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. Author manuscript; available in PMC: 2023 Sep 1.
Published in final edited form as: J Community Psychol. 2022 Apr 14:10.1002/jcop.22859. doi: 10.1002/jcop.22859

Harm reduction acceptability and feasibility in a North American indigenous reserve community

Silvi C Goldstein 1, Nichea S Spillane 1, Tessa Nalven 1, Nicole H Weiss 1
PMCID: PMC9464673  NIHMSID: NIHMS1819926  PMID: 35420216

Abstract

Aims:

The present study assessed community and culturally specific alcohol-related harm among North American Indigenous (NAI) individuals, as well as the acceptability and feasibility of harm reduction approaches in one reserve-based NAI community.

Methods:

Participants lived on or near a NAI reserve in Canada. Semi-structured focus groups were conducted with health care workers (N = 8, 75% NAI) and community members (N = 9, 100% NAI). Self-report questionnaires were administered that measured acceptability and feasibility of harm reduction strategies.

Results:

Conventional content analysis revealed loss of culture as culturally specific alcohol-related harm. Health care workers rated harm reduction approaches to be acceptable and feasible, while community participants were more mixed. Majority of participants felt that some harm reduction strategies could provide opportunities for individuals who use alcohol to connect to Indigenous culture and traditions. However, there were mixed findings on whether harm reduction strategies are consistent with Indigenous cultural traditions and values.

Conclusion:

Future research is needed to evaluate potential utility of harm-reduction approaches for NAI communities.

Keywords: alcohol, alcohol-related harm, harm reduction, indigenous culture, indigenous tradition, North American Indigenous, treatment

1 |. INTRODUCTION

Though North American Indigenous (NAI) adults, which includes American Indians in the United States and First Nations in Canada, among others, report lower alcohol use compared to whites (SAMHSA, 2018; SAMHSA, 2019a), they exhibit higher rates of alcohol use disorder (AUD) compared to other ethnoracial groups (Vaeth et al., 2017). Additionally, NAI individuals experience rates of alcohol-related morbidity and mortality that is 6.6 times higher than in the general population. Specifically, death from chronic liver disease and cirrhosis was 4.6 times higher, suicide was 1.7 times higher, alcohol-related hypothermia was 14.2 times higher, alcohol poisoning was 7.6 times higher, and alcohol-related psychosis was 5.0 times higher (Griffith et al., 1996; Indian Health Service, 2019; Landen et al., 2014). While the reasons for the disproportionate health inequity related to alcohol use among NAI communities is generally unknown, it is evident that environmental stressors experienced by NAI individuals—including historical trauma, institutionalized racism, and discrimination—precipitate these alcohol-related health and social inequities (SAMHSA, 2019b; Whitesell et al., 2012a).

Despite the alcohol-related harm experienced by NAI populations, there has been relatively little work testing and developing alcohol treatment interventions aimed at reducing harm for NAI communities. A useful intervention may be to focus on reducing the alcohol-related harm that is disproportionately higher among this population. Thus, harm reduction is one promising approach. Harm reduction approaches are a diverse set of compassionate and pragmatic strategies applied to policy, populations, communities, or individuals that aim to minimize alcohol-related harm and enhance quality of life without requiring or advising abstinence or use reduction (Collins et al., 2011; Marlatt & Witkiewitz, 2010). Harm reduction treatment entails accepting people “where they’re at” while simultaneously helping clients make informed decisions to reduce their alcohol-related harm and improve quality of life without requiring abstinence-related goals (Collins et al., 2011, 2019, 2021). This treatment approach allows for more flexible and attainable target goals than standard strategies that aim to engage people with a predetermined goal of abstinence (Collins et al., 2011, 2015, 2019, 2021). Indeed, harm-reduction treatment has been shown to be an efficacious treatment for reducing alcohol-related harm among individuals experiencing homelessness and AUD, who experience disproportionate alcohol-related harm (Collins et al., 2019, 2021). Given that harm reduction treatment has been shown to be effective for other marginalized groups experiencing disproportionate alcohol-related harm, it warrants exploration among NAI individuals specifically.

