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. Author manuscript; available in PMC: 2022 Jan 1.
Published in final edited form as: J Ethn Cult Divers Soc Work. 2020 Jun 8;30(1):149–162. doi: 10.1080/15313204.2020.1770654

SACRED Connections: A University-Tribal Clinical Research Partnership for School-Based Screening and Brief Intervention for Substance Use Problems among Native American Youth

Staci L Morris 1, Michelle M Hospital 1, Eric F Wagner 1, John Lowe 2, Michelle G Thompson 3, Rachel Clarke 1, Cheryl Riggs 2
PMCID: PMC7958493  NIHMSID: NIHMS1596719  PMID: 33732098

Abstract

Native American (NA) youth report higher rates of alcohol, marijuana, and drug use than U.S. adolescents from any other racial/ethnic group. Addressing this health disparity is a significant research priority across public health, minority health, and dissemination and implementation (D&I) sciences, underscoring the need for empirically-based interventions tailored for NA youth. Effective D&I with NA youth incorporates NA cultural values and involves tribal elders and stakeholders. SACRED Connections (NIDA R01DA02977) was a university-tribal research partnership that utilized a culturally derived Native-Reliance theoretical framework and a community-based participatory research (CBPR) approach. A significant objective of this randomized controlled trial was to close D&I gaps utilizing the RE-AIM Model and National Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care Standards (HHS, 2019).

Findings of this 5-year RCT revealed a statistically significant protective relationship between Native Reliance and baseline lifetime and past month alcohol and marijuana use; additionally, the likelihood of reporting marijuana use at 3 months post-intervention was significantly lower among the active condition than among the control condition. Implementation of a developmentally and NA culturally tailored brief protocol revealed: partnering with Native Americans and utilizing CBPR facilitated engagement with this hard-to-reach, underserved community; age and culture are associated with substance use severity among NA teens; a culturally adapted Motivational Interviewing (MI) brief intervention may be effective in reducing marijuana use among NA youth; the Native Reliance theory proved useful as a framework for working with this population; and RE-AIM proved helpful in conceptualizing health equity promoting D&I.

Keywords: Native-American, tribal, youth, adolescents, CBPR, motivational interviewing, dissemination and implementation, RE-AIM, university-community partnership

Substance Use among Native American (NA) Youth

Native Americans (NA) experience disproportionately high rates of substance use problems, yet data suggest that many do not receive effective interventions to manage substance use and associated comorbid conditions. Incidence rates for accidental death, domestic violence, suicide, incarceration, illness, and disease associated with substance use among NA people are between 2–3.5 times higher than any other ethnic group (Baciu, et al., 2017; CBHSQ, SAMHSA, & US Department of HHS, 2011; UIHI, 2011, 2014a). Incidence rates per 100,000 NA persons for alcohol and illicit drug use disorders among NA people age 12 and older are higher than any other US racial/ethnic group (CBHSQ, US Department of HHS, & SAMHSA, 2011). Furthermore, NA mortality rates per 100,000 NA persons, compared with the general U.S. population, are markedly elevated for alcohol related liver disease/cirrhosis (21.6% vs. 9.2%), and alcohol induced death (11.7% vs. 3.3%) (CDC, 2014). This health disparity plaguing NA people is a product of social exclusion, discrimination, poverty, historical trauma, and the disregard for NA cultural values that affect stress proliferation (Pearlin et al., 1997); these factors influence health-care decisions which can lead to maladaptive behaviors, substance use problems, and psychosocial vulnerability (Brave Heart, 1999; Brave Heart & DeBruyn, 1998; Lowe et al., 2016; Snijder et al., 2018).

