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. Author manuscript; available in PMC: 2021 Oct 1.
Published in final edited form as: Cultur Divers Ethnic Minor Psychol. 2019 Dec 30;26(4):437–446. doi: 10.1037/cdp0000315

Parenting in 2 Worlds: Effects of a Culturally Grounded Parenting Intervention for Urban American Indians on Participant Cultural Engagement

Stephen S Kulis 1,2, Monica Tsethlikai 1,2, Mary L Harthun 2, Patricia Hibbeler 3, Stephanie L Ayers 2, Nicholet Deschine Parkhurst 2
PMCID: PMC7326650  NIHMSID: NIHMS1064459  PMID: 31886683

Abstract

Background:

Culturally appropriate, evidence-based prevention programs are seldom available to the growing majority of American Indians (AI) who now live in cities. Parenting in 2 Worlds (P2W), a culturally grounded parenting intervention, was created to strengthen family functioning and reduce behavioral health risks in urban AI families from diverse tribal backgrounds.

Objectives:

This study reports on the AI cultural engagement of the P2W participants as an outcome of the intervention.

Methods:

Data come from 575 parents of AI children (ages 10–17) in a randomized controlled trial in three Arizona cities. Parents were recruited through urban Indian centers and randomized to P2W or to an informational family health curriculum, Healthy Families in 2 Worlds (HF2W). Both P2W and HF2W consisted of 10 workshops delivered weekly by AI community facilitators. Pretests and posttests measured identification and engagement with traditional AI heritage, culture and practices. Tests of the efficacy of P2W versus HF2W employed baseline adjusted regression models using FIML estimation to adjust for attrition, including random effects (site, facilitator), and controlling dosage. Moderated treatment effects by pretest levels of cultural engagement were tested with mean centered interactions.

Results:

Compared to parents in HF2W, those in P2W reported significantly larger increases in AI ethnic identity, AI spirituality and positive mainstream cultural identification. Increases in cultural engagement were significantly larger for P2W participants who were relatively less culturally engaged at pretest.

Conclusions:

Culturally adapted parenting interventions like P2W that effectively build on AI cultural heritage can also promote greater AI cultural identification and involvement.

Research into the sources of behavioral health and wellbeing of American Indians and Alaska Natives (AI) increasingly recognizes traditional cultural heritage as a potent factor (Henson, Sabo, Trujillo, & Teufel-Shone, 2017). Cultural heritage can be a powerful tool in AI tribal communities for addressing public health crises such as alcohol and drug addiction and suicide (e.g., Allen et al., 2018; Cwik, et al., 2017; Walters et al., 2018). For the growing majority of American Indians who live in cities (over 70%), however, evidence-based prevention programs that are culturally appropriate are often unavailable (Castor et al., 2006; U.S. Census Bureau, 2010; Urban Indian Health Institute, 2013). Parenting in 2 Worlds (P2W), a culturally grounded parenting intervention, was created to strengthen protective factors among urban AI families and reduce youth substance use and sexual health risks. The P2W curriculum systematically incorporated common AI cultural values and parenting practices through a multi-stage cultural program adaptation process employing community-based participatory research in urban AI communities with diverse tribal backgrounds. The culturally adapted P2W curriculum was tested in a randomized controlled trial with a comparison condition in which AI parents were taught an informational family health curriculum, Healthy Families in 2 Worlds (HF2W) that was not culturally tailored (Kulis, Ayers, Harthun, & Jager, 2016). This paper reports on the effects of P2W, relative to HF2W, on the participants’ connections to AI identity and cultural heritage, and how these effects vary depending on their initial level of cultural engagement.

American Indian Culture as a Protective Factor

Recognizing that culture shapes human development powerfully, culturally grounded interventions attempt to connect to the lived experiences and core cultural constructs of the targeted communities by starting from their values, behaviors, norms and worldviews (Okamoto Kulis, Marsiglia, Steiker, & Dustman, 2014). According to Gertz (1973) culture is a system of historically derived understandings embodied in symbols, artifacts, and meanings that originate from and perpetuate the social order through activities, practices and rituals. Historically based cultural practices shape human development powerfully through active engagement in shared, productive, and purposive endeavors (Rogoff, 2003; Tsethlikai, 2015). The influence of cultural learning is observable in how contemporary AI children pay attention and remember (Tsethlikai & Rogoff, 2013). Involvement in the complicated rituals and ceremonies associated with AI cultures requires children to learn through observing, listening, and modeling, and these practices transfer to learning in other settings (Bigfoot, 2011). Thus, as suggested by Vélez-Agosto and colleagues (2017) culture is the operationalizing part of the central processes of human development, making cultural legacies a part of everyday life.

