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. Author manuscript; available in PMC: 2024 Mar 29.
Published in final edited form as: Fam Process. 2023 Jan 29;63(1):97–112. doi: 10.1111/famp.12854

The Weaving Healthy Families program: Promoting parenting practices, family resilience, and communal mastery

Catherine E McKinley 1, Leia Y Saltzman 1, Katherine P Theall 2
PMCID: PMC10382600  NIHMSID: NIHMS1869974  PMID: 36710265

Abstract

Parenting quality, family resilience, and community resilience and support have been found to be primary protective factors for the disproportionate burden of anxiety, posttraumatic stress disorder (PTSD), substance use disorder (SUD), depression, and suicide that US Indigenous youth and adults tend to experience. The purpose of this research study was to examine pilot results for outcomes related to relational factors for Indigenous family members who participated in the Weaving Healthy Families (WHF) program (translated to Chukka Auchaffi’ Natana, in the Choctaw tribal language), a culturally grounded and empirically informed program geared toward promoting wellness, family resilience, parenting practices, and community resilience while also preventing SUD and violence. This nonrandomized pre-experimental pilot intervention followed a longitudinal design, which included pre-test, a post-test, and a 6-, 9-, and 12-month post-intervention follow-up surveys. Repeated-measures regressions were utilized with generalized estimating equations (GEE) to examine changes in parenting, family resilience, and communal mastery before and after the intervention for 24 adults and adolescents (12–17) across eight tribal families. Results indicate that the overall quality of parenting improved, as measured by improved parental monitoring and reductions in inconsistent discipline and corporal punishment. We identified sex differences in positive parenting, poor monitoring, and corporal punishment, with greater decreases in these measures among males over time. Family resilience and communal mastery improved for adolescent and adult participants after the WHF program. Our results indicate promising improvements across relational, familial, and community ecological, which provide clear clinical implications.

Keywords: communal mastery, family, indigenous, intervention, native Americans or American Indians, parenting: Family resilience

Parenting quality, family resilience, and community resilience and support have been found to be primary protective factors buffering against the anxiety, posttraumatic stress disorder (PTSD), substance use disorder (SUD), depression, and suicide; mental health inequities U.S. Indigenous youth and adults disproportionately experience as effects of settler colonial historical oppression (Burnette & Figley, 2015; Gone & Trimble, 2012; Ka’apu & Burnette, 2019; Liddell & Burnette, 2017). Historical oppression undermines families through past and present forms of chronic and intergenerational oppression where settlers have come onto land to erase and replace Indigenous peoples to make the land their own (Arvin et al., 2013; Burnette & Figley, 2017; Wolfe, 1999). As Wolfe explained (1999, p. 388), “Settler colonizers come to stay: invasion is a structure not an event”.

Assimilative forms of settler colonial historical oppression have aimed to restructure, erase, replace Indigenous family, parental, and gender relations (Burnette & Figley, 2017; McKinley, Liddell, et al., 2021; McKinley, Lilly, et al., 2021). Pre-colonial Indigenous societies tended to be characterized by egalitarian, balanced, gender expansive, and female-centered gender roles (McKinley, Liddell, et al., 2021; McKinley, Lilly, et al., 2021). Labor divisions across gender identities across fluid, and complementary roles among women, men, and Indigenous extended kin existed as a means of survival and tended to be flexible balanced (Burnette, 2014; Nickel, 2020; Weaver, 2009). Forms of historical oppression have ebbed and flowed across history based on shifting settler colonial power dynamics and the sociopolitical context. Two settler colonial policies particularly targeted Indigenous families, including the U.S. Boarding School Era (1860–1978) and Indian Adoption Policy (1958–1967), which institutionalized the state removal of U.S. Indigenous children; between the years 1941 and 1967 alone, 85% of Indigenous children were removed in regions were data were available (Weaver et al., 2021).

According to Arvin et al. (2013), this restructuring imposed dominant heteropatriarchal (imposing heterosexual and patriarchal norms) and heteropaternal (imposing hierarchical nuclear systems where fathers hold power to dictate decisions) gender and family relations. Over time, structures of settler colonial historical oppression have been imposed and (often implicitly) internalized across ecological familial and institutional structures ([e.g., religious, community governance, judicial, legal, business, educational etc.] Burnette & Figley, 2017). Rigid, prescriptive, and traditional gender role ideology are associated with inequities and imbalances in home life labor decisions along with intimate partner violence (McKinley, Liddell, et al., 2021; McKinley, Lilly, et al., 2021; Weaver, 2009). Indeed qualitative research indicated Indigenous mothers carried a majority of invisible labor, housework, financial responsibilities, and childcare as indicated by the theme: “Women and Childcare: “We do it all” and Men “If They’re There, They’re There”” (McKinley, Liddell, et al., 2021) Qualitative data from a mixed-methodology identified adverse childhood experiences (ACE), infidelity, and SUD abuse were frequently mentioned among IPV victimization, which quantitative results indicated was higher for women who experience more severe violence, and that historical oppression, ACE, SUD abuse, PTSD, and female gender were risk factors for victimization (McKinley, 2021). ACE, which include sexual, physical, and/or emotional abuse, household mental illness SUD, domestic violence and/or incarceration, and or parental divorce or separation (Giano et al., 2020), tends to be elevated for Indigenous peoples than non-Indigenous peoples, and is a contemporary expression of historical oppression (Giano et al., 2020; McKinley, 2021).