NA teenagers are at particularly high risk for substance use and substance use problems compared to teenagers from any other racial/ethnic group. NA youth report higher rates of past month cigarette use, binge drinking, and illicit drug use compared to U.S. adolescents from any other racial/ethnic group (SAMHSA, 2004; Snijder et al., 2018). NA adolescents tend to start using earlier and have more severe consequences, including higher rates of suicide and loss of potential years of life (e.g., Bachman et al., 1991; Beauvais, 1996; CBHSQ, 2011; Burnette & Figley, 2016; Gfellner & Hundleby, 1995; Gutierres et al. 1994; Guttmannova et al., 2017; SAMHSA, 2004; SAMHSA, 2008; Schinke et al., 2000; UIHI, 2014). According to the National Survey on Drug Use and Health, nearly 9.2% of NA ages 12 and older reported current heavy alcohol use, the highest rate of any ethnic group (SAMHSA NSDUH, 2015). Moreover, NA youth ages 12–17 reported twice the rate of past month marijuana use than non-Hispanics Whites (14.6% v. 7.1%) (SAMHSA, 2019).

Adolescence is a crucial period within which to intervene as it is a key period of brain development that can be severely negatively impacted by early and heavy alcohol and other substance use (Degenhardt et al., 2016; Morris & Wagner, 2007). Since NA youth are at especially high risk for substance use, developing effective interventions for NA teenagers is a significant research priority. Guttmannova et al. (2017) suggest that despite the reported differences in initiation and rates of alcohol and substance use, the trends among all US teenagers are similar; therefore, rather than reinventing a specific NA intervention, they suggest culturally adapting evidence-based interventions for use with NA youth.

Motivational Interviewing

Motivational Interviewing (MI; Arkowitz et al., 2015) is an evidence-based, directive, client-centered, collaborative counseling style. MI enhances motivation for change by helping the client clarify and resolve ambivalence about behavior change, thereby creating cognitive dissonance between where one is now and where one wants to be. A consistent empirical literature supports the effectiveness of motivational interviewing (MI) with adolescent substance users. While there are over two decades of published reports of randomized clinical trials (RCT’s) of MI with adolescent alcohol and marijuana users demonstrating its effectiveness (Borsari & Carey, 2000, D’Amico et al., 2008; D’Amico et. al, 2018; Daeppen et al., 2011; Larimer et al., 2001; Martin et al., 2005; McCambridge & Strang, 2004, 2005; Monti et al., 1999; Newton et. al., 2018; Roberts et al., 2000; Stein et al., 2006; Walker et al., 2006), studies of MI with NA youth have been limited (Wagner et al., in press). The consequences of health disparities, such as lack of funding, private space in small schools, institutional barriers, poverty, etc. are recognized as barriers to implementation. The current study was a D&I effort to address this problem and overcome identified barriers in an underserved population (Native Americans).

The underpinnings of motivational interviewing are consistent with Native Americans beliefs (Dickerson et al., 2016; Gilder et al., 2011; Venner et al., 2007). In their study utilizing a culturally adapted version of MI with American Indian/Alaska Native youth, Dickerson et al. (2016) reported that “urban AI/AN youth liked the open and collaborative nature of MI and said that this approach helped them feel more connected with each other.” Batliner et al., (2014) stressed that access to services for Native Americans is limited by virtue of high poverty rates, their rural location, and corresponding lack of treatment facilities, rendering them a medically underserved population; this is further complicated by the fact that while effective, brief interventions by virtue of the limited time for relationship building may prohibit the development of trust with a group who is distrustful of outsiders. These barriers and obstacles were addressed in the current study.

Approach

A community-based participatory research (CBPR) approach was utilized following principles that guided a partnered approach in all phases of the research process. This ensured equitable involvement by community members, academic researchers, and others (such as the Health Educators who conducted the MI sessions) and solidified the research partnership. All partners contributed expertise and shared in decision making and ownership of the project (Israel et al., 2003; Wallerstein & Duran, 2003). Following this CBPR approach allowed the joining of the health research team and tribal community members, which resulted in a genuine voice in the research process and the intervention’s successful implementation and attainment of project goals (Wallerstein and Duran, 2010).