The alcohol-related health inequity experienced by NAI individuals may speak to the importance of prioritizing harm reduction approaches and treatment among this population. Perhaps the focus that harm reduction places on supporting client-driven means of reducing alcohol-related harm and improving health-related quality of life for individuals and their communities can work in parallel with Indigenous groups’ focus on community- and family-driven priorities (Daisy et al., 1998), including tailoring treatment approaches to meet the different goals for each client in the context of their community (Landau, 1996). Core harm reduction principles, including a pragmatic emphasis on community outreach as the primary intervention mechanism, may align well with traditional NAI values (Daisy et al., 1998). However, before implementing a harm reduction treatment approach, it is important to assess the acceptability and feasibility of these approaches within NAI communities.

In addition to assessing acceptability and feasibility of a harm reduction approach, it is vital to understand specific alcohol-related harm that may be impacting NAI groups as this may be qualitatively different or culturally specific to NAIs. NAI individuals are subjected to unique harms related to historical trauma, colonization, persecution, and genocide. Research suggests that historical trauma related to colonization is significantly associated with NAI individuals’ alcohol use (Wiechelt, 2012) and offers etiological explanations for alcohol use (Whitesell, 2012). A number of studies show that lasting intergenerational effects experienced by NAI communities from social and cultural disturbance related to the colonization of North America—including forced removal from their tribal lands, broken treaties, and enforced placement of NAI children in boarding schools—is strongly linked to alcohol use (Evans-Campbell, 2008; Brave Heart, 2003; Ross et al., 2015; Wunder & Hu-DeHart, 1992). Indeed, NAI people did not have distilled, potent forms of alcohol before European contact (Beauvais, 1998). Historical accounts note that distilled alcohol was first introduced to Indigenous communities as a genocidal act, and that it was used to inhibit the capacity of Indigenous peoples to reduce offers to trade, to increase profits for traders (Duran, 2018), and to gain negotiating advantages for European political officials (Beauvais, 1998; Frank et al., 2000). No evidence exists of AUDs among NAIs before contact with European settlers (Hawkins & Blume, 2002), further suggesting a link between alcohol use and the devastating effects of colonization (Skewes & Blume, 2019). Moreover, acts of colonization (e.g., forced placement into boarding school) are tied to loss of culture and traditions (Reinschmidt et al., 2016), and thus traditional ways of coping.

Since the introduction of alcohol during colonialization, NAI individuals have struggled with harmful alcohol consumption and disproportionate rates of negative consequences due to alcohol consumption (Landen et al., 2014; Spillane et al., 2015; Swaim & Stanley, 2018). However, overall rates of alcohol consumption by NAI individuals are not higher than those of their white counterparts (Cunningham et al., 2016; U.S. Department of Health and Human Services, 2010). The firewater myth purports that NAI individuals are genetically “more sensitive to the effects of alcohol” and related problems; however, despite prevalent belief in this myth, including by over 50% of NAI college students (Gonzalez & Skewes, 2018), there is limited to no empirical evidence to support this claim (Garcia-Andrade et al., 1997). NAI individuals do not have higher prevalence rates of genetic variants that are linked with susceptibility to AUD compared to people of European ancestry (Enoch & Albaugh, 2017). Yet, NAI communities do experience stark health inequities related to alcohol use; it is theorized that poverty, trauma, and historical and ongoing racial discrimination are among the main explanatory variables for these disparities (Beauvais, 1992; Brave Heart, 2003; Gone et al., 2019). However, existing measures of alcohol-related consequences do not consider or capture community or culturally specific alcohol-related harms applicable to NAI. Thus, to fully understand feasibility of harm reduction for NAI communities, we must first assess community and culturally specific alcohol-related harms.

