -RRB- . Values are coded so that higher scores indicate better health . Several control variables are included in the present analysis . Gender is a dummy variable coded as male = 0 and female = 1 . Education is a five category item ranging from less than high school to an advanced degree . Employment is a dichotomous variable indicating if the respondents are employed full-time . Those with full-time employment are coded as 1 . To assess the difference between those enrolled tribal members living on and off the reservation respondents were asked if they currently lived on the reservation at the time of their interview . Those who lived off of the reservation were given a value of 1 . RESULTS Descriptive Characteristics The adults who comprised this sample had an average educational level falling between a high school diploma and at least some secondary school experience -LRB- mean = 2.4 ; SD = .87 -RRB- , and more than half -LRB- 57 % -RRB- were employed full-time . Very few of the adults lived off of the reservation -LRB- 12 % -RRB- at the time of our interviews . The self-reported health status of the adults in our sample averaged between ` good ' and ` very good ' -LRB- mean = 3.3 ; SD = 1.0 -RRB- , and the overall level of reported social support in the communities was 8.4 -LRB- SD = 4.1 -RRB- . Enculturation is a standardized variable in these analyses -LRB- mean = 0 ; SD = 1 -RRB- , while the mean level of perceived discrimination was 1.5 -LRB- SD = .69 -RRB- , indicating that the average response across all of the discrimination questions fell between ` never ' and ` a few times . ' Among the dependent variables concerning service preferences among respondents , the highest mean scores were found for informal/traditional services for both mental health -LRB- mean = 3.06 ; SD = 1.06 -RRB- and substance use -LRB- mean = 3.09 ; SD = 1.15 -RRB- related issues . Next highest were mean preference scores for on-reservation formal services -LRB- mental health = 2.51 ; SD = 1.01 ; substance use = 2.53 ; SD = 1.09 -RRB- , followed lastly by mean preference ratings for formal off-reservation care -LRB- mental health = 2.32 ; SD = 1.03 ; substance use = 2.34 ; SD = 1.09 -RRB- . Perceived Effectiveness of Services Figure 1 illustrates the perceived effectiveness of services that are commonly used for mental health or substance abuse problems . The reported percentage indicates those respondents who felt the services would be very or extremely effective . There is a clear distinction of the perceived effectiveness between informal or traditional services and more formal services . Seventy-one percent of respondents felt that talking to a family member would be very or extremely effective . Nearly 60 % felt talking to a tribal elder would be highly effective for dealing with mental health or substance problems . More traditional practices/services such as offering tobacco and praying , seeing a traditional healer , traditional ceremonies , healing circle , sweat lodge , and pipe ceremony all were rated between 30 % and 50 % . Speaking to a counselor on the reservation was the highest rated professional service with 32.9 % of respondents indicating it would be very or extremely effective . Most of the on reservation professional services rated higher than services off the reservation but lower than more traditional services . Those services that were seen as least effective were those professional services located off of the reservation.FIGURE 1Perceived Effectiveness of Services Use of Informal and Formal Services Table 1 reports the coefficients from ordinary least squares regression analyses for predictors of respondent perceptions of the effectiveness -LRB- i.e. preferences -RRB- of informal traditional and formal services for substance abuse and mental health concerns . Because this sample contains some cases where two adult reporters were interviewed within a household , reported coefficients are based on standard errors that have been adjusted to account for the potential bias of nested designs -LRB- analyses performed using STATA 7.0 -RRB- . The same sets of variables significantly predict informal service preference for both mental health -LRB- MH , Model 1A -RRB- and substance use -LRB- SU , Model 1B -RRB- related problems . For both models , females were more likely to prefer informal services -LRB- MH : β = .06 , p < .05 ; SU : β = .05 , p < .10 -RRB- , as were the employed -LRB- MH : β = .07 , p < .05 ; SU : β = .07 , p < .05 -RRB- . For both Model 1A and 1B , higher rates of social support -LRB- MH : β = .13 , p < .001 ; SU : β = .13 , p < .001 -RRB- , higher enculturation scores -LRB- MH : β = .49 , p < .001 ; SU : β = .44 , p < .001 -RRB- , and higher reports of perceived discrimination -LRB- MH : β = .09 , p < .01 ; SU : β = .11 , p < .01 -RRB- were all positively associated with informal service preferences.TABLE 1OLS Regression Models Predicting Perceived Effectiveness -LRB- Preferences -RRB- of Mental Health and Substance Use Related ServicesMental HealthSubstance Use1A2A3A1B2B3BInformalFormal -LRB- on res . -RRB- Formal -LRB- off res . -RRB- InformalFormal -LRB- on res . -RRB- Formal -LRB- off res . -RRB- BβBβBβBβBβBβAge − 0.003 − 0.030.010.05 − 0.002 − 0.020.0010.010.010.07 +0.000.003 Gender -LRB- female = 1 -RRB- 0.150.06 * 0.130.06 +0.040.020.130.05 +0.050.002 − 0.03 − 0.01 Education0 .040.030.140.12 ** 0.210.18 *** 0.040.030.170.13 *** 0.190.15 *** Employment0 .140.07 * 0.080.04 − 0.01 − 0.010.150.07 * 0.020.01 − 0.06 − 0.03 Live off reservation0 .170.050.180.060.280.09 * 0.070.020.270.08 * 0.470.14 *** Physical health status0 .010.010.030.030.020.02 − 0.02 − .010.020.010.010.01 Social support0 .030.13 *** 0.030.13 *** 0.020.08 * 0.040.13 *** 0.050.17 *** 0.020.09 *** Enculturation0 .520.49 *** − 0.05 − 0.05 − 0.05 − 0.050.510.44 *** − 0.05 − 0.05 − 0.08-.07 * Discrimination0 .140.09 ** 0.110.07 + − 0.07 − 0.050.190.11 ** 0.170.1 ** − 0.09 − 0.06 Constant2 .371.281.731.101.77 R20 .290.050.060.250.060.07 Adjusted R20 .280.040.050.240.050.06 + p < .10 ; * p < .05 ; ** p < .01 ; *** p < .001 -LRB- two-tail test -RRB- . Sample size across models ranges from n = 803 to n = 822 after listwise deletion . Moving to predictors of formal service preferences on reservations -LRB- Models 2A & 2B -RRB- , higher levels of social support were a significant predictor in both the MH -LRB- β = .13 , p < .001 -RRB- and SU -LRB- β = .17 , p < .001 -RRB- models , as were higher rates of perceived discrimination -LRB- MH : β = .07 , p < .10 ; SU : β = .10 , p < .01 -RRB- and education -LRB- MH : β = .12 , p < .01 ; SU : β = .13 , p < .001 -RRB- . Age is significantly associated with formal on-reservation service preferences only for substance use problems -LRB- β = .06 , p < .10 -RRB- , whereas females are more likely than males to prefer on-reservation formal care in the case of mental health problems -LRB- β = .06 , p < .10 -RRB- . Models 3A and 3B illustrate the coefficients for predictors of formal off-reservation service preferences . Both models contain similar findings : higher education -LRB- MH : β = .18 , p < .001 ; SU : β = .15 , p < .001 -RRB- , living off of reservation lands -LRB- MH : β = .09 , p < .05 ; SU : β = .14 , p < .001 -RRB- , and higher levels of social support -LRB- MH : β = .08 , p < .05 ; SU : β = .09 , p < .05 -RRB- were all positively associated with higher preferences for formal off-reservation services . In addition , Model 3B shows that those who scored higher on levels of traditional enculturation were less likely to perceive formal off-reservation care as effective in terms of substance use related problems -LRB- β = − .07 , p < .05 -RRB- . Across all of the models in Table 1 , the independent variables explain proportionately more of the variance for the informal service models than those with formal services as the dependent variable . Adjusted R2 values for these models indicate that the predictors explain 28 % and 24 % of the variance in informal service preferences for MH and SU problems , respectively . These values for formal reservation-based care are 4 % for MH and 5 % for SU problems . The models for formal off-reservation care explain 5 % of the variance in preferences for MH problems and 6 % of the variance for SU problems . DISCUSSION The adults in our sample felt that more culturally traditional services -LRB- such as family or a traditional healer -RRB- would be more effective than either professional services on the reservation , or professional services off the reservation . Off reservation services were perceived to be least effective . These findings support literature that suggests American Indians generally place considerable trust in traditional practices -LRB- i.e. Marbella et al. , 1998 -RRB- . The finding that mainstream professional services are perceived as less effective than traditional informal services and some of the on-reservation professional services underlies the previous discussion surrounding issues of trust and appropriateness of Western care in relation to American Indian cultures . It is also possible that a crisis-oriented care system may not be suited to adequately deal with mental health and substance abuse needs -LRB- Oetting & Beauvais , 1990 -- 1991 -RRB- . The multivariate analyses supported several of our hypotheses . Among the control variables , females were slightly more likely than males to report higher preference for both -LRB- MH & SA -RRB- types of informal care , as well as for on-reservation MH care . Though not explicitly hypothesized , these results correspond with previous help-seeking research that has found women more likely than men to view care as an appropriate remedy for psychological issues -LRB- Horwitz , 1987 -RRB- . Higher educational levels and employment were generally related to higher effectiveness ratings for services in this study , also corroborating previous research -LRB- see , for example , Horwitz , 1999 , p. 66 -RRB- . As expected , those who are more enculturated were more likely to utilize informal traditional services than those who are less enculturated . In addition , in the case of services for substance use disorders , higher levels of enculturation were negatively associated with preferences for formal off-reservation care -LRB- Model 3B -RRB- . Those who lived off the reservation were more likely to use formal services , especially in terms of off-reservation care . Consistent with past