Because family and psychosocial inequities stem from structural causes, family and parenting programs must situate these inequities in context. However, an absence of empirically informed family- and culturally grounded programs are available to promote relational factors to promote mental health equity among Indigenous peoples (Burnette & Figley, 2015; Gone & Trimble, 2012). Culturally grounded interventions for Indigenous peoples tend to be rare and available only 20% of the time (Urban Indian Health Institute, 2014). Clashes between conventional interventions and Indigenous approaches to wellness may stem from a disjunction between Indigenous values and Western paradigms for mental and behavioral health and wellness (Burnette & Figley, 2015; Getty, 2010). Indigenous paradigms tend to approach wellness as varying levels of harmony across interconnected aspects of behavioral, physical, psychological, emotional, and spiritual health (West et al., 2012).

For the purpose of this article, culturally grounded interventions are those that integrate cultural components into the primary or fundamental components of the intervention (Marsiglia & Booth, 2015). Such cultural components include cultural values, ways of knowing, norms, and practices (Marsiglia & Booth, 2015). The purpose of this research study was to examine pilot results for outcomes related to relational factors for Indigenous family members who participated in the Weaving Healthy Families (WHF) program. The WHF is an empirically informed and a culturally grounded program to promote wellness, family and community resilience, and parenting practices while preventing SUD and violence (McKinley & Theall, 2021).

The WHF program was developed after 10 years community-based participatory research (CBPR) with over 1000 Indigenous peoples across rural, reservation-based, and urban contexts (McKinley, Figley, et al., 2019; McKinley & Theall, 2021). The WHF program promotes family, parental, and community health through the Indigenist (Walters et al., 2009) FHORT, which situates familial, individual, and community strengths and challenges within their sociostructural context of settler colonial historical oppression (Burnette & Figley, 2017). Along with centering the four “R”s of Indigenist and decolonizing research, including reciprocity, responsibility, relationships, and respect (Walters et al., 2009; Wilson, 2008), the WHF program was developed using Whitbeck’s (2006) guidelines for culturally specific interventions with Indigenous peoples and adapted from the 16-session “Celebrating Families!” a cognitive-behavioral psychoeducational evidence informed program (National Association for Children of Alcoholics, 2011; White Bison, 2015). Extensive culturally grounded empirical research with Indigenous peoples was integrated throughout the program’s sessions through cross-nationally and community-based research and multiple community advisory boards (McKinley, Figley, et al., 2019; McKinley & Theall, 2021).

The WHF program, along with the FHORT, seeks to promote resilience through recovery, skills development, and the overcoming of adversity (Burnette & Filgey, 2017; Masten & Monn, 2015; McKinley & Theall, 2021). The FHORT examines the balance of risk and protective factors to predict wellness. Wellness is a state achieved through balance across mental, physical, emotional, social, environmental aspects of health (Burnette & Figley, 2017). The FHORT approaches wellness and health equity through the enhancement of ecological culturally grounded protective and promotive factors while reducing risk factors at the macro-, meso-, and micro-levels (Burnette & Figley, 2017; Bronfenbrenner, 1979). According to the FHORT, health equity involves all people having fair and socially just access to optimum levels of wellness, which involves reducing the risks and removing obstacles while promoting facilitators of wellness.

Although a complete description of the WHF program adaptation, development, and cultural components is beyond the scope of this inquiry (See Appendix S1 for a snapshot of cultural components and McKinley, Figley, et al., 2019; McKinley & Theall, 2021), this program integrates an Indigenous wellness approach by integrating the FHORT medicine wheel approach to wellness, including psycho-social, mental, spiritual, physical dimensions emotional, and environmental aspects of health (Burnette & Figley, 2017). The Indigenist (Walters et al., 2009) program approaches wellness by situating family, behavioral, and health problems within a context of settler colonial historical oppression while providing pathways toward resilience in culturally grounded ways, including tribal values identified in preliminary research (McKinley & Theall, 2021).

The program integrates the core components of the original program, which enhances skills and coping to promote resilience and session topics related to healthy living, relationships, choices, problem solving, boundaries, parenting practices (e.g., setting and retaining limits, affirming and communicating with children), emotional regulation and expression, and communication, while preventing SUD abuse and violence (McKinley & Theall, 2021). Communication and healthy living are integrated through family meals that integrate teaching on tribal foodways healthy living (McKinley & Theall, 2021). Culturally grounded and connective forms of communication and conflict resolution are integrated through talking circles (McKinley & Theall, 2021).

The structure of each of the WHF program’s 10 sessions lasting 2 ½ hour was as follows. Sessions began with a family meal and a nutrition and health component to promote communication and promotive family rituals (McKinley & Theall, 2021). Families included anyone living in the same household, and they began the program by sharing a family meal together before dispersing to developmentally tailored age groups (i.e., parents, adolescents [ages 12–17], children [ages 8–11], and young children [ages 5–7]) where each family focused on the session topic using developmentally appropriate learning activities. Finally, families then rejoined each other and engaged in joint experiential activities reinforcing session topics.

