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Thank you for submitting your revised manuscript. The reviewers and myself are now happy to accept it in its revised form.
[# PeerJ Staff Note - this decision was reviewed and approved by Jafri Abdullah, a PeerJ Section Editor covering this Section #]
The authors have adding to the literature review and have significantly strengthened their work in this way.
Both reviewers picked up the importance of clarifying the the sample size. This has now been corrected.
The authors clarified the issue of signficance between respondents and controls.
Overall, the authors have done a very good job of responding to the suggestions of both reviewers. The Conclusions section is now much stronger by including recommendations for other researchers.
This is a revision, all comments were addressed sufficiently and strengthened the manuscript.
This is a revision, all comments were addressed sufficiently and strengthened the manuscript.
This is a revision, all comments were addressed sufficiently and strengthened the manuscript.
This is a revision, all comments were addressed sufficiently and strengthened the manuscript.
This is a really interesting and important piece of work as noted by the reviewers. I look forward to receiving the revised manuscript.
**PeerJ Staff Note:** Please ensure that all review, editorial, and staff comments are addressed in a response letter and any edits or clarifications mentioned in the letter are also inserted into the revised manuscript where appropriate.
This is a generally good article on a very important topic.
The English is generally good but the article will benefit from closer copyediting.
The article structure is good, providing 4 specific aims that are then addressed in turn.
The Introduction could be improved by adding data on surveys that show the range of percentages of Native Americans that have substance use problems. For example, acknowledging that 15-18% of Native Americans have substance use problems. I would also include current estimates of the numbers who have diabetes and how this can be related to alcohol use disorder.
The literature review is very clear and strong. The reader gets a good sense of how substance abuse intertwines with other important social problems.
I can't get a sense of how many people were initially contacted and why it was determined to have 8 cases and 8 controls. That is a small number and the authors should provide a rationale for that.
I am not a research methodologist/statistician and I hope another reviewer has this expertise to share.
Aim 1. Cases and controls are very similar in demographics.
Aim 2. The cases and controls are comparable on age, source, place and social context of initial drug use.The finding that the controls used benzodiapines at earlier ages is an interesting.
Aim 3. Not a surprise that that cases and controls used several substances at similar rates.
Aim 4. It is one of the important findings that those without clinical training can determine if a substance use disorder is present. It seems as though the authors intentionally avoided using one of the screening tools widely available. If that is the case because the tools don't adequately address Native American substance use, that should be discussed.
There are so similarities between cases and controls it is hard to see the differences. The authors need to grapple with this issue.
Since this article is specifically addressing urban Natives, what can the authors say, if anything, about differences between urban natives and those on reservations?
I'd like to see the authors add some specific advice for other researchers to the Conclusions section.
Basic Reporting
“Context of Substance Initiation among Urban Native Americans: An Exploratory Retrospective Case-Control Study.”
This article is well organized and professionally written. The abstract is concise and clearly conveys the aims of the study as well as the results. One suggestion would be to list the total number of cases and controls on lines 20 and 21.
More emphasis on the use of lay professionals (line 24) would strengthen the abstract and a clear distinction between “obtaining first drugs” and “first use of drugs” would make results easier to interpret (lines 40 and 41).
The introduction is comprehensive, but I would suggest that emphasis be placed on a discussion of the use of lay professionals, in other underrepresented communities in general, if not in Native American communities. Also, on lines 74-75 there is a reference to the lack of studies that “have examined the ways in which Native Americans have succeeded in recovering from addiction, etc.” Studies exist based on Native healing methods and/or newly designed programs with Native input. I would suggest a perusal of the Indian Health Service site as well as SAMHSA sites to further research and briefly review (a sentence or two) examples like the Red Road to Wellbriety and not just referencing AA and western models of treatment.
There are gaps in the literature review that would strengthen this article. This is a thorough review of the literature on substance use and misuse among Native Americans and the relationship to trauma, ACES, etc. More mention of the use of lay professionals within Native American communities is needed. There are CBPR studies that have used Native community members to gather Patient Health Questionnaire-9 (PHQ-9) data in community settings. These community members also attended comprehensive training to conduct data on substance use/misuse and suicide. See “Social Work in Mental Health, 20, 530-541. doi:10.1080/15332985.2022.2032534.”
There is a recognition that the DSM criteria training may have been more detailed in nature, but other studies need to be thoroughly reviewed to then make the statement that this is the first study of this kind. If there is a clear distinction between them and this study, as in the training, then you might be justified in stating that.
Data were clearly presented in the tables and in the text, although more data on the demographics of the lay professionals, as well as data on their MH background is desirable.
Experimental Design
A retrospective cross-sectional case-control design with a community-based convenience sample was conducted. The aims of the study are clearly and concisely stated and are designed in such a way that they do fill a gap in the literature as to the factors involved in first obtaining drugs and first using drugs. This aim is important as it is a novel approach to gathering data on substance use as it is retrospective in nature, albeit not always accurate.
More information is essential to determine whether the research assistants were just members of the “lay community.” Did their “history of working with supportive mental health services” on line 204 and “past research collaboration” on line 205 positively impact their use of the measures as they were already partially experienced or trained in mental health services, or were they recipients of mental health services?
REDCap system information would help the reader to understand that it is an online survey/data collection system (lines 211-212).
Additional survey Information would support this section of the paper. Did the interviewer explain, in detail, the consent form especially if it was via the phone? Examples of questions are needed, how long did it take to complete the survey, when surveys were in person, where did they take place (in the home, in a community setting) and was it private? How long did it take for the participants to complete the survey, and did the randomly chosen individuals get another incentive for the phone conversation with the LDAC? Over what time period did the original raw data collection occur?
Validity of the Findings
The results section and the tables are easily understandable, but the total number of cases and controls should be listed. Given the nature and design of the study, more information provided in the methods section could assist in replication on a larger scale. More particulars on the nature of the DSM training and the demographics of the RAs would be helpful.
Discussion and Conclusion
This section would be strengthened if there was further information on how results are situated in the literature. In the conclusion section line 331 a limitation is mentioned and might be stated elsewhere with the other limitations (lines 298-302.) A more convincing argument regarding lay individuals could be supported with more information on relevant literature, DMS training and demographics as stated earlier in this review.
It would be important to replicate this study on a larger scale, with some revisions, as it is important to Native populations in general to experience research, participate in research and add to the sparse data sets that exist and do not thoroughly describe the Native people and their challenges as well as successes.
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