Evaluation
of a Regional
B
U.
LASS RENCE
\\ ILSON,
Indian
M.D.,
A\I)
Alcohol
JAMES
H.
Program
SHORE.
The authors analyzedfollow-up data collected by an Indian counselor and a psychiatrist on 83 A merican Indian alcoholic men. Follow-up status wasjudged by an interdisciplinary scale. The f avorably
panel
according
44 percent with other
view ofthe selection patients. The author.s ratingpanel judgments
process. suggest
i.s an approach ofthe
to a six-step
improvement treatment
drinking
rate programs,
rat ing
compares especiallt’
in
whichfat’ored difficult that the interdisciplinary that
can
.statu.s
ofA
prevent
erroneous
merican
Indians.
RAPID GROWTH of alcohol treatment programs for American Indians within the past three years has created the need for a systematic evaluation approach. This paper reports a follow-up evaluation of83 American Indian alcoholic men from five major Northwest tribes who were treated in a regional intertribal and interagency alcohol rehabilitation program. Their follow-up status was assessed at an average of 18 months after inpatient discharge. The purposes of the research were as follows: I ) to de-
THE
velop
a method
of
assessing
the
follow-up
status
of
In-
dian alcoholics: 2) to identify the characteristics of Northwest Indian drinkers who had been treated in this program; 3) to analyze the follow-up status data for differences between tribal groups and differences on demographic, social, and health variables; and 4) to cornpare these data with results from other American Indian alcohol treatment programs.
ALCOHOL
TREATMENT
FOR AMERICAN
INDIANS
Alcoholism as a major health problem of American Indians has been widely discussed by both Indian and non-Indian sources ( I ). Many theories and viewpoints
\1.1).
that attempt to explain the extent of drinking in Indian populations have been reported in the anthropological and sociological literature in past years. However, the earliest report on the effectiveness of’ alcohol rehabilitation programs for Indian people appeared in the literature in 1968. Ferguson (2) and Savard (3) reported on separate projects that evaluated the outcome of treatment with disulfiram in Navajo communities. Their reports described the therapeutic effect of disulfiram posilively and recommended its continued use. Shore and Von Fumeni (4) reported on three tribally sponsored alcohol programs, emphasizing four factors: I ) the involvement of Indian people in planning and operating their own programs; 2) the treatment philosophy that had evolved within the context of the Indian communities; 3) the relationship of the court to these programs; and 4) the need for uniform standards to evaluate patients. The regional alcohol rehabilitation program described in this paper is located in the Pacific Northwest, which ineludes the states of Washington, Oregon, and Idaho. The treatment service was coordinated by the Mental Health Program of the Indian Health Service and was a joint effort by tribal alcohol programs, the Indian Health Service, and a private inpatient treatment center. North
version of Psychiatric
a paper read Association,
at the Detroit,
127th annual Mich., May
meeting of 6- 10, 1974.
the
At the time this work was done, Dr. Wilson was a resident in psychiatry at the University of Washington School of Medicine, Seattle, Wash., where he is now Instructor, Department of Psychiatry and Behavioral Sciences. He is also Staff Psychiatrist, Veterans Administration Hospital, 4435 Beacon Ave. South, Seattle, Wash. 98108. Dr. Shore was Chief, Mental Health Office, Portland Area Indian Health Service, Portland, Ore., when this work was done: he is now Director, Community Psychiatry Training Program. and Associate Professor of Psychiatry, University of Oregon School of Medicine, Portland, Ore. The authors wish Dearborn, Program dian Health Service.
to gratefully Assistant,
acknowledge Mental Health
the aid of Ms. Office, Portland
Carolyn Area In-
Indian
Tribal
Programs
Indian tribes of the Pacific Northwest consist of 33 diverse and geographically isolated groups with two distinct cultural backgrounds, the Northwest coastal and plateau cultures. The large number of tribes and the absence of Indian hospitals necessitated sharing of the inpatient services for alcohol treatment. All tribes were included in the coordinated rehabilitation service. Five tribal alcohol programs from four plateau tribes and one coastal tribe were invited to participate in the evaluation of this program. These tribes were selected
because
tablished grams.
