Principles for Establishing Trust When Developing a Substance Abuse Intervention With a Native American Community

Abstract

This article traces the development of a research project with a Native American community. Four principles were used to guide the development of the “Community Partnership to Affect Cherokee Adolescent Substance Abuse” project using a community-based participatory research approach. The principles suggest that establishing trust is key when developing and conducting research with a Native American community.

Native American communities have been the focus of many research projects, resulting in overuse of tribal communities for research. Disease has often functioned both as a significant historical variable and as an occasion for unethical and disrespectful medical treatment and research among Native American populations within the United States (Halverson, 2007).

Native Americans are severely underrepresented among scientists, which has resulted in non-Natives conducting most of the research among Native American communities. Research with Native American communities has often benefited investigators and their academic communities more than the communities in which the research is conducted. Native American communities often do not benefit from the research because study findings are not shared with these communities. These historical events and current experiences have often resulted in distrust of health-related research projects.

This history of nonparticipation in the research process and dishonest research practices has led to many barriers to research among Native American communities. Research approaches that include the community as a full partner need to be considered when conducting research with Native Americans.

COMMUNITY-BASED PARTICIPATORY RESEARCH

Native American communities usually prefer, and are very supportive of, a community-based participatory research (CBPR) approach (Strickland, 2006). The CBPR approach is recognized as appropriate for addressing health disparities (Wallerstein & Duran, 2006).

CBPR favors participatory processes that enable people to thoughtfully evaluate their situation and determine solutions. Sometimes labeled “action research,” CBPR is a collaborative approach to inquiry or investigation that provides people with means to take systematic action to resolve specific problems (Stringer, 1999). Participatory action research includes three phases: look, think, and act. Constructing a preliminary picture precedes the look-think-act sequence. The preliminary picture sets the stage for the “look” phase of research, assuring that beginning information about stakeholders and key organizations is ascertained, essential community values are understood, the history of the health problem is explored, and the health issues for the community are identified. Even though the look phase is described in a linear fashion, it is actually a dynamic process in which all dimensions of the preliminary picture change as one gets to know the community better, and action overlaps with looking and thinking. In the look phase, the researcher engages with community members to clearly articulate their problem as it exists within the community context.

In the “think” phase, stakeholders’ views are synthesized to create an inclusive perspective of the problem, which can then be addressed with action. In the “act” phase, goals, objectives, and tasks are identified and stakeholders are engaged in the process of effecting change. The CBPR approach is an ideal way for intervention research to be developed and conducted with the full and equal involvement of the science community and representatives from the intervention population. This participatory approach is especially useful when seeking solutions to complex health disparity issues that demand consideration of cultural context. Recent research has successfully used a CBPR approach with Native American populations (Strickland, 2006).

The specific aims of the “Community Partnership to Affect Cherokee Adolescent Substance Abuse” research project included the following:

• Creating a community partnership steering committee (CPSC) that represented members from the local Cherokee community in which the CBPR was conducted.

• Assessing the Cherokee community needs regarding substance abuse, as a starting point for sensitizing the CPSC to the magnitude of the problem.

• Establishing a partnership with a Cherokee community to develop culturally appropriate and competent intervention materials and outcome measurements.

The following four principles suggested by Nichols, Lowe, and Parker (2002), were used to guide the development and achievement of the specific aims of the CBPR project.

Principle 1: Getting It Right

Principle 1 explains how to identify and define correctly the type of Native American community in which the researcher wishes to conduct a study. Among Native American communities, there are various tribal structures that define the type of tribal entity under which the community exists. Depending on historical and political events and circumstances, Native American communities can be reservation based, nonreservation based, a Native American nation, tribe, band, federally or nonfederally recognized, state recognized, or an urban Native American community. Researchers must become learners of the history and evolution of the Native American community being considered for research. For example, during the territorial period and before statehood, Oklahoma consisted of many Native American reservations. However, in the early 1900s, the reservations in Oklahoma were removed from the tribes and each tribal member was allotted a parcel of land (Scaff, 2005). Within Oklahoma, there are two federally recognized Cherokee tribes, each with a distinct tribal government. Their tribal members share geographical areas within several counties in eastern Oklahoma.

The researchers used this knowledge to include both tribes in the planning of the project. For example, two public schools within the tribes’ geographic area were used for the research project. One school was used to implement the experimental condition whereas the other school was used to implement the control condition. The schools are not owned or operated by the tribes but do have a large number of Cherokee students. Participant inclusion criteria provide that a Cherokee student participant can be a member of either tribe.

Principle 2: Working With What You Got

Principle 2 refers to the ability to identify and use the resources within the Native American community being considered for research. For example, during the first year of the project, a CPSC of Cherokee community representatives was assembled. The researchers carefully selected members for the CPSC that are representative of members from both tribes. The CPSC was pivotal to the project. Their role included reviewing and revising intervention materials, participating in selecting the most culturally appropriate measurements, and providing overall cultural advice and guidance to the researchers.

Many Native American communities have limited economic resources and are often located in rural and remote geographical areas. Researchers must be aware of this when planning the locations for data collection and other activities associated with the research project. Historically, many Native American community members were asked to provide advice, information, and knowledge for research projects without being compensated. Often, researchers would arrange a meeting place that required the community members to travel long distances, requiring community members to expend limited valuable economic and time resources. Because the location of this project extended over a large rural geographical area, the researchers included stipends for all members of the CPSC for each monthly meeting they attended. The monthly CPSC meetings were also conducted at various locations within the region so steering committee members could share rides.

