Formative Research and Cultural Tailoring of a Substance Abuse Prevention Program for American Indian Youth: Findings from the Intertribal Talking Circle Intervention

Abstract

Background

Substance use among American Indians (AIs) is a critical health issue and accounts for many health problems such as chronic liver disease, cirrhosis, behavioral health conditions, homicide, suicide, and motor vehicle accidents. In 2013, the highest rates of substance use and dependence were seen among AIs when compared to all other population groups, although these rates vary across different tribes. Among AI adolescents, high rates of substance use have been associated with environmental and historical factors, including poverty, historical trauma, bi-cultural stress, and changing tribal/familial roles. Our project, the Intertribal Talking Circle intervention, involved adapting, tailoring, implementing, and evaluating an existing intervention for AI youth of three tribal communities in the United States.

Formative Results

Community partnership committees (CPCs) identified alcohol, marijuana, and prescription medications as high priority substances. CPC concerns focused on the increasing substance use in their communities and the corresponding negative impacts on families, stating a lack of coping skills, positive role models, and hope for the future as concerns for youth.

Cultural Tailoring Process Results

Each site formed a CPC that culturally tailored the intervention for their tribal community. This included translating Keetoowah- Cherokee language, cultural practices, and symbolism into the local tribal customs for relevance. The CPCs were essential for incorporating local context and perceived concerns around AI adolescent substance use. These results may be helpful to other tribal communities developing/implementing substance use prevention interventions for AI youth. It is critical that Indigenous cultures and local context be factored into such programs.

Introduction

Substance use among American Indians (AIs) is a critical health disparity and accounts for many life-threatening diseases and fatalities, such as chronic liver disease, cirrhosis, homicide, suicide, and motor vehicle accidents (US Department of Health Human Services, 2011). When compared to other racial/ethnic groups, AI adolescents in the United States (US) live shorter and more challenging lives than other Americans and are consistently showing disproportionately higher rates of substance use and dependence, including lifetime tobacco and marijuana use as well as nonmedical use of pain relievers and prescription psychotherapeutics (Substance Abuse and Mental Health Service Administration [SAMHSA], n.d.). They also experience significantly higher rates of alcohol and illicit drug use, suicide rates, and traumatic exposure (Beals et al., 2013; Substance Abuse and Mental Health Services Administration [SAMHSA], 2011). Furthermore, AI populations show higher rates of alcohol use disorders; however, these rates can vary substantially across tribes (Miller, Stanley, & Beauvais, 2012; Swaim & Stanley, 2018). For example, Miller et al. (2012) found high rates of substance use in the Upper Great Lakes and Northern Plains regions of the country, whereas rates for those substances were comparably lower in the Oklahoma and Southwest regions.

Early substance use onset has been linked to antisocial behavior, aggression, conduct disorder, and other mental health disorders (Ehlers, Slutske, Gilder, & Lau, 2007). Underage alcohol use, specifically, demonstrates an increased risk in suicide, physical and sexual assault, as well as heavy drinking in adulthood (SAMHSA, n.d.). Among AI adolescents, high rates of substance use have been associated with a variety of environmental and historical factors, including poverty, historical trauma, bi-cultural stress, and changing tribal and family roles (Patchell, Robbins, Hoke, & Lowe, 2012). Such factors create a unique situation where a community-based, culturally centered intervention serves as a particularly relevant approach for addressing substance use for AI adolescents.

Culture-centeredness seeks to draw from cultural strengths, building from people’s agency, power, and language to direct health changes in their communities (Dutta, 2007; Wallerstein, Duran, Oetzel, & Minkler, 2017). Culture-centeredness also embraces interventions that are based on Indigenous history, language, values, and healing traditions. Findings suggest that a community-derived and culturally grounded curriculum can increase participant feelings of hope, optimism, and self-efficacy, all of which are crucial in substance use reduction (Donovan et al., 2015). Incorporating cultural, spiritual, and traditional practices in combination with evidence-based practice can help the recovery process for AI adolescents already seeking substance use treatment (Beckstead, Lambert, DuBose, & Linehan, 2015).