Revised American
west
of
their
larger
reservation-based Since
1969,
these
populations
alcohol five
programs
and
rehabilitation had
worked
their
es-
procoop-
eratively with the Indian Health Service to establish the regional treatment center. The reservation-based tribal alcohol programs are totally outpatient in design. They receive funding support from the National Institute of Alcohol Abuse and Alcoholism through their tribal governments. Mental health consultation is available through the Mental Health Branch of the Indian Health Service, a regional con sultalion service. A third component of the coordinated treatment program is a private residential treatment center for male problem drinkers that is located on a major Northwest Indian reservation. The inpatient program
Am
J Psychiatry
/32:3,
March
/975
255
INDIAN
ALCOHOl.
PROGRAM
consists of a standardized regimen of group and individual counseling and an intensive alcohol education program. Within this general program, a special treatment plan was developed for Indian patients that includes regularly scheduled sessions with Indian counselors and outpatient follow-up on the home reservation. The coordinated treatment aspects of this rehabilitation program include case identification by the local tribe alcohol program (usually by an Indian alcohol counselor), referral through the Indian Health Service to the regional inpatient center, including evaluation of physical status and special psychiatric examination where indicated, and coordinated
follow-up
after
discharge
by
each
of
the
tribal programs and the Indian Health Service. Thus, the treatment program is regional in scope, intertribal in nature, and interagency in operation.
METHOD
The study sample consisted of 83 Indian men from the Colville, Spokane, Warm Springs, Yakima, and Lummi tribes. All tribes were of the plateau culture except the Lummi, who are a coastal tribe. These five tribes consist of approximately 15,000 reservation Indians, 60 percent ofthe region’s reservation Indian population. Eight additional tribes were represented by I individual each. The sample included all Indian men referred to the regional inpatient treatment center during an 18-month period from January 1971 through June 1972. Since this was the beginning of the regional treatment program, Indian women were being referred in smaller numbers and were not included in the study sample. Information was collected systematically by the Indian alcohol counselor for each subject. This included demographic data, education and employment background, arrest record, and health history. The data were compiled from existing case records and personal interviews. Health histories were gathered by the project psychiatrist through a review of medical records. A profile was developed on each subject that was used as the data base to assess follow-up status. Subsequently, a rating panel met on each reservation to determine the follow-up status of all individual patients. The project psychiatrist (LGW) met with an Indian alcohol counselor from the local tribal program and a psychiatric social worker who was also working in the local Indian community. This three-member panel employed a six-step rating scale patterned after that developed by Fitzgerald and associates (5). The rating was specifically aimed at defining the patient’s status in areas of personal, family, and community functioning in relationship to his current drinking pattern and emotional adjustment. All information from the profile of’ individual patients was shared with the panel, as well as current information about the patient’s f’unctioning, which was usually supplied by the Indian alcohol counselor. Anecdotal information from friends, relatives, or other knowledgeable community people was included. Each patient (and his spouse, if’ applicable) was rated
256
Am
J Psychiatry
/32:3.
March
/975
separately by each of the three panel members. After separate ratings, a group consensus rating was given, which was used in the final analysis. There was a high degree of interrater agreement, which indicated that the Indian alcohol counselor and the project psychiatrist agreed about patient ratings.
RESULTS Demographic
Data
The average age of the subjects was 41 years, with a range of 21 to 67 years. Indian men in their 30s and 40s were most heavily represented (N=25 and 24, respeclively). Subjects in their 20s (N= 12) were underrepresented in comparison to an epidemiological pattern of an entire Northwest tribal population (6). Twenty-two ofthe men were married and 61 were unmarried. Educational experience ranged from the fourth grade to two years of college, with the average being a ninth-grade education. Forty-nine subjects were employed, either full-time or part-time, and 34 were unemployed. Of the 83 subjects, 40 had had military service. There was a representative
the
group,
members
sample
with ofthe
41
of’ religious
Catholics,
traditional
Indian
afliliation
12
throughout
Protestants,
II
and
religion.
The majority of the subjects did not fit the stereotype of highly mobile “skid-row” alcoholics: 68 of the 83 were living on reservations, and 45 had lived in their present home for more than one year. Using the two-factor social class index of Hollingshead and Redlich (7), distribution was predominantly in Classes IV (N=9) and V (N=55). In a further refinement, an Indian social class rating was assigned, using the method of Shore and associates (6).’ With this technique, there was I subject in Indian Social Class I, 28 in Class II, and 36 in Class III (unknown= 18). Since the ratio of these classes was 1:2:1 in a representative sample of one total Northwest tribal population (6), our sample is significantly overrepresented in Class
III.