The researchers also took the intervention activities to the school settings of the Cherokee student participants. Intervention activities involved 1 hour per week during school hours. As members of a rural farming community, many of the Cherokee students who participated in the project had responsibilities after school, which could have prohibited their involvement in the project.

Principle 3: Creating Co-Ownership

Principle 3 describes how Native American communities now demand that they have some sense of knowledge and co-ownership before, during, and after a study is conducted. This has become a mandate by many Native American communities because of experiences in which they have not benefited from research results and most studies have been conducted by non-Native Americans. The principal investigator (PI) for this study, who is of Cherokee heritage and is well-known by the leaders of the Cherokee tribes in Oklahoma, developed a way to stay engaged and give back to the Cherokee communities in Oklahoma. Indermaur (1998) suggests that Native American people should conduct research on topics pertinent to Native Americans. The dedication to the survival and well-being of the tribe and the ability to allow Native American communities to set the research agenda is often best done by Native Americans who are conducting the research (Christensen & Peacock, 1997; Crazy Bull, 1997). For many years, the PI has volunteered services and expertise to several of the tribal health programs. He has participated in developing health programs that originate from tribal and cultural initiatives. In particular, he has focused on culturally competent programs that promote youth health and fitness. A memorandum of understanding between the university where the PI is located and the tribes was also negotiated by the PI. This agreement has provided a mechanism for the PI to integrate his teaching and scholarly/research activity at the Florida Atlantic University (FAU) Christine E. Lynn College of Nursing in Boca Raton, Florida, with the Cherokee tribes based in Oklahoma. Students travel with the PI to Oklahoma to earn course credit for community-based health practicum and research activities. This has also provided students with a transcultural immersion learning and service experience within a Native American culture.

Cherokee tribal leaders and community members were invited to participate in cultural exchange activities located at FAU, where the research is being initiated. The FAU Christine E. Lynn College of Nursing has a commitment to the nursing as caring philosophy. Caring is conceptualized as a mutual human process in which the nurse responds with authentic presence to calls from clients with the nurturance of wholeness of persons and their environment (Boykin & Schoenhofer, 2001). The commitment of nursing to human caring is considered to be in contrast with social trends that emphasize materialism and individualism instead of being in relationship and human community. Tribal leaders and members participating as research partners felt comfortable accepting invitations from FAU to participate in seminars because these key concepts are congruent with the Native American worldview, values, and beliefs. Forums open to the entire academic FAU community shared information about how research should be conducted within Native American communities.

As a way to promote co-ownership, all of the potential data collection instruments were piloted with a sample of Cherokee senior high school students. After completing the instruments, the students participated in a focus group to discuss thoughts and feelings about the instruments. Their recommendations and feedback were discussed with the CPSC. Input and feedback were also received from the CPSC about the cultural relevance of each potential instrument. Together, the researchers and the CPSC selected the instruments used for data collection.

The PI’s continuous involvement and contribution to the health programs within the Cherokee community has displayed a sincere commitment to a shared process. The goal of community capacity building becomes the intention; the shared research process becomes a part of the intention. Therefore, the community members and tribal leaders become equal partners with the researchers throughout the entire process.

Principle 4: Playing by the (Cultural) Rules

Principle 4 reminds those who are interested in conducting research with Native American communities that cultural norms should never be violated when research is being conducted. The rich diversity of tribal heritages, traditions, and cultures of many Native American communities are often not recognized by researchers. When planning and conducting studies among Native American communities, researchers need to consider the ethical mandate not to violate cultural norms. They must take measures to protect the culture of the Native American community in which the research is being conducted (Christopher, 2005).

Many research projects are designed to occur in a linear fashion, which is contrary to the Native American worldview (Lowe, 2002). Often, the research topic is selected first without input from the Native American community. An approach to identifying the problem with input from members of the Cherokee community was included. For example, Year 1 of the look phase included an assessment of the Cherokee needs regarding substance abuse. The PI gathered assessment information from several sources including community members and leaders. Indermaur (1998) noted that researchers who are Native American are often allowed to ask new questions that originate from a Native American perspective. The PI acknowledged that the Cherokee community perspectives and knowledge of the alcohol/drug issues were important. In using this assessment approach, the PI validated the concerns and perceptions of the substance abuse issues by Cherokee community members and leaders. Local and tribal law enforcement, juvenile system, and behavioral health personnel were among those interviewed to gain information and data regarding substance abuse among the youth within the community. School officials and local community members such as elders and recent high school graduates were also asked for their perspectives.

A recognized tribal leader/elder and substance abuse counselor from the community joined the research team as the interventionist and community liaison. He has worked with the PI on many projects and provided guidance for cultural congruence and relevance. A mentee was selected to be mentored by the tribal leader/elder; the mentee became part of the project budget personnel. Passing along wisdom and knowledge to the next generation is part of the circular worldview of Native Americans. The inclusion of a mentee for the leader/elder to mentor exemplified the project’s cultural congruence with this Native American community. Community capacity building is a goal of the CBPR approach; the inclusion of a mentee was done with the intention of meeting this goal.

CONCLUSION

Developing a research project with a Native American community can be challenging. Using principles that establish trust can convey a commitment to conducting research in a culturally respectful way. The time invested in establishing trust will assure an acceptable and successful research process. Using approaches such as CBPR should be considered to enhance continued access and potential research involvement with Native American communities.