FILLING A GAP IN FAMILY CENTERED AND CULTURALLY GROUNDED PROGRAMS

Griner and Smith (2006) found culturally grounded interventions were four times more efficacious than non-culturally grounded interventions, partly because they integrate local values, customs, and lifeways (Barrera Jr. et al., 2013; Griner & Smith, 2006; Resnik et al., 1999) and take a more holistic wellness approach to health (Rowan et al., 2014). They also prevent harm (Griner & Smith, 2006; Whitbeck et al., 2012), as some non-culturally grounded interventions have actually worsened outcomes of Indigenous SUD (Dixon et al., 2007).

Although family approaches to SUD abuse have effect sizes between two to nine times greater than child-only approaches, family-based approaches are largely absent (Tutty, 2013), with child-only school-based programs comprising a majority of programs (Liddell & Burnette, 2017). A systematic review indicated the proportion of risk and protective factors arising at the family, community, or relational ecological levels accounted for over half of those driving Indigenous youth’s mental and behavioral outcomes (Burnette & Figley, 2015). With children returning to families and parental SUD use the primary driver of youth SUD use (Burnette & Figley, 2015; Dusenbury, 2000), the absence of family interventions for behavioral health represents a major disconnect. The absence of family centered and culturally grounded efficacious programs for wellness represents not only an alarming problem but also neglect of the trust responsibility based on treaty agreements to provide for the health and wellness of members of the 564 federally recognized and sovereign tribes (Bureau of Indian Affairs, 2021).

The WHF program fills a gap in existing programs addressing mental and behavioral health inequities, which fail to include family- (Klostermann et al., 2010; Kraanen et al., 2013; Satyanarayana et al., 2016; Tutty, 2013) or culturally based approaches (Urban Indian Health Institute, 2014). In this study, we examined promotive factors as the relational level of the FHORT, namely parental, familial, and community-related factors that have demonstratable protective effects for the mental health equity of Indigenous peoples, namely parenting quality, family resilience, and communal understanding (communal mastery), “defined as the belief that one is capable of successful goal attainment by being closely interconnected with others” (Hobfoll, Schröder, et al., 2002, p. 362). We also examined sex differences, which are integral to situating Indigenous research (Burnette & Figley, 2015; Ka’apu & Burnette, 2019).

PARENTAL, FAMILY, AND COMMUNITY PROTECTIVE FACTORS FOR MENTAL AND BEHAVIORAL HEALTH

According to the FHORT, positive parenting, family resilience, and communal mastery are relational promotive factors across the relational, familial, and community levels of the FHORT, respectively (Burnette & Figley, 2015, 2017). Indeed, a systematic review related to risk and protective factors among Indigenous youth indicated extensive implications of positive parenting practices for Indigenous youth’s well-being, including the prevention of substance abuse risk behavior, depression, and suicide, whereas harsh or poor parenting practices, such as yelling, rejection, posed risks for SUD and symptoms of depression and suicide (Burnette & Figley, 2015). Parenting quality consistently predicts mental health and SUD (Burnette & Figley, 2015). Indeed, parental warmth and attachment were found to aid in the prevention of SUD among Indigenous youth (Cheadle & Whitbeck, 2011; LaFromboise et al., 2006).

Family resilience is the process of families navigating, adapting, and recovering from adversity, and centers the protective role family plays in individual wellness and resilience (Masten & Monn, 2015). Risk factors exacerbate negative outcomes, promotive factors are strengths regardless of circumstances, and protective factors buffer against harm and enhance positive outcomes (Masten & Monn, 2015). Family support, communication, and caring play a protective role for Indigenous youth in abstaining from substance abuse (Cheadle & Whitbeck, 2011; LaFromboise et al., 2006) and have been found to offset historical oppression and the losses associated with disproportionate rates of mortality, loss, and death among Indigenous peoples (McKinley et al., 2020). Previous research with Indigenous peoples has found that the stress of losing a loved one was a risk for greater depressive symptoms, whereas family resilience was associated with lower depressive symptoms (McKinley et al., 2020).

Preliminary research with the focal Indigenous populations has indicated historical oppression was a risk factor for depressive symptoms, whereas family resilience is associated with lower depressive symptoms (Burnette et al., 2019). As predicted by the Indigenous FHORT, historical oppression and high daily stress were associated with higher depressive symptoms among Indigenous peoples, whereas family resilience and life satisfaction—a measure of transcendence—were both associated with lower depressive symptoms (Burnette et al., 2019). Family resilience was found to be associated with lower symptoms of anxiety and depression, whereas problems in Indigenous adults’ upbringing was found to add risk (McKinley, Boel-Studt, et al., 2021). Family resilience in both their family of origin and current family, has been associated with lower alcohol use among Indigenous peoples (McKinley, Boel-Studt, et al., 2021), whereas ACE and family problems were risks for depression, anxiety, suicide, and substance abuse (Caetano et al., 2013; Ka’apu & Burnette, 2019).