Method

Purpose

SACRED Connections (Self-Awareness Creates Responsible Empowered Decisions) was a 5-year RCT (NIDA R01DA02977, PI: Wagner) that formed an effective university-community partnership to culturally adapt, implement, and evaluate a brief evidence-based motivational substance use intervention among NA youth in Midwestern rural communities. Essential to the success of the project was the guidance received by school administrators, a prominent tribal chief, and a local Community Advisory Board (CAB). The primary goal of the proposed study was to conduct a clinical trial evaluating a culturally congruent, school-based motivational interviewing intervention targeting substance use among NA high school students. The study had 4 aims:

Aim #1: To compare three intervention conditions: (1) Brief Advice and a Personalized Feedback Report alone (BA+PFR; n=160), (2) Brief Advice, a Personalized Feedback Report, and Motivational Interviewing (BA+PFR+MI; n =160), and (3) Brief Advice, a Personalized Feedback Report, Motivational Interviewing, and a 6-months post-intervention Booster session (BA+PFR+MI+BOOST; n =160).

Aim #2: To evaluate the impact of a 6-months-post-intervention booster session on substance use and substance-related negative consequences.

Aim #3: To examine putative mechanisms of change (i.e., mediators) associated with response to our motivational interviewing intervention.

Aim #4: To explore gender and Native American cultural variables as moderators of intervention response.

Measures

As seen in Figure 1, all participants were evaluated at study entry (baseline), and at 3-, 6-, 9-, and 12-month follow-ups. The baseline interview took approximately 1 hour to complete; each follow-up assessment took approximately 30 minutes to complete. All assessment measures were carefully selected based on reliability, validity, developmental and cultural appropriateness and were approved by the CAB. Screening was conducted using The Personal Experience Screening Questionnaire (PESQ; Winters, 1991), designed to identify adolescents in need of a substance use assessment and referral. The use of screenings has been suggested by the Urban Indian Health Institute (UIHIb, 2014) to overcome barriers to access and improve treatment outcomes. The PESQ takes approximately 10 minutes to complete. Demographic information and counseling history were assessed as well as:

Figure 1:

Figure 1:

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Participant Flow Chart

*participants were recruited from 6 rural public high schools across 2 counties

**random assignment of condition

Substance Use Disorder Diagnosis: The Composite International Diagnostic Interview (CIDI), developed by the World Health Organization (WHO), is a comprehensive, fully structured diagnostic interview, designed to be administered by lay interviewers and was a product of more than 15 years of international collaboration aimed at standardized procedures for assessing disorders in community studies throughout the world (Kessler, et al., 1998).

Substance Use Patterns: Substance use at each contact was measured using the Timeline Followback Interview (TLFB; Sobell et al., 1980; Sobell & Sobell, 1992, 1996). Substance consumption information was collected using a calendar format to provide temporal cues (e.g., holidays, special occurrences) to assist in recall of days when substances were used. Alcohol use was measured in standard drinks and substance use was collected in terms of use/non-use given wide variations in potency and ingestion methods. Additionally, 10% of participants were randomly selected at both the 6-month and 12-month follow-up assessments for urine testing using the OnTrak TesTcup® (4 Panel) from Varian Diagnostics (http://www.varianinc.com/cgi-bin/nav?/products/dat/testcup).

Substance Use Consequences were assessed using The Drug Use Screening Inventory-Revised (DUSI-R; Tarter, 1990), a multidimensional questionnaire concerning teenager’s alcohol, marijuana, and other drug use frequency, substance use problem severity, and related domains (e.g., school performance, health status, peer relationships).

Readiness to change was assessed using a readiness ruler (Rollnick et al., 1999) on a continuum from not ready to change (0) to trying to change (10). A similar measure was used to assess the importance of changing substance use from not important at all (0) to the most important thing in my life (100).

Self-efficacy to resist substance use was measured via The Brief Situational Confidence Questionnaire (BSCQ), an 8-item version of the 39-item SCQ (Annis & Graham, 1988) that covers eight areas of high-risk situations for relapse in the SCQ. Respondents rated each situation regarding their confidence to resist urges to use substances, from 1 (not at all confident) to 100 (totally confident).