It is widely accepted among Indigenous peoples worldwide that culture is medicine. A qualitative examination of Native healers’ perspectives on trauma recovery among American Indians found that they viewed strong cultural knowledge and a strong AI identity as the most influential protective factors (Bassett, Tsosie, & Nannauck, 2012). Supporting this finding, a review of 16 quantitative studies that specifically searched for factors that promoted health and well-being among AI adolescents across individual, relationship, and community socio-ecological domains found that cultural connectedness served as a protective factor across all three domains (Henson et al., 2017). Cultural connectedness has been defined as enculturation, a lifelong process of identification with AI culture that includes involvement in traditional activities and traditional spirituality (LaFromboise, Hoyt, Oliver, & Whitbeck, 2006; Whitbeck, Hoyt, McMorris, Chen, & Stubben, 2001). Measures of enculturation include the extent to which individuals identify with their ethnic culture, feel a sense of pride in their cultural heritage, and participate in traditional cultural activities (Zimmerman, Ramirez-Valles, Wshienko, Walter & Dyer, 1996). Research documents that enculturation fosters resilience (LaFromboise et al., 2006; Stumblingbear-Riddle, & Romans, 2012), increases academic success (Whitbeck, et al., 2001), and reduces alcohol use and suicide risk (Allen et al., 2018) in Native adolescents.

Cultural Disruption and Engagement among Urban American Indians

American Indians living in urban areas have unique migration histories. Some have lived away from the reservation their entire life; others move back and forth between the reservation and the city seeking opportunities for a better life – staying when jobs materialize and moving back to the reservation if needed or when possible. Most maintain connections to their cultural heritage. Even when cultural legacies were disrupted through social policies designed to eradicate cultural practices—such as The Indian Relocation Act of 1956, which moved families from reservations to urban areas—the desire for connection to culture was not lost (Jackson, 1998; Lucero, 2014). Michelle Duncan, a second generation urban AI, eloquently captures in words this desire for connection (as cited in Jackson, 1998: 237):

The majority of us [city-raised Indian people] walk around with this hole in our heart. We know we’re different, that there’s a piece of our life that is missing. And once we can [find out] what’s missing, and fill that hole ourselves, then, we see a whole person emerge. We start asking questions, and we become these enormous sponges, and we just want to absorb, absorb, absorb. And it [a strong AI identity] fills that hole.

Research in urban AI communities demonstrates the continuing and vital importance of native cultural heritage to wellbeing even when living away from tribal communities. In a study of AI early adolescents in Phoenix a large majority (70%) of the youth were involved in enculturation-related activities, such as their sacred AI cultural traditions and learning their tribal language, which they saw as defining features of their AI identity (Kulis, Robbins, Baker, Denetsosie, & Deschine Parkhurst, 2016). AI youth from two California cities expressed a desire to expand their involvement in cultural activities as a means of fostering deeper connections to their cultural heritage, and AI parents affirmed the protective effects of a strong AI identity and the importance of AI cultural practices for healing, maintaining sobriety and a healthy lifestyle (Brown, Dickerson, & Amico, 2016). Researchers examining youth suicide prevention in a Midwestern urban AI community reported similar sentiments, with the majority of respondents emphasizing the importance of traditional AI culture in promoting the wellbeing of urban AI youth, and the key role of urban AI community centers for learning about cultural identities, engaging in cultural activities, and accessing traditional healers (Burrage, Gone, & Momper, 2016). The relatively few prevention interventions tailored to or involving urban AI youth reflect consensus on the foundational importance of AI cultural identity and connection to the wellbeing of urban AI communities. They have incorporated cultural engagement as an integral part of the interventions (Dickerson, Brown, Johnson, Schweigman, & D’Amico, 2016; Kulis, Ayers & Harthun, 2017; Moran & Bussey, 2007; Weaver & Jackson, 2010).

Parenting interventions in AI communities that have integrated cultural engagement activities and fostered connection to traditional culture have demonstrated improved family functioning. Lakota parents in a reservation setting reported positive parenting outcomes after participating in a culturally grounded parenting intervention that strengthened their sense of empowerment, connection to extended family networks, and knowledge of tribal parenting practices (Brave Heart, 1999). AI parents in New Mexico involved in a family-level intervention that explored culturally appropriate parenting practices reported improvements in parenting skills and parent-child communication (Goodkind, LaNoue, Lee, Freeland, & Freund, 2012). A culturally focused parenting program tested with parents of AI children in two southern California counties found evidence of improvements in parenting and in child behavior, compared to a control group (Dionne, Davis, Sheeber & Madrigal, 2009). This intervention culturally adapted or “overlaid” evidence-based parenting skills training with an exploration of AI family values and culturally rooted AI parenting approaches.

Although evaluations of some culturally focused AI parenting programs have included urban AI parents as participants, parenting interventions tailored specifically to urban AI communities are lacking. The current study assesses Parenting in 2 Worlds, which was designed to be a culturally grounded parenting intervention for parents and guardians raising AI adolescents in cities. P2W was created through a multi-phase cultural adaptation process, retaining core components of an existing efficacious parenting program but with modifications that addressed cultural and social challenges facing urban AI families (see Kulis et al., 2016). P2W systematically incorporates AI cultural values and worldviews for rearing healthy children and building strong families in urban environments using cultural elements that resonate across many tribes (Reeves, Dustman, Harthun, Kulis, & Brown, 2014).