In contrast to individual or psychological resilience, communal mastery is thought to be a form of community resilience where peoples’ sense of interconnectedness and close-knit community promote wellness and an ability to overcome life’s challenges (Hobfoll, Jackson, et al., 2002; Hobfoll, Schröder, et al., 2002; Meyer, 2015; Norris et al., 2008). In contrast to Western European values that prioritize individualistic notions of success, Indigenous peoples and collectively-oriented communities may identify with a collective sense of efficacy (Hobfoll, Jackson, et al., 2002; Hobfoll, Schröder, et al., 2002; Santiago et al., 2020). Santiago et al. (2020) recommend measuring communal mastery instead of personal mastery with Indigenous peoples (Santiago et al., 2020). Indeed, a collective sense of connectedness has been found to be instrumental in reporting suicidality (Hill, 2009). Community and family support are associated with Indigenous family resilience (Burnette et al., 2020) and lower symptoms of PTSD (McKinley, Miller Scarnato, et al., 2019). A systematic review with Indigenous youth (Burnette & Figley, 2015) identified social support and community support as protective factors against suicide (FitzGerald et al., 2017; Whitbeck et al., 2009), anxiety (McKinley, Boel-Studt, et al., 2021), PTSD (McKinley, Miller Scarnato, et al., 2019), and depression (Schure & Goins, 2017).

Past WHF program research reported reductions in substance use, violence reduction and prevention, and improved emotional regulation and mental health, healthy living behaviors, resilience across ecological levels, social support, and family skills (McKinley & Theall, 2021). This article extends this work to examine changes in parenting, family resilience, and communal mastery after the WHF program. Our preliminary hypothesis is that positive parenting behaviors, family resilience, and communal mastery will improve following the WHF program for youth and adults. Our overarching research question was how participation in the WHF program was associated with changes in parenting practices, family resilience, and communal mastery?

METHODS

Pilot research design

Extending past research (McKinley, Figley, et al., 2019; McKinley & Theall, 2021), this nonrandomized pre-experimental pilot intervention followed a longitudinal design, which included a pre-test, a post-test, and a 6-, 9-, and 12-month post-intervention follow-up survey. Generalized estimating equations (GEE; Schober & Vetter, 2018) was used to longitudinally examine post-intervention changes in population averages of parenting, family resilience, and communal mastery.

Setting and sample

The original aim of this pilot was to examine feasibility and acceptability of the WHF program; however, we received overwhelming interest and worked with the community health representatives and community advisory board to exceed our goal of four families, recruiting a convenience sample of eight families using word-of-mouth recruitment methods. All family members ages 5 and older participated in the intervention, yet we limited the scope of this inquiry to family members ages 12 and older as they were given the focal outcome measures (except for the parenting measures, which were only given to the adults). Family inclusion criteria were: (a) a tribally enrolled Indigenous parent or caregiver; (b) at least one child between the age of 12 and 17; (c) being able to attend sessions; and (d) a commitment to completing online surveys, with assistance (reading survey items to participants) if needed. No participants requested assistance, families with active violence or SUD abuse were excluded.

Families came from a Southeastern federally recognized tribe with its own education, law enforcement, family service, social service, behavioral health, and criminal justice systems. The tribal identity remains confidential to uphold agreements and follow recommendations for culturally sensitive research strategies with Indigenous peoples (Burnette et al., 2014; McKinley, Figley, et al., 2019). Sessions were held at a local venue selected by the community advisory board large enough for all families and community health representatives. The sample of eight families comprised 35 participants, including parents (n = 14), adolescents between the ages of 12 and 17 (n = 10), children between the ages of 8 and 11 (n = 8), and young children between the ages of 5 and 7 (n = 3). This analysis focused on the 24 adults and adolescents. The table in Appendix S2 presents the demographics of the sample. For eligibility, one tribally enrolled caregiver was required for family participation. However, family members who were not enrolled tribal members could participate as part of the family. With exception of two adults (one female and one male), all participants (n = 22, 91.7%) were enrolled tribal citizens. Along with tribal identity, some participants reported multiple racial/ethnic identities (i.e., White [n = 5, 20.8%]; Native Hawaiian/Pacific Islander [n = 1, 4.2%]; Asian [n = 1, 4.2%]; and other [n = 1, 4.2%]).

WHF program implementation

The WHF was facilitated by community health representatives who completed at least 6 days of program specific training and who resided in or near tribal communities. Two community health representatives facilitated each developmental group with at least one licensed mental health practitioner on-site. Two community health representatives coordinated session operations and completed weekly fidelity checks, which assessed whether: (a) primary concepts and important activities were adequately conveyed; (b) program structure was conducted according to protocol; (c) setting and materials were adequate and properly set up; and (d) quality and care group facilitation (See Appendix S3).

Data collection

Approvals from the university institutional review board and Tribal Council, along with written informed consent and assent from each participant, were acquired prior to data collection. Participants received $50 on Clincards, from which they could withdraw cash or use as credit, for completing each of the pre-test, post-test, and 6-, 9-, and 12-month follow-up online surveys using REDCap electronic data capture tools hosted by Tulane University (Harris et al., 2019). Participants’ completed online surveys and received reminders via email, phone, and SMS text.

Fidelity

Fidelity was assessed using a measure adapted from the original Celebrating Families! program ([See Appendix S3 and S4 for Fidelity Measure, and Table of Measures] National Association for Children of Alcoholics, 2011; White Bison, 2015). Two summative fidelity scores were calculated to assess (a) the quality of group facilitation skills (α = 0.86) included 15 items (e.g. “Group leaders talked with families during meal/snack; Ability to connect with members [develops trust]”) with response options ranging from 1 = (very poor) to 5 (excellent); and (b) fidelity to the core intervention components (α = 0.87) included 26 items (e.g., “Agenda was posted and reviewed; Talking circle agreements reviewed”) with response options ranging from 1 = (no explanation, participation, discussion) to 5 (thorough explanation, majority participation, positive discussion).