1.1 |. Current study aims

While prior research has assessed harm reduction treatment among populations experiencing disproportionate alcohol-related harm (Collins et al., 2019, 2021), no studies to date have assessed the acceptability and feasibility of harm reduction among a NAI reserve community. Thus, this study utilized a mixed-method approach to elicit perceptions on community and culturally specific alcohol-related harm, and the acceptability and feasibility of adapting a harm reduction treatment approach for an NAI reserve community.

2 |. MATERIALS AND METHODS

2.1 |. Study design

The present mixed-methods study involved three semi-structured in-depth focus groups that were conducted at the Health Center in one rural NAI reserve community located in Eastern Canada. In alignment with the tenants of community-based, participatory research (Wallerstein & Duran, 2006), interview questions were piloted to a community consultant from the NAI band with experience in mental health. In addition, a core member of the study team is a band member of the NAI community, though they do not live on the reserve. Before beginning data collection, all study procedures were reviewed and approved by Chief and Council as well as the university Institutional Review Board.

2.2 |. Participants

Snowball sampling was used to recruit participants during February–March 2020, with the assistance of a community elder who acted as a community consultant. A total of three focus groups were conducted: two focus groups were comprised of health care workers (N = 8, 75% NAI) and one focus group was comprised of community members (N = 9, 100% NAI). We obtained a sample size that was sufficient to achieve theoretical saturation, where no new concepts arose from participants (Vasileiou et al., 2018). See Table 1 for participant demographics.

TABLE 1.

Sample demographic and descriptive characteristics

Health care workers
 Community members
M (SD) Range n (%) M (SD) Range n (%)
Age 46.38 (12.28) 29–63 8 (47.1%) 44.56 (18.88) 20–74 9 (52.9%)
Sex (female) 6 (75%) 5 (55.6%)
Racial/ethnic background
North American Indigenous 5 (62.5%) 9 (100%)
 White 1 (12.5%)
 More than one race 1 (12.5%)
 Other 1 (12.5%)
 Hispanic or Latino/a 1 (12.5%)
Living location
 Reserve 6 (75.0%) 9 (100%)
 Small town 2 (25.0%)
Employment
 Full time (35+ hours per week) 7 (87.5%) 5 (55.6)
 Part time (less than 35 h per week or sporadic employment) 1 (12.5%) 1 (11.1%)
 Retired 2 (22.2%)
 Other 1 (11.1%)
Acceptability
 “I believe Harm Reduction strategies will be accepted by the people in this community.” 7.13 (1.96) 5–10 4.78 (2.05) 2–8
Feasibility
 “I believe that implementing Harm Reduction strategies into the community will be possible because they will work well for people in this community.” 6.38 (2.50) 3–10 5.00 (2.60) 1–9
Consistent with NAI Values
 “I believe Harm Reduction strategies are consistent with Indigenous cultural traditions and values.” 5.31 (3.13) 1–10 4.89 (2.32) 1–9
NAI acculturation (NAI only)
2.65 (0.42) 2.11–3.40 6 (75%) 2.60 (0.23) 2.90–2.25 9 (100%)
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2.3 |. Measures

2.3.1 |. Sociodemographic measures

Sociodemographic questions assessed participants’ age, gender, race, ethnicity, and education level.

2.3.2 |. Harm reduction acceptability and feasibility ruler

Participant’s attitudes towards the acceptability and feasibility of harm reduction are assessed across three items: (1) I believe harm reduction strategies will be accepted by the people in this community, (2) I believe that implementing Harm Reduction strategies into the community will be possible because they will work well for people in this community, and (3) I believe Harm Reduction strategies are consistent with Indigenous cultural traditions and values. Responses are recorded on a 10-point Likert-type ruler ranging from 1 = not at all true to 10 = totally true. Higher scores indicate higher endorsement of acceptability and feasibility of harm reduction approaches.