The most accessible treatments for non-Native individuals with substance use disorders are in the outpatient settings, using ecological family therapy, cognitive-behavioral therapy, and brief motivational intervention. These treatments show positive results for patient outcomes when implemented with fidelity and skill (Becker & Curry, 2008). However, the effectiveness of these interventions for AI populations is difficult to determine due to the woeful lack of randomized control trials involving AI populations and the absence of AI understandings of healing and wellness that are aligned with the Western biomedical definitions of mental health and treatment (Hartmann & Gone, 2012). Evidence suggests, however, that the foundations and framework of motivational interviewing may be harmonious with many AI beliefs (Dickerson et al., 2016; Gilder et al., 2011; Venner, Feldstein, & Tafoya, 2007). Furthermore, research has shown that traditional cultural services for substance abuse problems for AI youth is strongly preferred and AI parents/caregivers believe that these services are more effective compared to formal behavioral health services (Walls, Johnson, Whitbeck, and Hoyt (2006).

AI youth substance abuse prevention programs are also incorporating cultural, traditional, spiritual and family values. For example, the National Indian Youth Leadership Project emphasizes community service and wilderness education to bring the youth back to traditional practices (Carter, Straits, & Hall, 2007). Research also indicates strong support for the effectiveness of a talking circle influenced approach (Becker, Affonso, Blue Horse Beard, 2006). Indeed, talking circles remain an important concept for many indigenous groups today and may be valuable in reducing AI substance use through culturally congruent interventions. Utilizing traditional ceremonies, such as drumming and sweat lodge ceremonies, have demonstrated treatment and prevention success, as well (Greenfield & Venner, 2012).

Reflected in each AI community is a unique and distinct culture that requires existing interventions to be adapted and/or tailored for cultural relevance and appropriateness (Jackson & Hodge, 2010). Developing culturally tailored and competent interventions targeting health conditions and behavior is a well-established strategy that has been shown to decrease the burden of diseases among the AI population (Dickerson et al., 2018; Swaim & Stanley, 2018). Furthermore, active engagement with the community in the development and implementation of programs is critical for sustainability (Dickerson et al., 2018).

Our project, the Intertribal Talking Circle (ITC) intervention, involved adapting, tailoring, implementing, and evaluating an existing intervention (Keetoowah-Cherokee Talking Circle – CTC) for AI youth (Lowe, 2006) among three different tribes within the United States. We sought to adapt the active ingredients of the original intervention to address both efficacy and adaption among these three different tribes (Lau, 2006). Most evidence based intervention (EBI) adaptation studies focus on adapting a Western-based intervention for Indian Country. This study is unique in that it involved adapting a Keetoowah-Cherokee specific intervention used in one tribal setting and integrating it within an existing EBI substance use prevention framework for three culturally diverse tribal communities.

The Talking Circle prevention intervention has its origins in the Teen Intervention Project which was built on the standardized Student Assistance Program (SAP) designed to help adolescents address alcohol and substance abuse problems (Wagner, Kortlander, & Morris, 2001). The SAP is an evidenced-based program endorsed by SAMSHA as a model program. The SAP involves a 10-session motivational, skills-building group intervention, developed for use with 6^th through 12^th graders and utilizes a traditional group setting, approach and process. The Talking Circle intervention merges the core ideas of the SAP with AI values.

This study engaged professionals in the development and practical application of culturally tailored substance use prevention programs for AI tribes, promoting health and preventing substance use. The purpose of this article is to describe the formative research methods utilized and the approach to tailoring the ITC intervention to be culturally and contextually congruent for each tribal community involved in the ITC project.

Methods

In the first year of the ITC project, community partnership committees (CPCs) were formed in each site to identify the needs, priorities, and resources of each community regarding early adolescent substance use. A community needs assessment was conducted in each of the three sites, which helped to describe the extent and nature of the substance abuse concerns in the local communities. Available information from the literature and other sources, such as tribal data, was also gathered and reviewed as additional evidence regarding substance use related issues relevant to each of the three tribal sites.

Six CPC members were individually interviewed at each site and were asked to share their concerns and insights regarding substance use issues in their respective communities to provide local context for the intervention sessions. Examples of interview questions included, “What are the substances most abused in your community?”, “What are your concerns regarding alcohol and substance abuse among the youth in your community?”, “How is alcohol and substance abuse being addressed in your community?”, “Are there programs available in your community that address alcohol and substance abuse?”, and “What type of alcohol and substance abuse prevention activities/approaches do you consider appropriate for the youth in your community?”

All interviews and focus groups were audio recorded and transcribed verbatim. The transcriptions were coded using Atlas TI Qualitative Analysis Software (“ATLAS.ti Qualitative Data Analysis Software,” 2012). Analysis of the data followed a standard ethnographic process using emergent construct coding to identify consensus-level themes and trends as well as significant variation in themes across the three participating sites (LeCompte & Schensul, 2010).