Native American Culture was assessed using the Native Reliance Framework (Lowe, 2002; Lowe et al., 2016; Lowe et al., 2019). Cultural variables are related to values associated with rural community living. These values are steeped in the culture where the collective or group is emphasized versus individualism. As seen in Figure 2, Native Reliance is a cultural identity theoretical framework that describes the beliefs and values of seeking truth and making connections, being responsible, being disciplined, and being confident. Seeking truth and making connections for NA refers to knowing the spirit in everything, including themselves, so that connections become known in all aspects of their lives. Being responsible refers to providing by having an income and also accepting assistance for what is necessary. Being responsible refers to individuals learning and accepting the role of caring for the well-being of themselves and others such as family and community members. This may require NA individuals to accept assistance offered by tribal programs or other individuals within their tribal communities. Being responsible also refers to providing for others by respecting others, being present and accountable, and by calling on the Creator through speaking the traditional Native/Indigenous language and honoring the Creator through ceremony. Being disciplined refers to seeking a vision by making decisions based on honor and defending the vision. Being disciplined also refers to sharing the vision by counseling with elders, accepting the vision, and speaking the vision in the traditional Indigenous language. Being confident refers to having a sense of identity by being proud of one’s Indigenous heritage and accepting Indigenous or tribal beliefs and values. Being confident also refers to having a sense of self-worth by facing challenges and contributing to Indigenous or tribal knowledge and preserving ancestral stories. These beliefs and values are arranged in a circular manner to represent the circular nature of an Indigenous world view.

Figure 2:

Figure 2:

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Native Reliance

Finally, at the one year follow-up, participants completed the Interventionist Description Form, a version of McLennan’s (1990) 12-item Counselor Perception Measure (CPM), adapted for use with substance using youth to measure participants’ perceptions of the Health Educator’s (project staff) acceptance and competence.

All participants were randomly assigned to one of three treatment conditions: (1) Brief Advice and a Personalized Feedback Report alone (BA+PFR), (2) Brief Advice, a Personalized Feedback Report, and Motivational Interviewing (BA+PFR+MI), or (3) Brief Advice, a Personalized Feedback Report, Motivational Interviewing, and a 6-month post-intervention Booster session (BA+PFR+MI+BOOST). While the Health Educators were aware of condition assignment, participants were blind to condition assignment. The Health Educators were made aware of the nature of randomization during trainings and supervisors were trained to remain vigilant to any differences in the delivery of the intervention.

D&I and the RE-AIM Model

The science of D&I guides development, implementation, and dissemination of evidence-based practices while accounting for adaptations through the use of models. Dissemination, implementation, and evaluation of this study were guided by the RE-AIM D&I model (re-aim.org, 2017). The evidence-based practice was Motivational Interviewing (MI). As seen in Figure 3, RE-AIM is a non-linear framework that equally accounts for dissemination and implementation and allows for adaptations during the process. RE-AIM was developed to assist in the development and evaluation of real-world public health programs with the ultimate goal of implementing effective, generalizable, evidence-based interventions. RE-AIM was the model most often used in NIH and CDC D&I grant applications between 2006 and 2016 (Harden et al., 2018; Vinson et al., 2017). As shown in Figure 3 (re-aim.org, 2017), the plan cycles through the 5 key RE-AIM dimensions: (1) Reach; (2) Effectiveness; (3) Adoption; (4) Implementation, and (5) Maintenance. However, RE-AIM phases are best understood in the following order: (1) Adoption, (2) Reach, (3) Implementation, (4) Effectiveness, and (5) Maintenance.

Figure 3:

Figure 3:

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RE-AIM Model

*Elements of the RE-AIM Framework (Cummings Graduate Institute (2015–2019), retrieved from https://azhin.org/cummings/re-aim)

Adoption

Adoption refers to the number and representativeness of entities and interventionists. The key question is, “How can organizational (systemic level) support be developed?” For the current study, this was accomplished in several ways: trainings with Health Educators, the first of which was in Midwestern rural communities where the researchers were immersed in NA culture and traditions; development of the project name and logo guided by NA tribal stakeholders and project staff; continued involvement in traditional NA holidays, parades, and celebrations; annual CAB meetings with key stakeholders who reviewed and provided feedback on project materials and implementation strategies continually identifying and addressing pathways and barriers to adoption; repeated presentations to tribal leaders and school staff; and obtaining 2 tribal IRB approvals.