The P2W curriculum helps parents identify the values and strengths of their tribal cultures, explore how those cultural values can serve as protective resources for their families, and discuss how to pass on their culture to children and grandchildren. P2W recognizes that AI parenting approaches are distinctive, refocusing the parenting skills training away from “managing” to “guiding” children’s behavior in culturally appropriate ways, such as through modeling behavior. P2W also acknowledges AI traditions of shared responsibility for parenting with extended family and community members, and how to find a balance in urban areas between traditional and mainstream approaches to parenting. P2W lessons have strengths-based starting points that focus on AI cultural heritage as a foundation for raising healthy children and increasing family resilience and wellbeing.

The P2W intervention was deliberately infused with AI cultural elements that resonated across tribal heritages. In cities, AI organizations and events are typically multi-tribal, such that urban American Indians are regularly in contact with people of different tribes. While acknowledging tribal diversity in cultural heritage, P2W lessons are built on a foundation of inter-tribal shared values connected to parenting that have been previously identified as applicable in urban AI communities, such as an emphasis on the intergenerational transmission of culture, respect for elders, and oral storytelling (Reeves et al., 2014). P2W also encourages the active exploration of AI cultural heritage and identity, and fosters reflection on how AI family values promote resilience. For example, in the first workshop, participants are asked to represent their own culture and who they are by drawing 5–6 symbols on the inside of their name cards. Next, they gather in small groups to share what the symbols say about themselves. Then each small group reports to the whole group what they discovered they have in common with each other, and finally, each participant introduces him/herself in a sentence or two. In addition to establishing kinship and community—both important AI values—the activities begin to reveal commonalities in the participants’ AI values. Another example is the homework activity in Workshop 3, which asks participants to talk to their children about family values, create together a family shield/poster based on these values, and display the posters at the following session. This activity is a highlight for many parents because it gives them the opportunity to engage in a discussion and share the values of their heritage with their children. These examples illustrate that the intervention approached enculturation by focusing on the ways that urban American Indians bring their own cultural heritage into an inter-tribal urban setting, rather than have the curriculum present a particular tribal culture or a shared “pan-Indian” cultural identity.

In a randomized controlled trial of the efficacy of P2W the participants reported statistically significant improvements in parental agency and positive parenting practices, as well as reductions in discipline problems (Kulis et al., 2016). The current study examines the effects of the P2W intervention in increasing the cultural engagement of the participants, with tests of two research questions. First, does P2W enhance participants’ sense of AI cultural identity, alignment/orientation toward American Indian and mainstream cultural values, involvement in AI traditions, and sense of AI spirituality? We predicted that P2W participants would significantly increase their cultural engagement, compared to participants in a non-culturally grounded intervention. Although P2W was not intentionally designed to enhance the participants’ identification or degree of involvement with their AI backgrounds, participants in the workshops delve into and share their experiences of traditional AI cultural values that support strong families. This process may influence their sense of connection to an AI identity, exploration of their AI heritage, and involvement in AI cultural and spiritual practices. Second, do the effects of P2W on these measures of cultural engagement differ depending on the individual participant’s level of cultural engagement at the beginning of the intervention? We predicted that P2W would have the strongest effects among those with relatively weaker connections to AI culture at the outset. That is, the P2W intervention would improve AI cultural engagement most for those who initially felt least connected to their cultural heritage.

Methods

Data come from 575 parents of AI children living in urban areas in a randomized controlled trial conducted in the three Arizona cities with the largest AI populations. Parents were recruited through non-profit urban Indian centers and individually randomized to the P2W intervention or to a strictly informational family health curriculum, Healthy Families in 2 Worlds (HF2W). Although the topics included in HF2W were selected by AI professionals as relevant to urban AI families, the HF2W curriculum was not culturally tailored in a deliberate manner to AI communities. Eligibility, recruitment, enrollment, randomization, survey administration, and implementation processes were identical across all cities. Those eligible for the study were: (1) primary caregivers of an AI adolescent 10–17 years old; (2) responsible for making health, educational and social decisions for the adolescent; (3) residing off the reservation with the youth attending an urban school; (4) not a prior participant in the P2W pilot trial; and (5) not a spouse or partner of another study participant. Both parents of the adolescent were permitted and encouraged to attend the workshops, but they designated only one parent to serve as a responding participant in the trial. Personnel at the urban Indian centers recruited, screened, and enrolled eligible participants. Recruitment efforts took place locally at schools, churches, youth centers, health fairs, pow-wows, and other community events, and through word of mouth.

P2W and HF2W both consisted of 10 workshops delivered weekly by AI community facilitators who received training by the research team. Implementation of the two interventions occurred over 25 months in 26 workshop cycles (11 in Phoenix, 9 in Tucson, and 6 in Flagstaff). At each cycle, facilitators delivered parallel P2W and HF2W workshops in separate areas of the same buildings and on the same timetables, with childcare available. Workshop groups averaged 11 participants. Workshop attendance declined gradually, from 85% completion at the third workshop, to 71% at the seventh and 66% at the last (mean = 7.6 workshops attended).