To culturally tailor the intervention to each tribal community, the team utilized results from the interviews as well as the Circular Model of Cultural Tailoring (CMCT), which acknowledges that many tribes possess a circular worldview with constant flow and movement. The CMCT framework was developed to reflect certain aspects of the medicine wheel, which exists as a traditional and sacred symbol across many AI cultures. According to Patchell et al. (2012), “The medicine wheel is a conceptual framework universally used by many AI tribes to represent wholeness, direction, and connection between all things of creation; it provides a roadmap for balance in all aspects of life – physical, mental, emotional, and spiritual” (pg. 47). Applying the CMCT framework allowed the researchers to incorporate the essential elements of self, time, relationships, and tribes into the tailoring approach for each tribal community (Patchell et al., 2012). For example, responses to the interview questions related to intervention approaches that might be important to consider for AI youth were viewed from the perspective of self, time, relationships and tribes. Self is the entry point for tailoring to know the beliefs and traditions of one’s own culture. Time involves the process to spiritually connect with the group through the sharing of stories and experiences. Relationships emphasize the value of growth that comes with active listening and respect so that trust can be developed that builds the foundation for openness and sharing. Finally, tribe refers to the importance of honoring tribal structures that include consulting with tribal experts regarding the past and current expressions of the cultural beliefs in addressing substance use. The present study and its conduct were approved by all tribal councils and institutional review boards involved in the study.

Results

Formative Research Findings

Common themes across all sites are described in detail in Table 1. Exemplar quotes which reflected common themes are included in Table 2. In general, the substances identified as greatest concern to CPC members were alcohol, marijuana, and prescription medications. Community members focused on the increase of substance use in local communities and the negative effects of use on families. CPC members especially expressed concerns about youth not having coping skills, positive role models, and hope for the future. A lack of positive alternative activities for youth was also voiced as a concern across all three sites. All participating CPCs mentioned that there were some services available in their communities, but few were focused on prevention and many were deemed to be ineffective. There was an expressed need for more integrated programs and widespread reinforcement across many sectors of the community, parents, and tribal leadership. CPC members also recommended strategies that might be effective in the future. Our team then incorporated these local, contextual research findings about substance use into the intervention sessions to assist with the cultural tailoring step. This included strategies such as promoting dialogue between many generations of community members including youth, parents, and elders; incorporating traditional cultural activities and teachings; drawing on cultural sources of resilience; focusing on the consequences of substance use; and teaching with real life situations that are common and relatable to youth.

Table 1:

Common Themes Across All Three Sites

Themes	Specifics
Drugs of Greatest Concern	• Alcohol, Marijuana, Prescription Medications, some mention of cocaine, meth, heroin, and over-the-counter medications
Community Concerns	• Increase in usage, availability, and social acceptability of alcohol and drugs
	• Negative effects of substance use on familial relationships and the degradation of the traditional family structure
	• Substance use issues not being addressed directly in the communities
	• Shame around the issue and a general unwillingness to acknowledge the deeper roots of the problem that paralyze the development of prevention and treatment programs
	• Lack of opportunities and positive alternative activities that would steer people away from drugs and alcohol
Concerns for Adolescents	• Larger problems facing youth including not having adequate coping skills, sense of self-sufficiency, morality, positive role models, or hope for the future
	• Some youth feel lost which causes them to turn to drugs as a way to cope, form social bonds, and escape a sometimes harsh reality
	• Legal consequences of criminal behavior associated with underage drinking and drugs that limit future opportunities for young people
Opinions about Services Available	• Services were viewed as inadequate and largely ineffective to address the large scope of the problem
	• Common programs for youth including school counseling, awareness education (DARE), and one-on-one mentorship programs
	• Treatment programs and AA groups are available, but there are a lack of prevention programs
	• Need for more integrated programs and widespread reinforcement across many sectors of the community, parents, and tribal leadership
	• Most services offered are not designed to be effective for youth and are not culturally tailored to American Indian people in general
Effective Strategies	• Promote dialogue between many generations of community members including youth, parents, and elders
	• Include community-based activities that promote positive social relationships in the community, develop traditional skills, incorporate traditional cultural activities and teachings, and draw on cultural sources of resilience
	• Focus on the consequences of substance use and teaching with real life situations that are common and relatable to youth
	• Design programs to address a wide array of social issues that get to the larger roots of the problem

Table 2:

Quotes Related to Common Themes

Themes	Quotes
Drugs of Greatest Concern	Alcohol, and, well, marijuana is a staple, cocaine, prescription drugs. Nowadays, people go doctor shopping. (Location 3)
	Alcohol is often the drug of choice. Prescription medication. Whatever they can get their hands on. (Location 3)
Community Concerns	There are not enough opportunities or options in this town to keep kids from turning to drugs. (Location 1)
	I watch young people drift toward those things as coping mechanisms as substitutes for the extended Native family due to the breakdown in the family system. The social, economic, and cultural breakdown as a result end up as a thing that is passed down to the next generation. (Location 1)
	There is a lack of commitment on Tribal leadership. There are not enough community-initiated programs. (Location 2)
	Shame. A lot of people are trying to hide it so they’re not getting help. (Location 2)
	Prescription abuse – it is on the increase, and once that is cut off from the person, they go to heroin. If we see this kind of increase – and we already are losing – then most of our people are being lost. And there is a lot being lost within this young generation. I mean think about it – they don’t know how to be self-sufficient, don’t know how to kill hogs, grow gardens. In education – they are lost. I see more dependence on government and then there I the degradation of the family unit. It’s like we are becoming ghetto and it is detrimental. (Location 3)
Concerns for Adolescents	There are a lot of unsupervised youth which can lead to the opportunity to use. Parents get too comfortable or busy to pay attention. (Location 1)
	The troubles that come with substance abuse, such as legal troubles, limit the future options of the young and is devastating to the population. (Location 1)
	Young people are disrespectful and lack discipline and honor. This stems from not having guidance from adults or positive role models. (Location 2)
	There is not a system-wide conversation. Behavioral health, mental health, and the judicial department leaves education out of the conversation regarding how to address substance abuse. (Location 2)
	The problem with our youth is that they are going to model what they see at home. Drug addiction is in the homes, and there is easy money when selling, and then there is now way out. Students need to realize there are other options besides drugs – but the issues here stem from the family. (Location 3)
Opinions about Services Available	Wellbeing needs to be a priority. We wait until people come in, after they have engaged in this lifestyle, and they are in a mess, the family is in a mess, the children are in a mess. We need to be more proactive. (Location 2)
	[The programs] have the potential of being really effective if reinforced in the home. (Location 1)
	[The programs are] only as effective as the person wants them to be. The individual has to choose to change. (Location 2)
	[Programs] are not designed for young people. They lack help. Teens have no program that is designed for their age group. (Location 2)
	We need structured activities around the Drum that cleans them up. I would like to see needs addressed through culture – the talking stick and the circle. (Location 3)
	There are [programs] but our county is so large – we need more local support. I mean, our people don’t have vehicles, there is no transportation. The [programs] aren’t reaching the population they need to. (Location 3)
	There is not a community program awareness activity or project that I am aware of where I live which focuses on alcohol and drug prevention. Now, the schools in my community do have exposure to such programs through their counselors and through their health curriculum. We tend to be part of “after the fact” processes instead of preventive awareness of alcohol and substance abuse in and around where I live. (Location 3)
Effective Strategies	We need traditional [tribal] lifestyle activities, build pride in being traditional/spiritual, connecting pride with traditions, get parents out with them, gardening, traditional games, Elder involvement, learning tradition (respect for each other, respect for the things Creator gives us), culture camp for youth, arts (birch bark baskets, moccasins), they need to realize what it means to be Indian (can’t be negative, focus on the positive aspects of being Indian). (Location 2)
	Drugs and alcohol are not the problems – we are self-medicating – we must determine what the root is. Let’s grow and stop using crutches.
	Schools need to help more. Our churches need to get more involved and well-being needs to be a priority. Right now, we wait until people come in, after they have engaged in that lifestyle, and they are in a mess, the family is in a mess, the children are in a mess… so we can fix it. That isn’t working. We need to be more proactive. (Location 3)

Results from the Cultural Tailoring Process

As noted, each site formed a CPC that was tasked with tailoring the intervention for each tribal community. The first tribal site put out a call through tribal venues such as community centers, meetings, and gatherings for volunteers to serve on the CPC. These efforts were rewarded with a diverse six-person panel consisting of a tribal elder and cultural expert, parents, youth outreach and youth center workers, and a healthcare worker. This committee began the task of reviewing the ITC intervention manual, which was originally developed for the Keetoowah-Cherokee people, and making it relevant for the local tribal community. The process included translating the Keetoowah-Cherokee language, cultural practices, and symbolism into the local tribal language in order to make it relevant to the community. Individuals worked together as a group to create an intervention that was both educationally and culturally relevant. As with many tribes, there is a movement to rejuvenate the language and culture, and the group utilized this opportunity to further that effort. The Keetoowah-Cherokee symbolism was replaced with relevant local tribal cultural symbols, stories, and history. Finally, the cover of the intervention manual was redesigned by a local artisan to reflect how the particular tribe gathers together in a group, while maintaining the symbolism of the sacred circle. The result was an intervention manual that was both relevant and reflective of the tribal people in this community.