In particular, the CAB recommended that key tribal community members with expertise in substance use counseling engage with the HEs and researchers in “mock” sessions using the proposed materials and intervention strategies. During these sessions, the HEs and researchers received feedback and input from the tribal experts. For example, body language, posture, and voice tones that could potentially be considered intrusive, disrespectful, and threatening and may have resulted in the youth participants disengaging in the project sessions were noted by the tribal experts. This CBPR principle is referred to as “participation with action” (Israel et al. 2003) and was a crucial, yet time consuming process. It became apparent that extra training sessions were needed which presented a project challenge as extra training sessions meant additional time and resources, which not only included salaries for project staff, but also compensation for community consultants who dedicated their time and had a cultural expectation of meal provision and shared food, expenses often not covered by grant funding.

The NA youth were located in rural Midwestern communities where resources are limited. The communities are small with long distances separating them from other communities. Therefore, there is great reliance and dependence on each other and many communities comprise multiple related families. Most of the communities are of lower socioeconomic status and the majority of incomes come from labor jobs such as farming and construction. Ultimately, the project was implemented in 6 schools across 2 counties.

Staffing proved to be a crucial component; the project coordinator and Health Educators were tribally enrolled, trained in mental health, and immersed in both Native and school communities. RE-AIM proposes an Adoption calculator which is equal to sites participated/approached. In terms of schools approached, all schools participated, so the Adoption rate was 100% (6/6).

Reach

The total population (REACH) of this 5-year RCT included NA tribal community elders (n=14), Health Educators (n=15), and youth (N=405); total N=434. Reach accounts for the number and representativeness of participants on an individual level. The key question is, “How can the targeted population be reached on an individual level?” For the current study, this was accomplished by: (1) cultural tailoring regarding the language, images, and references with input and approval by the CAB; (2) repeated meetings and class presentations at schools; and (3) recognition of program participation at holidays and at the end of the school year. CAB members’ feedback and approval proved to be crucial to the success of the project, specifically in terms of Reach. CAB members remained active during the entire length of the project. The CAB met regularly throughout the duration of the project and was instrumental in reviewing and approving all materials, receiving updates by the research team on a regular basis regarding the progress of the project, and was provided a report of the findings at the conclusion of the project. Additionally, they provided cultural interpretation regarding the findings of the study. CBPR stresses the importance of cultural tailoring of intervention, acknowledging native and Western science approaches, and supporting the selection of a culturally appropriate framework (Dickerson et al., 2016, 2018; Getty, G. A., 2010; Whitbeck et al., 2012). CAB meetings allowed for this process to occur, for the materials to be culturally and scientifically appropriate, and their endorsement was pivotal in obtaining consent. This process was informed by The National CLAS (culturally and linguistically appropriate services) Standards (HHS, 2019), 15 action steps intended to ensure heath care for diverse populations is provided in culturally and linguistically sensitive and respectful approaches.

Clinical trial participants were recruited from rural public schools with predominantly NA students by NA project staff who had a consistent presence at the schools for project purposes and important school and NA events and holidays. CAB involvement and endorsement were acknowledged during in-school recruitment presentations. The RE-AIM Reach calculator is equal to # of participants (N=405)/# eligible (461), making Reach 87.85%. Reach also accounts for attrition, which was calculated overall and for each assessment time point: Overall attrition (baseline-12 mos) = 259/405=36%, followed by 15% 3 month attrition, 11.3% 6 month attrition, 15.1% 9 month attrition, and 6.2% 12 month attrition. Reach also considers whether the sample was representative of the population; demographics for this sample were as follows: mean age 16.37 (SD 1.26); sex 49.8% female; grade level 9th (14.8%), 10th (25.4%), 11th (30%), and 12th (32.2%). It is important to note that 12th graders were not included in the original recruitment plan due to the 12 month follow-up; however, the CAB urged for inclusiveness so inclusion criteria was altered accordingly.