Following IRB approved protocols, participants in P2W and HF2W completed half-hour, paper and pencil pretest questionnaires during Workshop 1, and posttests at Workshop 10. Parents received modest monetary incentives for participating in the workshops regardless of survey completion, and 98% consented to complete the questionnaires. The surveys measured parenting skills, family functioning, youth and parent risk behaviors, and identification and engagement with traditional AI heritage and culture. The posttest was completed by 63% of the consented participants in both interventions. In addition, there were no significant differences in number of workshop lessons completed or in attrition to posttest by participant gender, age, number of children, education, or length of residence in urban and reservation settings.

The demographic profile of the participants was notably diverse (data not presented in tables). Although the sample was predominantly female (77%), a notable minority of participants were male (23%). Participants ranged widely in age, from 18 to 71 years old (M=37), but most were age typical for parents of early adolescents: 23% were under 30, 62% between 30 and 45, and 16% over 45. The respondents’ marital status varied considerably: 20% were currently married, 15% separated, divorced or widowed, 29% unmarried but living with a partner, and 36% were single and never married. Educational attainment varied as well, with 15% not completing high school, 49% with a high school degree or GED, and 36% with college credits or a college degree. Annual household income, however, was generally quite low, with over half the sample reporting incomes under $10,000 (51%) and only 25% reporting incomes above $25,000. The households of the participants averaged 4.6 people, with 2.2 being their own dependent children. Most respondents reported close family contact and connections to AI reservation communities, both in the past and currently. A large plurality (74%) had lived on a reservation at some time, on average for 19 years, more than half (54%) had spent their childhood on a reservation, and 92% had relatives currently living on a reservation. Nearly all participants (96%) reported an AI tribal affiliation, largely with Arizona tribes (90%). These affiliations encompassed 16 of the 22 federally recognized tribes in Arizona and 21 tribes outside Arizona. Average length of urban residence was 16 years, with 25% living in the city for 5 years or less and 35% for over 20 years. There were no statistically significant differences between the P2W and HF2W groups on any of these demographic characteristics.

Measures

This study examines four types of measures of cultural identification and engagement.

Ethnic Identity.

We measured American Indian ethnic identity based on Phinney’s (1992) Multigroup Ethnic Identity Measure [MEIM], following the precedent of other studies with American Indians that tailor the original questions to refer specifically to AI identity (Brown & Smirles, 2005). The MEIM is a widely reported measure of ethnic identity (Smith & Trimble, 2016), with two subscales, ethnic identity attachment and ethnic identity exploration. The two-factor structure of the MEIM has been verified psychometrically in studies of different populations (Brown et al., 2014; Chakawa, Butler, and Shapiro, 2015; Spencer, Icard, Harachi, Catalano, & Oxford, 2000; Yoon, 2011). The ethnic identity attachment subscale is calculated as the mean of four items measuring the respondent’s strength of felt connection to his/her ethnic group (α=.83 in this sample). Representative questions include: (a) I am proud to be American Indian; and (b) I feel like I really belong to an AI community. The ethnic identity exploration subscale (α=.77) is calculated as a 7-item mean score assessing the respondent’s learning about, involvement in, and understanding of his/her ethnic group and culture. It includes questions such as: (a) I have often talked to other people to learn about my AI background; (b) I think about how my life is affected because I am American Indian; and (c) I am involved in American Indian customs, such as food, music, or celebrations. Responses for both subscales form Likert scales coded from 1 (Strongly disagree) to 4 (Strongly agree).

Cultural Orientations.

The Bicultural Ethnic Identity Scale (BEIS) measures the cultural orientations of American Indians. Originally developed for AI adolescents (Moran, Fleming, Somervell, & Manson, 1999) and adapted for adults (Garroutte, Sarkisian, Arguelles, Goldberg, & Buchwald, 2006), the BEIS produces separate mean score subscales for cultural orientations toward following the “American Indian Way” and following the “White Way” based on involvement in cultural traditions, beliefs, and language. Research using the BEIS has generally examined both subscales separately although they are sometimes combined to form a measure of biculturalism. The BEIS is based on evidence that cultural orientations for American Indians toward AI and mainstream cultures can be independent of each other (Brown & Smirles, 2005; Oetting, Randall & Chiarelli, 1998). Although not entirely consistent, studies also suggest that a bicultural orientation, consisting of moderately strong orientations toward AI and mainstream cultures, and a strong orientation toward AI culture alone, are associated with positive psychological well-being and social adjustment (Garrett & Pichette, 2000; Oetting & Beauvais, 1991). This study assessed each cultural orientation subscale of the BEIS with three items, asking participants how much (a) they live by or follow the [AI way / White way]; (b) your family lives by or follows the [AI way / White way]; and (c) your family does activities or traditions (such as holiday parties, special meals, religious activities, trips, or visits) following the [AI way / White way]. The items for each subscale, measured on a 4-point Likert scale with responses ranging from 1 (Not at all) to 4 (A lot), are combined by calculating their mean. Both subscales have good reliability in this sample (AI way, α=.84; White way, α=.86).