In the
epidemiology
pattern
for
one
tribe,
alco-
holism though
was more evenly spread through the classes, althe most severely impaired alcoholics were from Class Ill. A history of arrest records, obtained for 64 of the 83 subjects, indicated that 8 subjects had had no arrests, while 56 had one or more. There was no previous treatment history in 24 of the 83 subjects; 29 listed one or more prior rehabilitation programs. Of the 68 subjects who answered a question assessing their own medical status, 34 judged themselves to have good or excellent health, while 34 considered themselves to be in fair or poor health. Fifty-two individuals reported one or more hospitalizations, usually related to alcoholism; 16 subjects were admitted a second time to the inpatient center and 2 subjects had three inpatient admissions. Many sub‘Since most reservation Indians fall into the lowest Hollingshead-Redlich categories, Shore and associates (6) divided the Indian population into three main modal distributions of Hollingshead-Redlich scores. This gave a distribution they called “Indian Social Class,” thought to be a truer description of the social stratification of Indian communities.
LAWRENCE
TABLE
G. WILSON
ANI)
JAMES
11. SHORE
I
Iollow-Lp
Status’
of 83
lndia,z
.Ilcoholic,s’
N umber
Rating*
Clear improvement I. Complete abstinence in past year or since discharge from treatment facility and maintaining vocational, home, responsibilities. 2. Occasional or sporadic drinking in past year or since discharge. but maintaining vocational, home, and famil Erratic improvement 3. Drinking periodically or regularly during past year or since discharge, but no outstanding community problems on home and family. No improvement 4. Drinking to the extent that vocational and family responsibilities are not maintained-has come to the attention for drinking in the past year or since discharge. to follow-up 5. Drinking status 6. Deceased.
and
family I 12
responsibilities. or severe
effects 13
of the community 3S
Lost
*
Based
on
the
10 2
unknown.
classilication
ssiern
by Fitigerald
used
and
associates
(5).
jects in the group had experienced severe drawal, but the medical records were enough for a statistical analysis. Disulfiram
alcoholic withnot complete played a mi-
nor
of this
role
in the
follow-up
spite of the positive Navajo alcoholics. Follow-Up
treatment
results
plans
previously
group
reported
in
with
improvement and
no
5 had
improvement.
erratic Also,
improvement, the
lack
of a sig-
nificant relationship between follow-up status and religious affiliation did not substantiate earlier impressions of many counselors, who hypothesized a positive relationship between treatment outcome and traditional Indian
Status
follow-up,
at
16 showed
religion.
subjects
Instead,
to show
there
greater
was
a trend
improvement
for
Protestant
at the
time
of fol-
In order to summarize follow-up status and compare the results with the outcome of other treatment programs, categories I and 2 of the six-step classification (see table I ) are considered to be clear improvement, category 3 represents erratic improvement, and category 4 indicates no improvement. Categories 5 and 6 indicate loss to follow-up. Clear improvement was demonstrated in 28 percent of the subjects (N=23), erratic improvement in 16 percent (N=13), and no improvement in 42
ered to have shown no improvement. Married subjects had a significantly higher improvement rating than those who were unmarried (i.e., single, separated, divorced, or widowed) (x2= 10.88, p =005). Less than 20 percent of the married subjects were un-
percent
for
(N=35).
Thus,
some
Twelve
subjects
were
lost
to
follow-up.
improved, while were unimproved. 16 of the
over half Drinking
married
of I I Protestants while only 2 were
of the status
subjects,
and
of
unmarried wives
the
showed consid-
subjects known
was
man/wife
drinking
status was a direct one-to-one relationship for 10 of these couples. In the group of 18 subjects who were readmitted for two (N I 6) or three (N 2) inpatient treatment sessions, 8 showed improvement, 7 showed no improvement, and 3 were lost to follow-up.
for
DISCUSSION
of
employment
was
Eight out or erratic),
seen in 44 percent of the patients and no improvement in 42 percent at follow-up. Follow-up status was then compared to specific characteristics in the profile of the Indian alcoholic. There were no significant differences in follow-up status between the five major tribal groups or between decade of life, type of marriage (intra-, inter-, or extratribal), type of religion, or Indian social class (which includes scores type
improvement
low-up (.OS
of a Regional
B
U.