Outcome measures

All measures were piloted with the focal tribe, including those developed for and recommended for use with Indigenous peoples, such as the FRI (Burnette et al., 2020) and communal mastery (Hobfoll, Jackson, et al., 2002; Meyer, 2015; Santiago et al., 2020). Measures focal to this inquiry included the Alabama Parenting Questionnaire-Short Form (APQ; Kyriazos & Stalikas, 2019) was used to assess parenting practices such as involvement, positive parenting, poor monitoring or supervision, disciplinary practices, and corporal punishment. In past research, the APQ was piloted with the focal population and vetted with cultural insiders (McKinley, Figley, et al., 2019). Such preliminary research indicated that corporal punishment was a core theme that warranted inclusion (McKinley, Figley, et al., 2019). In the current study, we extended the APQ to include three items on corporal punishment from the longer form, creating a 13-item questionnaire including the following four subscales with reliability statistics: (a) positive parenting (α = 0.85); (b) poor monitoring/supervision (α = 0.88); (c) inconsistent discipline practices (α = 0.84); and (d) corporal punishment (α = 0.68).

Subscales were coded in the direction that measured the construct such that higher scores reflected higher levels of the construct (e.g., higher score of on poor monitoring reflect poorer quality of parental monitoring). A total score of parenting quality was calculated by summing all 13 items with very strong reliability (α = 0.85), this scale included reverse coded items such that higher scores on the sum scale reflected better quality of parenting practices. The questionnaire was only given to the adult subsample and included items such as: “You praise your child if he/she behaves well” (positive parenting); “Your child is out with friends you don’t know” (poor monitoring); “You let your child out of a punishment early (like lift restrictions earlier than you originally said)” (inconsistent discipline); and “You spank your child with your hand when he/she has done something wrong” (corporal punishment). All responses were scored on a 5-point Likert scale ranging from 1 (never) to 5 (always).

Family resilience was measured using the Family Resilience Index (FRI), a 40-item assessment designed to measure family resilience in the current family and the family of origin through family promotive and protective factors (Burnette et al., 2020). This inventory was developed and validated with the focal tribe in past research (Burnette et al., 2020). In the current study, we used 20 items from the “Current Family” subscale (e.g., “We know what is expected of each other,” “We express love and affection freely,” and “We have a lot of family time together.”). Response of “yes” is coded as “1” and “no” as “0,” with higher total scores indicating greater family resilience. Reliability for scales in the current study was strong across the adult (α = 0.92), the adolescent (α = 0.86), and the combined sample (α = 0.87). Appendix S4 and S5 display the FRI and the table of measures, respectively.

Communal mastery is a measure of community resilience characterized by a collective sense of self-efficacy and is measured by the communal mastery scale, which was piloted in past research with the focal population (McKinley & Theall, 2021); it has been widely used and recommended for use with Indigenous populations given its congruence with Indigenist worldviews and collective orientation (Hobfoll, Jackson, et al., 2002; Hobfoll, Schröder, et al., 2002; Santiago et al., 2020). The communal mastery scale consists of 10 items scored on a 4-point Likert scale from 1 (strongly disagree) to 4 (strongly agree). Items included “Working together with friends and family, I can solve many of the problems I have” and “I can meet my goals by helping others meet their goals.” Higher total scores were indicative of higher communal mastery. Scale reliability was strong for adults (α = 0.87), adolescents (α = 0.82), and overall (α = 0.86).

Data analysis

Given the small sample and data set, after the second author’s preliminary screening, the first author, who oversaw data collection and was familiar with all participants visually scanned for outlier and missing data. Outliers were scanned visually and were excluded where clear errors were made in data entry (e.g., a child was over the age of 18 and entered incomplete parenting information despite not having children). Although all families completed the entire program, some individual participants missed sessions. With exception of pre-test, data given no baseline was available, missing data for items were imputed using the median of post-test data for participants. Next, we examined descriptive statistics including estimates at baseline and each follow-up wave – pre-test, post-test, and 6-month, 9-month, and 12-month post-intervention waves. Next, we used repeated measures regressions with non-parametric generalized estimating equations (GEE) to examine significant changes over time (Schober & Vetter, 2018). We accounted for repeated responses within participants as well as clustering within the family-unit using multiple repeated statements with SAS’s GEE procedure in Proc Genmod. Primary measures (See Table 1 in Results) were assessed at all five events, or longitudinal waves of data collection (pre-test, post-test [immediately after the intervention], and 6-, 9-, and 12-months post-intervention), whereas secondary measures were assessed at three time points (i.e., pre-test, post-test, and 12-month post-intervention).

TABLE 1.

Changes in parenting, family resilience, and community resilience from baseline to 12-month follow-up.