Implementation

The next phase in the RE-AIM process after the intervention was adopted and participants were reached was implementation. Implementation refers to fidelity to the intervention’s protocol. The key questions are: “What activities are required?” and “Is the protocol being implemented as intended?” This was accomplished through (1) the development of the protocol and manuals, which included cultural tailoring; (2) securing of confidential locations; (3) determining who would deliver the intervention and initial and subsequent trainings at least twice a year at the beginning and end of each school year; and (4) supervision, which included weekly reports, monthly video calls, and tracking of project achievements and problematic activities.

For the current study, inclusion criteria for the substance use screening were: (1) 9th, 10th, 11th or 12th grade enrollment; (2) self-reported NA race/ethnicity; (3) active parental consent; and (4) student assent. The intervention phase of the clinical trial had the added inclusion criterion “substance user,” operationalized as the use of drugs or alcohol on one or more occasions during the past 90-days. Exclusion criteria for the intervention were: (1) clinically significant mental health problems (e.g., depression) as identified through assessment and interview; (2) clinically significant substance use problems as identified through assessment and interview; or, (3) behavior that places the participant or others around him in danger (e.g., suicidality).

Prior to initiating the screening assessment, written parental consent was obtained. Adolescent participants’ informed assent was obtained by project staff prior to taking part in the screening and clinical phases of the study. In response to feedback from Health Educators, a rapport building “getting to know you” initial meeting with participants was added prior to conducting the baseline assessment in order for participants to feel comfortable disclosing accurate reports of their substance use at the next meeting. During this meeting, Health Educators met with participants and discussed: the description of the program and topics addressed; the assessment schedule and types of questions to be asked; confidentiality; planning for a convenient time for the baseline assessment and personalized feedback session; and any questions or concerns.

All clinical trial participants (overall N = 480) completed a baseline assessment, and were randomly assigned to one of three treatment conditions: (1) BA+PFR; n = 160, (2) BA+PFR+MI; n =160, or (3) BA+PFR+MI+BOOST; n=160. BA+PFR involved a meeting with a Health Educator during which participants were given an informational handout about the risks of drug and alcohol use, a list of local substance abuse treatment resources, and their own personalized feedback report (PFR). In addition, BA+PFR participants were encouraged to stop using substances and to get assistance if necessary. Both BA+PFR+MI and BA+PFR+MI+BOOST participants took part in a motivational interview feedback session, which (a) was conducted based on the techniques of MI (Miller & Rollnick, 1991, 2002) and (b) included written personalized feedback in areas including descriptive norms, perceived beliefs regarding friends’ and parents’ approval of drug and alcohol use, financial costs of drug and alcohol use, and self-reported negative consequences of substance use. Also discussed were the participant’s typical use patterns, social supports for reducing or ending use, personal goals and their relation to substance use, and how important and confident the teen was about reducing substance use.

The PFR was a computer generated personalized intervention booklet that utilized participant reported substance use from the baseline assessment. The resulting booklet was printed in color and presented much of the feedback and intervention activities graphically in order to be engaging and consistent with motivational strategies. It contained a summary of age at first alcohol and marijuana use and lifetime alcohol and marijuana use as well as comparative rates of other adolescents in the same state. This allowed for examination of patterns of use as well as focusing in on consequences of substance use. There was a section on confidence to resist substance use in various situations, set goals, consider social support, and a change plan on how to reduce substance use and anticipate possible barriers. At the 12-month follow-up assesment, 89 participants completed a Participant Feedback Report; 92% reported that they liked the materials used.

After the 6-month follow-up assessment, BA+PFR+MI+BOOST participants received a MI booster session; the format paralleled that used in the initial MI intervention with personalized feedback provided in the areas of self-reported substance use, self-reported substance use problems, perceived current and future risks of substance use, impact of substance use on short- and long-term personal goals, social support for making changes in substance use patterns, and methods for risk reduction. The booster session also included feedback about changes in use patterns based on data collected at baseline, 3-month, and 6-month assessments. The only difference between BA+PFR+MI participants and BA+PFR+MI+BOOST participants was whether or not they received a booster session at 6-months post-intervention.