2.3.3 |. Native American Acculturation Scale (NAAS)

The NAAS is a 20-item self-report measure that assesses language, identity, friendships, behaviors, generational/geographic background, and attitudes among NAI individuals (Garrett & Pichette, 2000). Only NAI participants were administered this measure (n = 15). Responses are provided on a 5-point Likert-type scale ranging from 1 = low acculturation to 5 = high acculturation. A mean score is calculated from the 20 NAAS items, with higher scores indicating greater acculturation (M = 2.68 [SD = 0.42]). A mean score below 3 on the NAAS indicates that the respondent culturally identifies themself as NAI. Conversely, a mean score above 3 indicates that the respondent identifies themself more with mainstream American culture (assimilated).

2.4 |. Procedure

Following written informed consent, participants took part in a 60-min semi-structured focus group. Focus groups were audio recorded and included open-ended questions to assess cultural and community specific alcohol-related harms as well as harm reduction approaches’ acceptability and feasibility in a NAI reserve community. Participants then completed paper-and-pencil questionnaires. Each participant was paid $20 USD for participation.

2.5 |. Data management and analysis plan

2.5.1 |. Descriptive analyses

Descriptive analyses were conducted in SPSS.27 to provide a sociodemographic description of the sample as well as the means, standard deviations, and frequencies of harm reduction acceptability and feasibility as well as acculturation.

2.5.2 |. Content analysis

Audio recordings were transcribed for qualitative analysis by a professional transcribing company and verified by the Principal Investigator for accuracy (Creswell, 2014). Transcripts were stripped of identifying information before data coding. The electronic copy of transcripts was retained for analysis. Open-ended responses documenting community and culturally specific alcohol-related harm as well as acceptability and feasibility of harm reduction strategies were analyzed using conventional content analysis. Conventional content analysis is a qualitative analysis method that is used to interpret the content of text data through a systematic classification process involving coding and identifying themes (Hsieh & Shannon, 2005; Krippendorff, 2004). In conventional content analysis, researchers do not start with preconceived, theory-based notions about what types of codes or categories of codes will be identified. Instead, researchers allow the data to drive the codes and categories (Hsieh & Shannon, 2005). Qualitative data were recorded in ATLAS.ti and were independently coded by a team of three advanced undergraduates who were trained and led by the Principal Investigator using a constant comparative process (Charmaz, 2014; Miles & Huberman, 1994). Initial coding was conducted using a line-by-line technique, whereby coders narrated the actions occurring in the interviews (Charmaz, 2006). Following independently conducted initial coding, a codebook was created in consensus meetings, pooling incident-by-incident codes, and removing or collapsing idiosyncratic or redundant codes. In the next coding phase, the codebook was used to independently double code the sessions. Any discrepancies and issues in coding were addressed during weekly coding meetings and resolved via consensus. Double coding continued until at least adequate intercoder consistency (80%) was established (Miles & Huberman, 1994; Shek et al., 2005) and then the remaining interviews were coded independently.

3 |. RESULTS

3.1 |. Community and culturally specific alcohol-related harm

Focus group participants were asked about their knowledge and experiences with alcohol-related harm. Overall, four themes of alcohol-related harm derived from participant interviews: cultural, emotional, health, and environmental. In the theme of culture, health care workers and community members identified loss of culture, disconnecting and disengaging from culture (e.g., spirituality), not engaging in cultural activities because of drinking (e.g., needing to be sober for 4 days before engaging in traditional ceremony), and coping with racism as community and culturally specific alcohol-related harm. When discussing types of alcohol-related harm, one health care worker remarked:

Continued loss of culture because people aren’t always – when I look at people that start to become well…because they’re able to follow that cultural path – that spiritual piece that’s been helpful for them. So, conversely, people that are addicted or using substances or alcohol are getting further and further away from that cultural piece of themselves.

Other types of prevalent alcohol-related harm noted included emotional harms, with participants naming trauma, frequent death, emotional difficulties, violence, family stress and issues with self-worth. One community member explained: “It all boils down to some kind of trauma that we’re trying to cover up. We’re trying to bury.” A health care worker affirmed this:

It’s comes down to trauma. A lot of people are, they just think it’s trauma. So, the base, the foundation of so many people who drink is because of the trauma that has been passed down. And they keep passing it down, and people don’t know how to cope. They do not have the proper coping mechanisms for anything.