Crude models
 Adjusted modelsa
Beta estimate (SE) for time/wave Z (p-value) Beta estimate (SE) for time/wave Z (p-value) Effect size (R2) Timepointsb
Parenting
 Overall quality (n = 60)   3.35 (1.37)   2.44 (0.01)   0.54 (0.56)   0.97 (0.33) 0.18 Primary
 Positive parenting (n = 60)   0.08 (0.10)   0.75 (0.45)   0.11 (0.11)   1.01 (0.31) 0.10 Primary
 Poor monitoring (n = 60) −0.47 (0.23) −2.05 (0.04)   0.01 (0.07)   0.04 (0.97) 0.07 Primary
 Inconsistent discipline (n = 60) −1.01 (0.22) −4.50 (<0.01) −0.07 (0.18) −0.40 (0.69) 0.06 Primary
 Corporal punishment (n = 59) −0.53 (0.19) −2.77 (0.01) −0.31 (0.14) −2.27 (0.02) 0.29 Primary
Family resilience (n = 72)   0.88 (0.28)   2.97 (<0.01)   0.22 (0.11)   2.01 (0.04) 0.21 Primary
Communal mastery (n = 120)   2.95 (0.38)   3.70 (<0.01)   3.05 (0.37)   8.17 (<0.01) 0.46 Secondary
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a

Adjusted for sex and baseline value of outcome of interest.

b

Primary measures are asked at pretest, posttest, and 6-, 9- and 12-month post-intervention. Secondary measures are asked at pretest, posttest, and 12-month post-intervention.

Given the socioeconomic homogeneity in the sample, there were minimal confounding factors to control for. Due to small sample sizes and given no significant differences were identified across age groups (i.e., adults as compared with adolescents), only sex differences were examined in this inquiry. We examined potential confounding by sex and education and controlled for sex and the baseline value of the outcomes in adjusted models. We also examined modifications by sex (with an interaction term between sex and the survey wave under examination). Unlike most widely used statistical methods, GEE limits bias by not assuming independence of longitudinal observations (Schober & Vetter, 2018). GEE estimates expected means yet accounts for the fact that repeated measures within the same person and family may be more similar than people from different families across units (Schober & Vetter, 2018). Given its non-parametric nature, it is the preferred choice over generalized linear mixed-effects model. Effect sizes identified the amount of variance accounted for by predictors from crude and adjusted models with R-squared utilizing the SAS macro RsquareV (Zhang, 2017).

RESULTS

Implementation, participation, and sample characteristics

Sample demographics indicated some economic strain and higher exposure to trauma with participants reporting an average of 4.86 (SD = 3.82) ACE (See Appendix S2). Regarding income, all (100%) families incomes hovered at or below the Federal Poverty level, a measure of the minimum amount of annual income needed to pay for essential for living, such as room, board, food, and transportation (Paying for Senior Care, 2022). Moreover, well over half (64.3%; n = 9) of adult participants indicated that it was “somewhat” or “very” difficult to live on their current income, all adult participants reporting some level of financial difficulty. Regarding participation, all families completed study components (McKinley & Theall, 2021), including the 10 WHF sessions and electronic pre-test, post-test, and 6-, 9-, and 12-month follow-up surveys. Most (62.5%; n = 5) families attended all sessions, with remaining families attending all but one (12.5%; n = 1) or two (25%; n = 2) sessions. On average, the fidelity score for the quality of group facilitation skills was 4.27 (SD = 0.33) and fidelity to the core intervention components was 4.61 (SD = 0.33), indicating fidelity scores between good (4) and excellent (5).

Adult parenting outcomes

All scores trended in the expected direction (See Appendix S6 for the table and figures of means by event [pre-test, post-test, and 6-, 9-, and 12-month follow-ups] and by sex). As displayed in Table 1, we observed significant post-intervention improvements in sample population averages (as indicated by beta = B) for overall parenting quality (B = 3.35, p = 0.01) and significant decreases in poor parental monitoring (B = −0.47, p < 0.04), inconsistent discipline (B = −1.01, p < 0.01), and corporal punishment (B = −0.53, p = 0.01). Positive parenting practices scores improved but not significantly. Exploratory analysis of descriptive statistics of parenting scores over time revealed sex-specific trends (See Appendix S6). Fathers tended to report less optimum parental scores at baseline but reported greater improvements in parenting practices after attending the WHF program than mothers. Significant interaction effects for sex differences were detected for positive parenting, poor monitoring, and corporal punishment. After controlling for sex and post-intervention changes from baseline scores, only corporal punishment remained significant (B = 0.31, p = 0.02), accounting for 29% of its variance. Fathers’ post-intervention scores dropped by 37–40%, hovering around 60% of baseline scores. These changes indicate fathers’ lower reported use of corporal punishment after the intervention.

Adult and adolescent family resilience and communal mastery

We observed significant increases over time in family resilience (B = 0.88, p < 0.01), even after accounting for sex and baseline family resilience (B = 0.22, p < 0.05). Sex and change from baseline scores accounted for 21% of the variance in family resilience. Significant sex differences indicated slightly greater increases in family resilience for males than females. Robust post-intervention increases in communal mastery was evident across models (B = 2.95, p < 0.01) accounting for 46% of the variance with sex and baseline scores (B = 3.05, p < 0.01).

DISCUSSION

Given all families completed the program components indicates some promise for culturally grounded and family based program, which because they are fundamentally tailored to the local environment, have been found bolster retention and engagement (Kumpfer et al., 2002; Marsiglia & Booth, 2015). Culturally adapted programs have also been found to reduce practitioners’ attempts to adapt spontaneously to meet the needs of the situation, which can enhance intervention fidelity and effectiveness (Marsiglia & Booth, 2015), which was supported by fidelity to the intervention and the quality of facilitation ranging from great to excellent.