LASS RENCE
\\ ILSON,
Indian
M.D.,
A\I)
Alcohol
JAMES
H.
Program
SHORE.
The authors analyzedfollow-up data collected by an Indian counselor and a psychiatrist on 83 A merican Indian alcoholic men. Follow-up status wasjudged by an interdisciplinary scale. The f avorably
panel
according
44 percent with other
view ofthe selection patients. The author.s ratingpanel judgments
process. suggest
i.s an approach ofthe
to a six-step
improvement treatment
drinking
rate programs,
rat ing
compares especiallt’
in
whichfat’ored difficult that the interdisciplinary that
can
.statu.s
ofA
prevent
erroneous
merican
Indians.
RAPID GROWTH of alcohol treatment programs for American Indians within the past three years has created the need for a systematic evaluation approach. This paper reports a follow-up evaluation of83 American Indian alcoholic men from five major Northwest tribes who were treated in a regional intertribal and interagency alcohol rehabilitation program. Their follow-up status was assessed at an average of 18 months after inpatient discharge. The purposes of the research were as follows: I ) to de-
THE
velop
a method
of
assessing
the
follow-up
status
of
In-
dian alcoholics: 2) to identify the characteristics of Northwest Indian drinkers who had been treated in this program; 3) to analyze the follow-up status data for differences between tribal groups and differences on demographic, social, and health variables; and 4) to cornpare these data with results from other American Indian alcohol treatment programs.
ALCOHOL
TREATMENT
FOR AMERICAN
INDIANS
Alcoholism as a major health problem of American Indians has been widely discussed by both Indian and non-Indian sources ( I ). Many theories and viewpoints
\1.1).
that attempt to explain the extent of drinking in Indian populations have been reported in the anthropological and sociological literature in past years. However, the earliest report on the effectiveness of’ alcohol rehabilitation programs for Indian people appeared in the literature in 1968. Ferguson (2) and Savard (3) reported on separate projects that evaluated the outcome of treatment with disulfiram in Navajo communities. Their reports described the therapeutic effect of disulfiram posilively and recommended its continued use. Shore and Von Fumeni (4) reported on three tribally sponsored alcohol programs, emphasizing four factors: I ) the involvement of Indian people in planning and operating their own programs; 2) the treatment philosophy that had evolved within the context of the Indian communities; 3) the relationship of the court to these programs; and 4) the need for uniform standards to evaluate patients. The regional alcohol rehabilitation program described in this paper is located in the Pacific Northwest, which ineludes the states of Washington, Oregon, and Idaho. The treatment service was coordinated by the Mental Health Program of the Indian Health Service and was a joint effort by tribal alcohol programs, the Indian Health Service, and a private inpatient treatment center. North
version of Psychiatric
a paper read Association,
at the Detroit,
127th annual Mich., May
meeting of 6- 10, 1974.
the
At the time this work was done, Dr. Wilson was a resident in psychiatry at the University of Washington School of Medicine, Seattle, Wash., where he is now Instructor, Department of Psychiatry and Behavioral Sciences. He is also Staff Psychiatrist, Veterans Administration Hospital, 4435 Beacon Ave. South, Seattle, Wash. 98108. Dr. Shore was Chief, Mental Health Office, Portland Area Indian Health Service, Portland, Ore., when this work was done: he is now Director, Community Psychiatry Training Program. and Associate Professor of Psychiatry, University of Oregon School of Medicine, Portland, Ore. The authors wish Dearborn, Program dian Health Service.
to gratefully Assistant,
acknowledge Mental Health
the aid of Ms. Office, Portland
Carolyn Area In-
Indian
Tribal
Programs
Indian tribes of the Pacific Northwest consist of 33 diverse and geographically isolated groups with two distinct cultural backgrounds, the Northwest coastal and plateau cultures. The large number of tribes and the absence of Indian hospitals necessitated sharing of the inpatient services for alcohol treatment. All tribes were included in the coordinated rehabilitation service. Five tribal alcohol programs from four plateau tribes and one coastal tribe were invited to participate in the evaluation of this program. These tribes were selected
because
tablished grams.