American Indian Cultural Practices.

The American Indian Traditions scale gauges involvement in 11 spiritual and cultural practices (coming of age ceremonies, powwows/dances, drumming groups, putting out tobacco, giveaways, sweats, healing ceremonies, talking circles, memorial/feasts, naming ceremonies, and other similar activities specified by the respondent). This scale is constructed as a count of the total number of practices the respondent participates in, from 0 to 11 (Kulis, Hodge, Ayers, Brown, & Marsiglia, 2012).

Spirituality.

American Indian Spirituality (α=.67) is a mean scale calculated from two items assessing the respondent’s involvement in AI spiritual practices and their perceived importance: (a) How involved are you in private AI spiritual activities such as using sweetgrass, juniper, sage, corn pollen or meal, or praying at home? (b) How important is it for you to follow traditional AI beliefs? (Kulis et al., 2012). Responses to both items were coded from 1 (Not at all) to 4 (A lot).

Analysis Strategy

Tests of the relative effects of P2W versus HF2W on cultural engagement outcomes included pairwise t-tests (assessing changes from pretest to posttest) and baseline adjusted regression models in Mplus using full information maximum likelihood (FIML) estimation to adjust for attrition. These models included random effects adjusting for any facilitator level differences and stratification by the three geographical sites. Models also controlled for dosage, the number of workshops attended by the participant. We tested for intervention effects moderated by pretest levels of cultural engagement using mean centered interactions.

Results

Table 1 presents means, standard deviations, and mean differences from pretest to posttest on the cultural engagement measures. Pretest means for many of the outcomes fell within or close to the top quartile of their theoretical ranges, suggesting that levels of initial cultural engagement were relatively high for most participants. For example, the possible range for all outcomes except AI traditions was between 1 and 4, and the pretest means were around scores of 3, which corresponds to “agreeing” with the individual scale items, but not “strongly agreeing” (scores of 4). The means for AI traditions suggested that a typical respondent was engaged in about 2 of the 11 specific cultural activities. Tests of baseline equivalence (data not presented in tables) demonstrated that there were no significant differences in pretest means between P2W and HF2W participants on the outcomes except one: P2W participants had slightly higher initial scores than HF2W participants for following the “White way” (M=2.8, 2.7; t=1.98; p < .05).

Table 1.

Pretest to Posttest Changes in Cultural Identification Outcomes, by Intervention Condition

Parenting in 2 Worlds (N=312) Healthy Families in 2 Worlds (n=263)
Pretest Posttest Difference Pretest Posttest Difference
Mean (SD) Mean (SD) (Post-Pre) t-test Mean (SD) Mean (SD) (Post-Pre) t-test
AI Ethnic Attachment 3.388 0.535 3.521 0.444 0.133 4.68*** 3.383 0.547 3.438 0.548 0.055 1.67†
AI Ethnic Exploration 3.078 0.597 3.272 0.529 0.194 5.41*** 3.115 0.589 3.191 0.571 0.076 2.69**
Follows AI Way 2.916 0.756 3.062 0.681 0.146 3.62*** 2.950 0.793 3.014 0.777 0.064 1.63
Follows White Way 2.844 0.851 3.004 0.824 0.160 3.21** 2.704 0.835 2.703 0.858 −0.001 −0.02
AI Traditions 2.329 2.095 2.252 2.041 −0.077 −0.58 2.155 1.912 1.897 1.632 −0.258 −2.05*
AI Spirituality 3.066 0.846 3.184 0.742 0.118 2.52* 3.057 0.851 3.142 0.822 0.085 1.93
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†

p < .10.

*

p < .05.

**

p < .01.

***

p < .001.

Changes in Cultural Engagement

There were numerous changes in the cultural engagement outcomes from pretest to posttest Table 1). In pairwise t-tests, P2W participants reported statistically significant increases in cultural engagement on all measures except AI traditions. In contrast, although mean scores also increased on several measures in the HF2W comparison group, their increases were significant only for the AI ethnic identity subscales. Unlike any other measure of cultural engagement, the mean number of AI traditions declined from pretest to posttest, but the decrease was statistically significant only in the HF2W group.

In a direct test of the relative effectiveness of the two interventions in increasing the cultural engagement of the participants, results in Table 2 control for the baseline pretest level of cultural engagement of the participants and the workshop dosage. The models apply statistical adjustments for participant data missing at the posttest, mostly through attrition, as well as adjustments for any effects of the clustering of data by different facilitators and geographical stratification by three sites. For each outcome in Table 2 there are two models: first, the main effects of the contrast between interventions (P2W versus HF2W), and a second model below adding the interaction between the contrasted interventions and the baseline level of the particular outcome. The main effects models indicate that P2W enhanced the cultural engagement of the participants on several measures. Compared to parents in HF2W, those in P2W reported significantly larger pretest to posttest increases in AI ethnic identity attachment and AI ethnic identity exploration, as well as larger increases in following the “White way.” The marginally significant P2W intervention main effect for AI traditions is due, not to an increase in P2W, but rather to a much sharper decrease in HF2W.