Another community member explained how families are hurt by alcohol use: “You’re not the person that you used to be, which can destroy families…Just because family’s so big within our communities and stuff. Like, I consider that our cultural aspect too.”

Health-related types of harm noted included issues with physical and mental health, limited access to health care services off the reserve, and lack of positive modeling of healthy choices. One health care worker explained how the combination of racism and limited health care services off the reserve cause harm within the community:

Racism, because you go to the hospital in [closest city], and once they find out you’re from First Nations, you don’t get the same kind of care as someone that’s from [closest city], that’s non-native. We’ve seen that so many times where someone from here … they don’t get the same type of care…Someone tries to commit suicide and they’ll stitch them up, or make them wait around for 18 hours to talk to somebody from the psych department, say okay, I’m fine now, and then they just send them home. But they make a point of making them wait for hours, and hours, and hours before they do even speak to that person.

Another health care worker chimed in:

Or yeah, go in there, what do you want? What did you come here for? Are you going to tell me I’m okay? I’m not dying? Come on, now. There’s always that assumption that it’s for a substance or something. No matter who you are, what you look like, as soon as they see your [First Nation] status card, bam, it changes just like that.

Lastly, specific environmental types of alcohol-related harm noted included isolation, employment issues, housing issues, money problems, boredom, issues with childcare, and easy access to alcohol. A health care worker explained about isolation: “A lot of people end up becoming isolated because their family gave up, or give up on them. Or separation from a family” Another health care worker agreed: “…That’s a big one. Loss. Loss of a loved one, by separation, or death”

3.2 |. Acceptability of harm reduction approaches

3.2.1 |. Acceptability: Health care workers

Focus group participants were asked about their attitudes towards harm reduction. Overall, health care workers found harm reduction approaches to be acceptable (M = 7.13, SD = 1.96). The high prevalence of alcohol-related mortality was noted as a reason for why they endorsed acceptability of harm reduction methods. When asked about the harm reduction concept of “meeting people where they are at” with regards to alcohol use, one health care worker reported: “I’ve seen plenty of people die from alcoholism. I’ve seen people die because they couldn’t stop. So, why would I wanna take that risk of sending somebody away from something that can help them out?” Another health care worker further described how they already utilize a harm reductions approach: “I say put time in between relapsing. I just talk to them about putting time in between being sober, having more sober days than drinking days.” Another health care worker agreed: “If they set that goal to abstinence of alcohol, then you’re setting them up for failure. But pointing out that yeah, you were sober 4 days this week instead of only one, that’s showing them that they accomplished something.” Indeed, health care workers on the reserve were already utilizing some harm reduction strategies.

Strengths of harm reduction noted by health care workers included the ability to engage more individuals in meeting people where they are at, cultural healing, and creating healthier communities. For example, health care workers explained how a strength of harm reduction approaches allows them to reach more people who may be struggling with alcohol use: “if we took an abstinent only approach, then people wanting to change but not being at a position that they want abstinence, we’re not gonna see any of that population to be able to offer services.” One health care worker explained how meeting people where they are at allows them to engage in cultural ceremony:

And that’s what [elder healer] told me, too. She said we’ve got to stop with the rejection. She said, because the thing is with our people, they believe that if you drink, do drugs, anything like that, for four days, you’re not supposed to enter any kind of ceremony, because your spirit’s gone, your soul’s gone. They left your body, right? But I had an elder come up to me one day, and she said, I stopped doing that. I’ve had people who come who were intoxicated, and sometimes for them, that was the only way they could show up to my ceremony…And she said, I see more people healed from me allowing them in the way they were under their state than I did turning them away. It’s to each their own, to everybody…this is how I found a lot of my people started healing, was because [elder healer] stopped turning them away and I let them enter.