Although the great enthusiasm and program completion may imply a lower level or risk exposure, this did not bear out in the data. All families reported financial strain and hovered at or below the Federal Poverty Level (Paying for Senior Care, 2022), indicating that the sample experienced economic disadvantage. Moreover, exposure to risk in the form of ACE was almost 5, a number 2.5–4 time higher than the average 1–2 ACEs reported in the general population (Giano et al., 2020). This number was even higher than averages of approximately 3 ACEs reported in prior Indigenous samples (McKinley, Boel-Studt, et al., 2021), including those drawn from the focal population for this article. Participants reported post-intervention improvements in outcomes across relational (parenting), familial (family resilience), and community (communal mastery) ecological levels of the FHORT after participation in the WHF program. With exception of communal mastery, males’ pretest scores were lower (less optimum) than females’ at baseline. Given this more room to grow, post-intervention improvements tended to be greater for males than for females, indicating the salience of sex differences in family and parenting programs.

WHF program post-intervention changes in parenting

Pilot results indicated post-intervention improvements in scores for overall parental quality, parental monitoring, inconsistent discipline, and corporal punishment. Such findings may be protective for youth behavioral and mental health factors, as parental quality has been found to be associated with reductions in youth SUD, suicide, anxiety, and depression (Burnette & Figley, 2015; Cheadle & Whitbeck, 2011; LaFromboise et al., 2006). Positive parenting improved, but not significantly, likely due to small sample size and sex differences. Indeed, Sex differences were robust, and accounted for a majority of significant post-intervention changes in parenting outcomes. Results indicated sex differences for positive parenting, poor monitoring, and corporal punishment, with greater post-intervention improvements in scores for males than females. When sex was included in the model, the post-intervention change for parenting quality, poor monitoring, and inconsistent discipline was no longer significant. Across parenting scores mothers reported more optimum parenting practices to begin with (at pre-test). After completing the WHF program, fathers parenting scores tended to rise to the approximate level that mothers came into the program with (See Appendix S6). Though preliminary, sex differences in parenting practices and greater improvements for fathers than mothers after WHF program completion hold significant implications to redress gender imbalances in parenting and family relationships.

WHF program post-intervention changes in family resilience and communal mastery

Family resilience increased for adolescent and adult participants after completing the WHF program. Family resilience may offset the risk of SUD, ACE, depressive symptoms, and anxiety (Burnette et al., 2019; Cheadle & Whitbeck, 2011; LaFromboise et al., 2006). Communal mastery, a component of community resilience involving a sense of belonging and support of a community to overcome obstacles, improved for adolescents and adults after WHF program participation. Improvements have implications for mental and behavioral health outcomes given communal mastery and community support has been found to be protective against anxiety, suicide, PTSD (FitzGerald et al., 2017; McKinley, Figley, et al., 2019, 2021; Whitbeck et al., 2009).

Strengths and limitations

Despite the strengths of the study, there were also notable limitations, namely the small non-representative sample and the lack of a control group. It should be noted that these significant findings were identified even with quite a small sample; a larger sample would likely indicate more robust fundings if replicated. Despite positive changes, effect sizes tended to be lower. Given results are preliminary with a small sample, all findings should be taken with caution. Future research is needed to include control groups and to identify whether changes may be attributed to the program. Moreover, assessments were self-report, rather than observational. The limited sample size limits the power to detect true differences and the convenience sample makes the results of this study not generalizable. However, given the aim of the original study was to assess feasibility and acceptability (McKinley & Theall, 2021), finding significant outcomes in a limited sample size warrants future research to examine the efficacy of the intervention in a larger sample and through a more robust study design.

Conclusions and implications

Post-intervention improvements across parenting practices, family resilience, and communal mastery after completing the WHF program are promising, with especially robust increases for males. With exception of communal mastery (See Appendix S6), females reported higher pre-test scores for optimum parenting outcomes, family resilience measures. Fathers’ outcomes improved and tended to reach the pre-test levels for mothers; in this way the program helped fathers to “catch up” to where mothers parenting practices began. Preliminary findings indicated improvements in parenting, family resilience, and communal mastery—all of which are promotive and protective factors for youth and adult SUD and mental health inequities, including depression, anxiety, PTSD, and suicide (Burnette & Figley, 2015; Ka’apu & Burnette, 2019).

Results indicate the WHF program’s potential to strengthen community cohesion (Hobfoll, Jackson, et al., 2002; Meyer, 2015; Norris et al., 2008), and prevent mental and behavioral health inequities. Centering long-term relationships and collaborations with Indigenous peoples to build upon strengths-based prevention efforts for mental and behavioral health conditions that incorporate a holistic family- community- and culturally- orientation and that promote the skills needed for wellness (Burnette & Figley, 2015; Gone & Trimble, 2012; Liddell & Burnette, 2017). Culturally grounded programs may be developed by or with the focal cultural communities they are tailored for (Marsiglia & Booth, 2015). Collaborative culturally grounded programs can integrate Indigenous wellness incorporate cultural elements—including experiential activities, a connection to land and place, sweat lodges, medicine wheels, Indigenous foodways, and talking circles—with conventional treatment services (Rowan et al., 2014). In contrast to a majority of programs that tend to be school-based, the WHF program is inclusive of the whole family (Liddell & Burnette, 2017). This family based approach is responsive to past research with Indigenous parents and families, whose preferences reflected a desire for involvement with youth services yet an absence of such programs (Burnette & Sanders, 2017; Kumpfer et al., 2002; Novins et al., 2012).