Revised American
west
of
their
larger
reservation-based Since
1969,
these
populations
alcohol five
programs
and
rehabilitation had
worked
their
es-
procoop-
eratively with the Indian Health Service to establish the regional treatment center. The reservation-based tribal alcohol programs are totally outpatient in design. They receive funding support from the National Institute of Alcohol Abuse and Alcoholism through their tribal governments. Mental health consultation is available through the Mental Health Branch of the Indian Health Service, a regional con sultalion service. A third component of the coordinated treatment program is a private residential treatment center for male problem drinkers that is located on a major Northwest Indian reservation. The inpatient program
Am
J Psychiatry
/32:3,
March
/975
255
INDIAN
ALCOHOl.
PROGRAM
consists of a standardized regimen of group and individual counseling and an intensive alcohol education program. Within this general program, a special treatment plan was developed for Indian patients that includes regularly scheduled sessions with Indian counselors and outpatient follow-up on the home reservation. The coordinated treatment aspects of this rehabilitation program include case identification by the local tribe alcohol program (usually by an Indian alcohol counselor), referral through the Indian Health Service to the regional inpatient center, including evaluation of physical status and special psychiatric examination where indicated, and coordinated
follow-up
after
discharge
by
each
of
the
tribal programs and the Indian Health Service. Thus, the treatment program is regional in scope, intertribal in nature, and interagency in operation.
METHOD
The study sample consisted of 83 Indian men from the Colville, Spokane, Warm Springs, Yakima, and Lummi tribes. All tribes were of the plateau culture except the Lummi, who are a coastal tribe. These five tribes consist of approximately 15,000 reservation Indians, 60 percent ofthe region’s reservation Indian population. Eight additional tribes were represented by I individual each. The sample included all Indian men referred to the regional inpatient treatment center during an 18-month period from January 1971 through June 1972. Since this was the beginning of the regional treatment program, Indian women were being referred in smaller numbers and were not included in the study sample. Information was collected systematically by the Indian alcohol counselor for each subject. This included demographic data, education and employment background, arrest record, and health history. The data were compiled from existing case records and personal interviews. Health histories were gathered by the project psychiatrist through a review of medical records. A profile was developed on each subject that was used as the data base to assess follow-up status. Subsequently, a rating panel met on each reservation to determine the follow-up status of all individual patients. The project psychiatrist (LGW) met with an Indian alcohol counselor from the local tribal program and a psychiatric social worker who was also working in the local Indian community. This three-member panel employed a six-step rating scale patterned after that developed by Fitzgerald and associates (5). The rating was specifically aimed at defining the patient’s status in areas of personal, family, and community functioning in relationship to his current drinking pattern and emotional adjustment. All information from the profile of’ individual patients was shared with the panel, as well as current information about the patient’s f’unctioning, which was usually supplied by the Indian alcohol counselor. Anecdotal information from friends, relatives, or other knowledgeable community people was included. Each patient (and his spouse, if’ applicable) was rated
256
Am
J Psychiatry
/32:3.
March
/975
separately by each of the three panel members. After separate ratings, a group consensus rating was given, which was used in the final analysis. There was a high degree of interrater agreement, which indicated that the Indian alcohol counselor and the project psychiatrist agreed about patient ratings.
RESULTS Demographic
Data
The average age of the subjects was 41 years, with a range of 21 to 67 years. Indian men in their 30s and 40s were most heavily represented (N=25 and 24, respeclively). Subjects in their 20s (N= 12) were underrepresented in comparison to an epidemiological pattern of an entire Northwest tribal population (6). Twenty-two ofthe men were married and 61 were unmarried. Educational experience ranged from the fourth grade to two years of college, with the average being a ninth-grade education. Forty-nine subjects were employed, either full-time or part-time, and 34 were unemployed. Of the 83 subjects, 40 had had military service. There was a representative
the
group,
members
sample
with ofthe
41
of’ religious
Catholics,
traditional
Indian
afliliation
12
throughout
Protestants,
II
and
religion.
The majority of the subjects did not fit the stereotype of highly mobile “skid-row” alcoholics: 68 of the 83 were living on reservations, and 45 had lived in their present home for more than one year. Using the two-factor social class index of Hollingshead and Redlich (7), distribution was predominantly in Classes IV (N=9) and V (N=55). In a further refinement, an Indian social class rating was assigned, using the method of Shore and associates (6).’ With this technique, there was I subject in Indian Social Class I, 28 in Class II, and 36 in Class III (unknown= 18). Since the ratio of these classes was 1:2:1 in a representative sample of one total Northwest tribal population (6), our sample is significantly overrepresented in Class
III.