A similar process was utilized for the second tribal site. The CPC was comprised of six tribal key stakeholders (community leaders, administrative leaders, elders, educators, and parents) that met four times within the first year to tailor the intervention manual for cultural appropriateness and to discuss the implementation procedures for the Talking Circle Intervention. An image of the local river was purposely included on the front cover of the manual as a cultural symbol in which youth could clearly identify. Furthermore, a description and logo of the tribe was included in the introduction to the manual to demonstrate tribal endorsement and promote cultural identity. Input from the CPC was also used to revise words and phrases (e.g., Who’s Your People, Tell It), images (e.g., pinecone, river), and references to traditional activities (e.g., hog killing) throughout the manual to enhance the local and cultural relevance to tribal youth.

At the third tribal site, the teaching guide signified a deliberative process undertaken to capture the seven traditional teachings of bravery/courage, honesty, humility, respect, wisdom generosity, and trust. The front cover of the manual features a traditional elder holding an eagle feather in front of a group of children in a talking circle. A fire is burning to carry messages to the Creator on the air/wind. The elder wears a ribbon shirt with the sacred colors of red, black, white, and yellow. The ground is green, representing Mother Earth and the sky is blue, which is representative of Father Sky. A circular tribal symbol depicts the sacred elements (earth, air, fire, and water), colors, and the direction with the teaching gift from each direction (north: wisdom from the elders; east: courage; south: teaching to instill values for growth; west: vision quest/maturity; Charbonneau-Dahlen, Lowe, & Morris, 2016). The sacred teachings are enriched as one grows as a young man or woman who seeks wisdom from the elders. Throughout the manual, lessons are designed to enhance these tribal values for the participating youth to grow in a holistic manner.

Discussion

To our knowedge, few projects to date have created a culturally centered manualized intervention for unique/different tribal communities from an established tribal intervention to address adolescent substance use. Instead, most evidence based intervention adaptation studies have focused on adapting a Western-based intervention for AI communities (Walters et al., 2018). Thus, this makes our study a unique contribution to the field, in that it involved adapting a Keetoowah-Cherokee intervention for three culturally diverse AI communities.

Our team felt it was critical to approach this project employing a culture-centered perspective and hence, we successfully used the CMCT, a process that is interactive and iterative. Through the CPC’s, we also felt that it was imperative to incorporate local context and perceived concerns around substance use and abuse from our formative research assessment. Themes from the interviews varied somewhat across sites, but common concerns included the increased use of substances (especially alcohol, marijuana, and prescription drugs) in local communities and the negative effects on youth and families. There was also an expressed need for more integrated, culturally-based programs and active involvement of tribal community members in these services and programs.

By focusing on a cultural activity (i.e., talking circle) with a common function of providing a space for group support, this health intervention increases the likelihood of adaptation and generalizability to other tribal nations (Rowan et al., 2014). Incorporating traditional AI traditions and ceremonies into substance use treatments has been shown to improve effectiveness of Western based interventions (Patchell et al., 2012). Sweat lodge, smudging, traditional dancing, prayers, and singing are among the traditional AI rituals and ceremonies incorporated into general substance use treatment. The process of cultural tailoring included working with community members and elders to adapt the intervention materials by translating the Keetoowah-Cherokee language, cultural practices and symbolism to the relevant community. Through working with tribal community members and elders, each of the three sites was able to increase cultural validity and relevance of the health intervention. Thus, culture-centered knowledge and perspective from communities are necessary to aid in intervention development and implementation that are sustainable within AI communities. The emphasis on community co-creation and local adaptation of interventions based on local cultural knowledge and practices is also necessary to ensure efficacy of interventions.

This study represents findings from 3 tribal sites across the United States, and thus, cannot be generalized to all other tribes. However, lessons learned from the methodological approach used in the formative assessment and the culturally tailoring process may be very helpful to other tribal communities developing and implementing substance use prevention interventions for AI youth. It is critical that AI cultures and local context be factored into such programs. This study also translates research to practice in tribal communities through culturally centered strategies that may inform substance use prevention, treatment and policies at the local, state, tribal, and federal levels.

The team is in the process of analyzing longitudinal data from student participants to assess change in substance use behaviors and cultural identity outcomes. In addition, the team plans to analyze results from the training program for the adult facilitators. We hope this study may serve as a model to others trying to combat substance use and abuse among youth in our AI communities.