Results indicating a greater sense of community and collective well-being indicate the program’s protective pathways for urgent behavioral health inequities, namely depression, anxiety, PTSD, and suicide (Burnette & Figley, 2015; Ka’apu & Burnette, 2019). The promotion of collective efficacy relates to pilot results indicating robust improvements in communal mastery after participating in the program (Hobfoll, Jackson, et al., 2002; Meyer, 2015; Santiago et al., 2020). Continued involvement with families and facilitators is evidenced through 75% (n = 6) of families maintaining involvement with the WHF program; they have become trained as community health representatives or have enrolled in the full-scale clinical trial. Participants’ exceptionally high attendance and continued involvement in the program indicate the importance of centering reciprocity, responsibility, relationships, and respect in intervention research with Indigenous peoples (Wilson, 2008).

Examining how gains from program participation change over time unveils whether and when further program may be needed to sustain benefits. Positive gains after the program were consistent, especially through 9 month follow-up; some improvements tended to wane at 12 month follow-up, indicating that program benefits may “wear off”, when a program “booster” may be beneficial. Given improvements in parenting outcomes became lower at around one year post-intervention, interventions may integrate refreshing programming. As such, the full clinical trial of the WHF program integrates enhanced mobile health features that reinforces key session teachings with psychoeducational SMS text message for one year after the active intervention, which include reminders for sessions and program components. This trial also aims to sustain the community by inviting families to engage in follow-up family talking circles after the active intervention phase. This long-term engagement not only provides opportunity to be involved in youth care and remain engaged in the program but it has enabled the need for the development of community health and mental health leaders through family members’ facilitation and continued involvement in the program.

Supplementary Material

Supplemental_Materials_A_Snapshot_of_WHF_Cultural_Components
Supplemental_Materials_B_Demographics
Supplemental Materials C_Fidelity_Survey
Supplemental Materials D Family Resilience Inventory
Supplemental Materials E Measures
Supplemental Materials F Means By Event and Sex

ACKNOWLEDGMENTS

The authors thank the dedicated work and participation of the tribes and collaborators who contributed to this work. We thank Jennifer Lilly, Jessica Liddell, Hannah Knipp, Jennifer Martin, Tamela Solomon, Maple Dynan, Nikki Comby, the late Harold “Doc” Comby, Patricia Haynes, Kathleen Ferris, Juannina Mingo, Dan Isaac, Clarissa Stewart, Mariah Lewis, and Jeremy Chickaway for their incredible commitment, time and energy devoted to the Weaving Healthy Families (WHF) Program. We also thank Dana Kingfisher, Emily Matt Salois, d’Shane Barnett, and all the staff at the All Nations Health Center in Missoula, Montana for their important contributions to the pilot program. We thank Charles R. Figley, Karina Walters, James Allen, and Tonette Krousel-Wood for their support and mentorship for this pilot program. We thank The National Association for Children of Addiction for the original program from which the WHF program was developed, and White Bison for introducing cultural components. This work was supported, in part, by Award K12HD043451 from the Eunice Kennedy Shriver National Institute of Child Health & Human Development of the National Institutes of Health (Krousel-Wood-PI; Catherine McKinley (formerly Burnette)-Building Interdisciplinary Research Careers in Women’s Health (BIRCWH) Scholar); and by U54 GM104940 from the National Institute of General Medical Sciences of the National Institutes of Health, which funds the Louisiana Clinical and Translational Science Center. Research reported in this publication was supported by the National Institute on Alcohol Abuse and Alcoholism of the National Institutes of Health under Award Number R01AA028201. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Funding information

Eunice Kennedy Shriver National Institute of Child Health and Human Development, Grant/Award Number: K12HD043451; National Institute of General Medical Sciences, Grant/Award Number: U54 GM104940; National Institute on Alcohol Abuse and Alcoholism, Grant/Award Number: R01AA028201

Footnotes

SUPPORTING INFORMATION

Additional supporting information can be found online in the Supporting Information section at the end of this article.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplemental_Materials_A_Snapshot_of_WHF_Cultural_Components
NIHMS1869974-supplement-Supplemental_Materials_A_Snapshot_of_WHF_Cultural_Components.docx (1.2MB, docx)
Supplemental_Materials_B_Demographics
NIHMS1869974-supplement-Supplemental_Materials_B_Demographics.docx (16.2KB, docx)
Supplemental Materials C_Fidelity_Survey
NIHMS1869974-supplement-Supplemental_Materials_C_Fidelity_Survey.pdf (60.3KB, pdf)
Supplemental Materials D Family Resilience Inventory
NIHMS1869974-supplement-Supplemental_Materials_D_Family_Resilience_Inventory.docx (15.7KB, docx)
Supplemental Materials E Measures
NIHMS1869974-supplement-Supplemental_Materials_E_Measures.docx (15.1KB, docx)
Supplemental Materials F Means By Event and Sex
NIHMS1869974-supplement-Supplemental_Materials_F_Means_By_Event_and_Sex.docx (271.9KB, docx)

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