Table 2.

Intervention Effects (P2W versus HF2W) on Cultural Engagement, with Tests of Moderation by Pretest Level

Intercept (SE) Outcome @ Pretest (SE) Dosage: # of Lessons (SE) Intervention P2W=1 HF2W=0 (SE) Intervention X Outcome @ Pretest (SE) R2 N Cohen’s d P2W versus HF2W
AI Ethnic Attachment 3.252*** (0.508) 0.601*** (0.069) −0.023 (0.142) 0.102* (0.043) 0.371 561 .152
7.058*** (0.630) 0.632*** (0.084) −0.022 (0.142) 0.103* (0.044) −0.044 (0.055) 0.371 561
AI Ethnic Exploration 2.750*** (0.474) 0.611*** (0.038) −0.043 (0.111) 0.098* (0.043) 0.383 562 .211
5.970*** (0.368) 0.708*** (0.054) −0.053 (0.111) 0.097* (0.045) −0.134* (0.057) 0.389 562
Follows AI Way 1.782*** (0.496) 0.719*** (0.039) −0.097 (0.130) 0.053 (0.039) 0.525 562 .120
4.012*** (0.437) 0.754*** (0.070) −0.100 (0.140) 0.051 (0.034) −0.125† (0.073) 0.452 562
Follows White Way 1.250** (0.435) 0.645*** (0.037) −0.020 (0.100) 0.104** (0.039) 0.439 560 .177
3.388*** (0.351) 0.653*** (0.039) −0.022 (0.101) 0.105** (0.039) −0.011 (0.053) 0.438 560
AI Traditions 0.322 (0.664) 0.596*** (0.057) −0.046 (0.215) 0.080† (0.044) 0.368 573 .135
0.865 (0.539) 0.470*** (0.103) 0.066 (0.167) 0.056 (0.036) 0.075 (0.102) 0.293 573
AI Spirituality 2.167*** (0.384) 0.663*** (0.041) −0.171 (0.109) 0.015 (0.040) 0.470 560 .042
4.619*** (0.329) 0.765*** (0.048) −0.190t (0.109) 0.018 (0.039) −0.138* (0.064) 0.485 560
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†

p < .10.

*

p < .05.

**

p < .01.

***

p < .001.

Tests of moderation shown in the second row of models in Table 2 showed that several of the increases in cultural engagement in P2W versus HF2W were significantly larger among participants who were less culturally engaged at pretest compared to those who initially were more culturally engaged. Specifically, the second model’s interaction term for the intervention effect shows that increases for P2W participants in cultural engagement were relatively larger for those with lower initial scores on AI ethnic identity exploration, following the Indian way, and AI spirituality. Figure 1 depicts the nature of this interaction graphically for the AI ethnic identity exploration outcome. Using the regression model estimates from Table 2, the figure graphs the predicted posttest values of this outcome for those with relatively low, mean, and high values at pretest, contrasting P2W and HF2W participants; the low and high groups were defined as those scoring one standard deviation below or above the pretest mean. The graph indicates that differences between P2W and HF2W participants on posttest scores for AI ethnic identity exploration were greatest among those who began the interventions with relatively lower scores on this measure. Among those beginning with relatively higher AI ethnic identity exploration scores, predicted posttest scores converge for the two interventions.

Figure 1.

Figure 1

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Moderated P2W Intervention Effect for AI Ethnic Identity Exploration

Based on calculations of Cohen’s d shown in the far right column of Table 2, the effect sizes for the outcomes with significant differences between P2W and HF2W were small, slightly above .2 for AI ethnic identity exploration, but around .15 for AI ethnic identity attachment and AI traditions.

Supplemental Exploratory Analyses

Because of the deliberate grounding of P2W in AI traditional culture, including workshops where the participants actively shared their knowledge and experience of AI cultural values supporting strong families, we conducted additional analyses to test whether increases in the P2W participants’ AI cultural engagement contributed to the intervention’s desired effects on parenting skills and family functioning. These mediational analyses examined three outcomes where the randomized controlled trial demonstrated that P2W produced larger desired changes from pretest to posttest than in HF2W (Kulis et al., 2016): measures of parental agency (Dumka, Soterzinger, Jackson, & Roosa, 1996), positive parenting practices (Tolan, Gorman-Smith, & Henry, 2000), and effective discipline (Coleman & Karraker, 2000). For all of these outcomes we estimated mediation models using, in turn, each of the measures of cultural engagement in Table 2 as the mediator. The models predicted the particular family-related outcome at posttest, controlling for the same outcome as measured at pretest, and added as predictors the cultural engagement mediator as measured at posttest and the intervention condition (P2W versus HF2W). Predictors of that mediator included its associated pretest measure and the intervention condition. In the 18 models tested (3 family functioning outcomes, 8 cultural engagement mediators), the direction of the mediational effect was as expected in all but two instances, with the mediator contributing to the desired effects of P2W on the family outcomes. However, the indirect effects of the cultural engagement mediators were all small and non-significant at p<.05, with standardized coefficients ranging in absolute value from 0.001 to 0.013.