Participants were evaluated at study entry (baseline), and at 3-, 6-, 9-, and 12-month follow-ups. Assessments addressed demographic and background variables, drug and alcohol use, drug and alcohol use-related problems, and indicators of Native American cultural variables. To aid in participant retention, all research participants received gift cards of increasing value over time ranging from $20 to $50, resulting in a potential remuneration of $160 for complete participation through the 12 month follow-up.

As far as measurement of implementation, RE-AIM does not propose an implementation calculator, but rather recommends accounting for consistency of implementation or the extent to which protocol was implemented as intended, while acknowledging that unfortunately, such data are hardly ever available. Fidelity to implementation was ensured by conducting weekly supervision with Health Educators, monthly team meetings, and annual re-trainings. Additionally, there were 25 Adverse Events that were managed and systematically reported; all were to protect participants from harm and none were related to study participation. Most adverse events were related to self-reported symptoms of depression, self-harm (cutting), and suicidality.

Results

Effectiveness

Effectiveness, the next phase, is dependent on proper implementation. Effectiveness is the impact of an intervention. The key question is “Are the planned outcomes of the intervention achieved?” This was accomplished by: (1) the development of baseline and follow-up assessments; and (2) the creation and maintenance of an elaborate tracking system. Primary findings from the current study will be published in a forthcoming manuscript. Preliminary results showed that participants who were older and had unemployed mothers demonstrated greater and more frequent substance use at baseline. Additionally, results show that at baseline there was a statistically significant protective relationship between Native Reliance and substance use. Specifically, on average, for every unit increase in Native Reliance, lifetime alcohol use at baseline decreased .8 units, and lifetime marijuana use decreased .78 units. Additionally, results showed that after controlling for baseline use, participants assigned to the active condition (BA+PFR+MI) reported greater reductions (β= −.11, p<.01) in marijuana use at 3 months post baseline than the control condition (BA+PFR). At the 12-month follow-up assessment, participants (n=89) were asked to complete a Participant Satisfaction Survey; the results were overwhelmingly positive with 100% sating that they “liked the program;” 91% reporting that they found the program “helpful,” of which 36% found it “very helpful;” 97% reporting that the Health Educators were “always accepting;” and 92% liked the materials used. These results were shared with stakeholders after the conclusion of the project.

Maintenance

Maintenance in the RE-AIM framework is the extent to which a program becomes institutionalized. The key questions are “Is the intervention sustainable over the long term?” and “Does the program produce lasting effects?” This was accomplished by: (1) biannual CAB meetings and (2) annual trainings of Health Educators. As the project progressed and evolved, several adaptations were necessary. Since many schools were small in terms of enrollment, saturation was often reached quickly, so additional schools were added and the project was extended to another tribe. The additional tribe was represented by a member of the CAB who had heritage, affiliation, and cultural knowledge from both tribes. This member provided input into materials and processes that were used for the intervention. At the request of the schools and CAB, inclusion criteria were expanded to include 12th graders; they were originally excluded to ensure higher long-term response rates at 12-months. To address issues of trust and confidentiality, a brief “getting to know you session” for the Health Educator and participant was added and white noise machines were purchased. Additionally, as time and drug trends changed, the assessments were edited accordingly. Maintenance is, of course, dependent on funding; however, 405 participants were reached across 6 schools in 2 counties and 15 Health Educators were trained, many of whom report continuing to use the MI skills acquired during SACRED Connections.

Discussion, Challenges, Limitations, and Conclusions

Thus far, the first aim of the study has been accomplished: The three intervention conditions (BA+PFR, BA+PFR+MI, and BA+PFR+MI+BOOST) were implemented as intended and compared. Aims 2 (To evaluate the impact of a 6-months-post-intervention booster session on substance use and substance-related negative consequences), 3 (To examine putative mechanisms of change (i.e., mediators) associated with response to our motivational interviewing intervention), and (4) (To explore gender and Native American cultural variables as moderators of intervention response), have not yet been explored.