In the
epidemiology
pattern
for
one
tribe,
alco-
holism though
was more evenly spread through the classes, althe most severely impaired alcoholics were from Class Ill. A history of arrest records, obtained for 64 of the 83 subjects, indicated that 8 subjects had had no arrests, while 56 had one or more. There was no previous treatment history in 24 of the 83 subjects; 29 listed one or more prior rehabilitation programs. Of the 68 subjects who answered a question assessing their own medical status, 34 judged themselves to have good or excellent health, while 34 considered themselves to be in fair or poor health. Fifty-two individuals reported one or more hospitalizations, usually related to alcoholism; 16 subjects were admitted a second time to the inpatient center and 2 subjects had three inpatient admissions. Many sub‘Since most reservation Indians fall into the lowest Hollingshead-Redlich categories, Shore and associates (6) divided the Indian population into three main modal distributions of Hollingshead-Redlich scores. This gave a distribution they called “Indian Social Class,” thought to be a truer description of the social stratification of Indian communities.
LAWRENCE
TABLE
G. WILSON
ANI)
JAMES
11. SHORE
I
Iollow-Lp
Status’
of 83
lndia,z
.Ilcoholic,s’
N umber
Rating*
Clear improvement I. Complete abstinence in past year or since discharge from treatment facility and maintaining vocational, home, responsibilities. 2. Occasional or sporadic drinking in past year or since discharge. but maintaining vocational, home, and famil Erratic improvement 3. Drinking periodically or regularly during past year or since discharge, but no outstanding community problems on home and family. No improvement 4. Drinking to the extent that vocational and family responsibilities are not maintained-has come to the attention for drinking in the past year or since discharge. to follow-up 5. Drinking status 6. Deceased.
and
family I 12
responsibilities. or severe
effects 13
of the community 3S
Lost
*
Based
on
the
10 2
unknown.
classilication
ssiern
by Fitigerald
used
and
associates
(5).
jects in the group had experienced severe drawal, but the medical records were enough for a statistical analysis. Disulfiram
alcoholic withnot complete played a mi-
nor
of this
role
in the
follow-up
spite of the positive Navajo alcoholics. Follow-Up
treatment
results
plans
previously
group
reported
in
with
improvement and
no
5 had
improvement.
erratic Also,
improvement, the
lack
of a sig-
nificant relationship between follow-up status and religious affiliation did not substantiate earlier impressions of many counselors, who hypothesized a positive relationship between treatment outcome and traditional Indian
Status
follow-up,
at
16 showed
religion.
subjects
Instead,
to show
there
greater
was
a trend
improvement
for
Protestant
at the
time
of fol-
In order to summarize follow-up status and compare the results with the outcome of other treatment programs, categories I and 2 of the six-step classification (see table I ) are considered to be clear improvement, category 3 represents erratic improvement, and category 4 indicates no improvement. Categories 5 and 6 indicate loss to follow-up. Clear improvement was demonstrated in 28 percent of the subjects (N=23), erratic improvement in 16 percent (N=13), and no improvement in 42
ered to have shown no improvement. Married subjects had a significantly higher improvement rating than those who were unmarried (i.e., single, separated, divorced, or widowed) (x2= 10.88, p =005). Less than 20 percent of the married subjects were un-
percent
for
(N=35).
Thus,
some
Twelve
subjects
were
lost
to
follow-up.
improved, while were unimproved. 16 of the
over half Drinking
married
of I I Protestants while only 2 were
of the status
subjects,
and
of
unmarried wives
the
showed consid-
subjects known
was
man/wife
drinking
status was a direct one-to-one relationship for 10 of these couples. In the group of 18 subjects who were readmitted for two (N I 6) or three (N 2) inpatient treatment sessions, 8 showed improvement, 7 showed no improvement, and 3 were lost to follow-up.
for
DISCUSSION
of
employment
was
Eight out or erratic),
seen in 44 percent of the patients and no improvement in 42 percent at follow-up. Follow-up status was then compared to specific characteristics in the profile of the Indian alcoholic. There were no significant differences in follow-up status between the five major tribal groups or between decade of life, type of marriage (intra-, inter-, or extratribal), type of religion, or Indian social class (which includes scores type
improvement
low-up (.OS