Discussion

Although with considerable variation across different measures, this study found evidence that confirmed the initial hypotheses that P2W would increase the identification and involvement of the participants with their AI culture heritage. Participants in P2W reported increases in cultural engagement on four types of measures, these increases were larger for P2W than for HF2W participants on multiple measures, and in several instances the increases were larger for P2W participants who began the intervention at comparatively lower levels of cultural engagement. P2W participants reported significant increases in AI ethnic identity attachment and exploration, AI spirituality, as well as an increasing sense of identification with AI culture and mainstream culture. Tests of the relatively effectiveness of P2W, compared to HF2W participants in an informational family health intervention that was not culturally grounded, showed that P2W participants reported relative improvements in AI ethnic identity attachment, AI ethnic identity exploration, involvement in AI traditions, and mainstream cultural orientations. Moderation tests demonstrated that increases in AI ethnic identity exploration, AI spirituality and sense of connection to AI culture were significantly larger for P2W participants who entered the intervention at relatively lower levels on these measures.

The findings are not surprising given the systematic efforts, guided by principles of Community Based Participatory Research, to ground the P2W intervention in AI cultural elements that resonated across tribal heritages. To some degree, the results are consistent with arguments that intensive exposure to others from similar cultural background builds an individual’s “cultural capital” (Silva, 2005; Trueba, 2002). Both the P2W and HF2W interventions brought urban American Indians together around their concerns about raising healthy children, and provided opportunities for interaction with others from the same or similar cultures. There were some indications of increasing cultural engagement among the participants in both interventions. However, the deliberate cultural grounding in P2W, along with the design of the intervention around discussions and explorations of cultural heritage and its relevance to parenting, resulted in a wider array and more intensive increases in cultural capital than those experienced by HF2W participants who discussed less culturally focused topics.

Although there were statistically significant differences between the two interventions on several outcomes, the effects differed in size and statistical significance. Although all the P2W effects sizes were small, it is important to consider that they are calculated relative to an alternate intervention, and thus are likely to underestimate the effects that would be obtained relative to a non-intervention control group. P2W effect sizes were larger for the exploration than for the attachment subscales of the AI ethnic identity measure, possibly for several reasons. The P2W intervention included numerous topics and discussions where the participants shared and reflected on their AI heritage, providing ways to recall, recover, rediscover, reinterpret, and reintegrate the meaning of that heritage and its relevance to parenting and positive family functioning in the urban environment. The difference in effect sizes may also be due to ceiling effects. Means were higher on the attachment than on the exploration subscale at pretest and posttest, suggesting that most participants began the intervention embracing their identity as American Indians very strongly. The P2W intervention may have influenced how participants understood that attachment more than it amplified its degree or intensity.

Another difference across outcomes in effect sizes was that P2W participants reported stronger gains in their orientation to mainstream culture, or the “White way,” than the AI way of living. Pretest scores suggested that participants in both interventions already felt a somewhat higher degree of alignment with AI than with mainstream culture. The P2W intervention may have enhanced the participants’ sense of bicultural orientation while remaining culturally rooted within their own AI heritage. For example, P2W discussions addressed the realities of parenting in urban settings, cognizant that monitoring and guiding children in the city may require more directive and less hands-off strategies than those commonly employed in reservation settings. Participants spend time in two workshops discussing the topic of guiding their child’s behavior effectively. They identify family/home rules they had (if any) when they were growing up and whether there were consequences for not following them. Facilitators ask parents, “If you grew up on the reservation, are there rules that have changed now that you are living in the city?” Volunteers also share examples of rules they have established for their own children such as setting a curfew time, assigning routine chores, clarifying the consequences of good and bad behavior, and having all those involved in parenting apply the rules consistently. These explorations of parenting approaches may relate to the increases by P2W participants on the measures of living the “White way.” The results do not necessarily indicate cultural realignment toward the mainstream, but may reflect greater awareness of living in two cultural worlds, of the values overlapping those worlds, and of how to cross between them in healthy ways. As stated by one participant on an open-ended evaluation of P2W, “When we have a sense of our (AI) identity then we can live in two worlds. We want to be able to navigate successfully in this (White) culture…like a bridge you can cross over anytime…and so we can learn how to get through the uncomfortableness zone and be able to do that and then come across again.”