Overall impact, while not formally included as a dimension of the RE-AIM framework, is proposed as part of the framework as being conceptually helpful to discuss implications and future implementation on a larger scale. Overall impact is defined as the public health impact of the program. This project achieved several successes and great impact, including: the forming of a successful university/NA partnership that resulted in several project goals being attained; the development of a culturally tailored and scientifically sound protocol and materials; engagement of tribal and community leaders and public schools with predominantly NA students; and a brief, substance use intervention offered to 405 NA youth who may not otherwise have received services.

The findings that there was a statistically significant protective relationship between Native Reliance and substance use is an important scientific advance and should be considered in future studies with Native Americans. In their systematic review of risk and protective factors with American Indian and Alaska Native youth, Burnette and Figley (2016) found that there was a lack of consensus in the literature; while they attributed this to difficulties in measurement, they concluded that this was a “severe limitation.”

Challenges

University and community partnerships require more time and training than traditional research projects. Following the recommendation of the CAB, NA community members with expertise in substance use counseling reviewed the intervention materials and participated in mock sessions. Consistent with cultural traditions, they often brought additional counselors. The challenge to the project was in adjusting the timeline to accommodate these additions and resulting changes as well as creatively reallocating and finding additional resources to cover efforts by all involved. A particular challenge was meeting the cultural expectation of shared food, which is often an expense minimally covered by federal grants or not allowed at all. Future funding opportunities for NA research can take this into consideration and allow for such expenses to be built into the budget.

Limitations

While the Native Reliance measure addressed some of the documented measurement limitations, there were other limitations that must be acknowledged. Participant recruitment was limited to public high schools with large enrollments of NA youth from two rural counties in the Midwest, and from predominantly three tribal nations. NA are a heterogeneous group; we do not know how generalizable our findings are to NA youth living in more urban settings or on reservations, in other geographic areas, or with different tribal affiliations. Our MI intervention was limited to individual sessions with participants, and did not involve contact with parents, family, or peers, all of whom are powerful social influences on adolescent substance use. Relatedly, our primary data source was limited to participating adolescents; we did not collect data from parents, teachers, or peers. Additional data sources may help future studies better understand the depth and breadth of MI effects, as well as factors that may moderate effectiveness. Finally, our intervention sessions were limited to school settings and school hours. Among students with substance use problems, tardiness, repeated absences, and truancy are common, complicating the attempts to meet at school. Future studies should consider adding a home-based, non-school-based, and/or after-hours option for MI implementation among students who miss sessions because they miss school.

Conclusions

As supported by the literature (Getty, 2010; Liddell & Burnette, 2017; Marsiglia & Booth, 2015), the partnership between the researchers and the tribal community was critical to the success of this project and resulted in effective cultural tailoring. The partnership with the tribal community ensured that NA cultural values were integrated into implementation and not simply acknowledged (Burnette & Figley, 2016; Whitbeck, 2006; Whitbeck et al., 2012), which facilitated tribal community ownership (Whitbeck, 2006). D&I science, specifically the RE-AIM model, provided a framework that guided the adaptation of the evidence-based practice, Motivational Interviewing, for implementation allowing for adaptations while still holding to the integrity of the evidence-based practice and supporting “long standing partnerships beyond the term of the research” (Whitbeck, 2006).

Results demonstrated that: (1) a culturally responsive MI-based brief intervention may be effective in reducing substance use among NA youth with statistically significant reductions in marijuana use at 3 months; (2) Native Reliance theory is an appropriate framework and protective factor; and (3) an intentional, well-planned, and flexible university-tribal partnership utilizing CBPR methods and a D&I model allowed effective implementation and engagement with a hard to reach underserved community.

Acknowledgments

The authors would like to acknowledge NIDA (1R01DA029779-01A1; MPI’s: Wagner & Lowe), NIMHD (1U54MD012393-01; PI: Wagner), and the Training Institute on Dissemination and Implementation Research in Health (NCI & US Department of Veteran’s Affairs) funding, support, and training of this research project. They also extend gratitude to the staff of FIU-CBRI (including Robbert Langwerden for his assistance with the preparation of this manuscript), FSU-INRHE, and most importantly, to their tribal partners, elders, Community Advisory Board members, schools, participants, and project staff.

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