research -LRB- Novins et al. , 1996 -RRB- and as hypothesized , perceived social support was positively associated with higher perceptions of effective care across all types of services . Our hypothesis that higher rates of perceived discrimination would be associated with preferences for informal or traditional care is supported here . We found similar effects for discrimination and formal on-reservation care . These findings are congruent with Rodenhauser 's -LRB- 1994 -RRB- description of the barriers to dominant-culture care in terms of mistrust of government agencies , all stemming from a history of colonization and continued institutional racism experienced by many American Indian peoples -LRB- see , for example , Duran & Duran , 1995 -RRB- . Overall , the results of this study highlight a preference for informal or culturally based care , especially among the enculturated . The differences in the proportions of variance explained across each of the models in Table 1 warrant discussion . These analyses include only one measure of cultural identity : enculturation . As discussed , this measure was significantly associated with ratings of informal service preference , but did little in terms of predicting formal service preferences . It may be that an important predictor of formal services is acculturation , or perhaps even biculturalism . Future work might include such measures to further our understanding of how cultural identity affects service preference and utilization -LRB- see Novins et al. , 2004 -RRB- . Limitations Although we interviewed a broad range of American Indian adults on multiple reservations that are dispersed geographically across two Midwestern states , these results pertain to a single culture and capture variations within this culture . We believe the findings represent the culture well , but they can not be generalized to other Native cultures . A second caution regarding the sample is that it is made up of parents and caretakers of children aged 10 -- 12 years . This could reflect a selection bias in that parents/caretakers may be more likely to utilize services and to be currently mentally healthy and alcohol and drug free than individuals with no children . Finally , all of our measures are based on self-reports . We did not have access to service utilization rates from local clinics or reports of services use from traditional healers . Policy Implications These findings have important policy implications for those who provide health services to American Indian people . Cultural traditions are very much alive on U.S. reservations and are preferred methods of healing for mental health or substance abuse problems . This should be taken into account when designing health services systems either by providing alternative services onsite or through creatively engaging informal traditional services . Simply acknowledging informal service providers by asking the patient if they have seen a traditional healer and then contacting him or her for an opinion would be an important step . Health providers could include key community spiritual leaders and healers on health advisory boards or create health partnerships that would encourage mutual referrals . Perhaps the place to begin would be to respectfully seek the advice of elders on decreasing barriers between the two . Actual integration of services is already taking place on many reservations , but implementation is not always straight forward -LRB- Marabella et al. , 1998 ; Mohatt & Varvin , 1998 ; Rhoades , & Rhoades , 2000 -RRB- . Issues about selection of traditional healers , and how to reimburse them such as whether they should charge fees for services and coverage for third party payments must be worked out culture by culture . Some view such integration as a potential acculturation risk . Changing the current short comings in mental health delivery first involves acknowledging that parallel systems exist in some cultures . The impetus for change may have to come from formal services providers who should demonstrate respect for traditional healers , invite their advice , and consult with them if patient 's give permission . Clinicians may need to be proactive in offering their patients this option rather than waiting for the patient to request it . Creating this sensitivity may require specialized training for services providers on American Indian reservations . Grant funding groups may want to consider supporting model programs that bring together the two healing modalities . Future Research There is much to be done to increase American Indians ' confidence in health services systems . One avenue for this would be to work more closely with informal traditional services that are trusted . We need control group trials of innovative services models that cross over between formal medical services and traditional approaches to healing to assess the efficacy of combining the approaches . Continued failure to acknowledge the strong preferences for traditional ways is to ignore a valuable health resource .

B I O B I O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O B I O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O 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