Evidence for increasing cultural engagement through P2W was weaker for the measure of involvement in AI traditions and practices. Scores did not change significantly for P2W participants from pretest to posttest, and the marginally significant difference between the interventions was due to a decrease over time reported in the HF2W group. This may be a measurement issue as 1) our count of the number of different traditional practices does not reflect the frequency or intensity of involvement, 2) a restricted set of practices was enumerated, and 3) some of the practices listed occur infrequently or intermittently (naming ceremonies) while others can be practiced more regularly (drumming). Many AI traditions and practices occur solely in sacred places and on specific dates dictated by spiritual calendars, making it difficult to increase actual participation in these traditional activities even if the desire to do so has increased.

Results for the final measure, AI spirituality, showed no significant differences between P2W and HF2W overall, only among those reporting relatively low AI spirituality pretest scores. There may have been a measurement issue here as well. The two-item AI spirituality scale had low reliability, and respondents may not have interpreted the item asking about AI spiritual practices in a consistent manner. Although several examples of such practices were given, spiritual practices may not be viewed in some AI communities as distinct from cultural practices.

The relatively high initial levels of attachment to and alignment with AI culture reported by participants in both interventions are notable, challenging the assumption that living off the reservation and in urban areas leads inevitably to disconnection from AI culture and its teachings. Although the sample may not completely represent urban AI families with pre-adolescents and adolescents, the teams in the field employed a wide array of recruitment strategies to expand outreach to AI families living throughout the three metropolitan areas. Recruitment efforts targeted organizations and events where urban American Indians connect with one another for social, health and employment services—such as the urban Indian centers and Indian health organizations—and for shared community celebrations, such as pow-wows. These are comfortable venues for American Indians who often face discrimination elsewhere. Recruitment efforts disseminated information through health fairs and school fairs for the general population, through advertising on public transportation routes utilized by urban American Indians, and through urban schools with relatively higher enrollments of AI children and Native parent committees within those schools.

Finally, the results confirming that P2W produced significantly larger increases in several measures of cultural engagement—ethnic identity exploration, following the “Indian way,” and AI spirituality—among those relatively less engaged at the start are, in part, related to the overall high levels of engagement noted above. That is, they may reflect ceiling effects where already highly engaged participants have little “room” to demonstrate increases on bounded scales. However, the results also provide support for the effectiveness of systematically culturally grounded interventions as a means of increasing the sense of cultural connection for urban AI parents who may harbor uncertainties about their connection to their heritage. Although the increases in AI ethnic identity and AI spirituality attributable to participation in P2W were small, these changes have larger potential implications for behavioral health and well-being. In studies across diverse AI communities, strong AI ethnic identity and the maintenance of AI spiritual practices is associated with better physical and mental health, and less risk of substance abuse and suicide (Allen et al., 2018; Beebe et al. 2008; LaFromboise et al., 2006; Lester, 1999; Whitbeck et al., 2001; Whitesell, Beals, Crow, Mitchell, & Novins, 2012).

Sampling Limitations

Interpretations of the results are subject to several limitations. The sample was not selected through population-based methods and recruitment procedures could not prevent self-selection. Although prospective parents for the study were informed that they would be randomly assigned to either of two interventions, knowledge of the culturally grounded P2W intervention spread throughout the communities and may have attracted the interest of parents who felt more connected to their AI cultural heritage. Of the prospective parents who expressed an initial interest in the study interventions and enrolled to become participants, one-quarter did not start the intervention after randomization. Another source of self-selection was that, despite efforts to minimize access barriers (transportation costs, childcare provision), the time and effort required for parents to attend workshops for 10 weeks limited the ability of some parents to become participants. Finally, the geographic limitation of the study may be a significant consideration. Although parents came from over 40 different tribal backgrounds and from multiple cities, each with somewhat different tribal compositions and migration histories, the results cannot be generalized reliably to urban AI communities outside Arizona. Arizona has the second largest state population of American Indians, after California, and includes 22 tribal reservations, several located adjacent to or in relative proximity to the three urban sites for this study. A large plurality of the participants in this study belonged to a tribe from a reservation in Arizona. Results may be different if P2W were implemented in another state with a smaller AI population, different tribal makeup, and larger distances between tribal and urban areas.

Conclusions

The promising evidence of the effects of P2W in improving the cultural engagement of urban AI parents, particularly those feeling relatively less connected to their heritage, suggests that it can help fill the widespread need for evidence-based and culturally grounded parenting interventions for the growing population of urban AI families.

Public Significance.

This study highlights the importance of traditional cultural heritage as a key component of evidence-based parenting interventions for urban American Indian families. The culturally grounded Parenting in 2 Worlds curriculum increased the participants’ sense of American Indian ethnic identity and spirituality, which prior research has identified as protective factors that reduce behavioral health risks and promote the physical and mental health of American Indians.

Acknowledgements:

Data collection and analysis for this study was supported by the National Institute on Minority Health and Health Disparities of the National Institutes of Health (R01MD006110, S. Kulis, PI). We thank the American Indian Steering Group at the Southwest Interdisciplinary Research Center, Arizona State University, for their guidance in the development of the Parenting in 2 Worlds intervention and advice on the means of delivering it in urban communities.

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