However, this sentiment from health care workers was accompanied by mixed attitudes. Mixed attitudes arose among health care workers when considering whether harm reduction was consistent with Indigenous cultural traditions and values (M = 5.31, SD = 3.13). For instance, one health care worker cited harm reduction as contrasting with cultural practices, “I don’t completely agree with harm reduction 100% because a lot of things that I do aren’t harm reduction.” They also explained: “I know there’s people that would be mad at me for letting somebody drunk into my sweat lodge. So it is the way it is. You’re never going to get 100% of the people to.”

Health care workers described the drinking culture on the reserve as oriented toward ultimate goals of sobriety due to the challenges for individuals to gain a “healthy relationship with alcohol” likely due to self-medicating to deal with trauma. One health care worker reported: “So, there’s a few people that go through treatment that come out, like hey I’m going to continue to drink, but as a social drinker. And I tell them, as long as you can be a social drinker, As long as you can have a healthy relationship.” But other health care workers chimed in with “it’s very rare” and “It’s very rare to have a social drinker, actually, because you’re either, there’s no in-between. It’s a switch… It’s either on or off.” Another health care worker commented: “most people that say they are social drinkers are the ones that didn’t grow up here and don’t have those higher traumas that they’re trying to numb.”

However, health care workers identified only one disadvantage to harm reduction strategies, which was the possibility of further enabling substance use. One participant explained:

They talked about the needle exchange or putting needle drop-offs and stuff in the community. There was people that were happy with that and thought it was a good idea, and then there were people that were like—why do you want to do that? You’re just encouraging them… so enabling is kinda one of the attitudes people might be having towards it.

3.2.2 |. Acceptability: Community members

Community members were more mixed on whether they felt harm reduction strategies would be acceptable (M = 4.78, SD = 2.05). For instance, one community member noted challenges with considering alternatives to sobriety: “I don’t think there is no cutting back. It’s either you drink, or you don’t drink.” However, community members also cited that a positive aspect of harm reduction is the ability for people who use alcohol to engage in cultural activities. For example, a dialog between community members describing the experience of someone who actively uses alcohol attending a cultural ceremony articulated this sentiment: “There’s been Sacred Fires, and someone’s [who is drinking] come around. Like, ‘You’re not supposed to be around a Sacred Fire.’ But at the same time, you don’t want to refuse someone either, because maybe that’s where they needed to be at that moment.” …“and drinking gives you that false courage to walk over to them [at ceremony].” …“Yeah, they might not have come over.”…“what if they’re trying to reach out and the only way they can do it is if they’re intoxicated?”…“Yeah, so, that’s why you don’t refuse anybody. You just come over, and you educate them and let them know, like, ‘This is what it’s about.’”

While community members did agree harm reduction can enable individuals to engage more with traditional cultural healing methods, overall, community members felt mixed about the acceptability of harm reduction approaches. Like health care workers, community members reported mixed attitudes when considering whether harm reduction was consistent with Indigenous cultural traditions and values (M = 4.89, SD = 2.32). Some community members expressed that sobriety is necessary for cultural ceremonies. One community member explained: “Anytime it’s culture, then it’s no drinking.”

Further, community members reported that there is an all-or-nothing drinking culture on the reserve and that if you are drinking, it can be difficult to improve your life:

Well, you’re never gonna stop self-harm if you don’t stop drinking. So, I mean, if you say, ‘Well, you can still drink, but try to work on happiness, ‘it’s a depressant. Alcohol’s a depressant, so I don’t know how you can really work on yourself and be happy when you’re still drinking and still being – ‘cause it’s gonna hold you back.’

Despite an overall hesitancy towards harm reduction among community members, harm reduction seemed to be noted as acceptable when considered as an approach to reach sobriety. One community member articulated: “I think, it [harm reduction] is a starting spot. But I think it should be directed towards abstinence.” Some community members expressed positive regard toward harm reduction. Regarding their own process of reducing their substance use, one community member explained, “I wish I would have been a little bit easier on myself and a little bit more harm reduction than flat out abstinence,”

3.3 |. Feasibility of harm reduction approaches

3.3.1 |. What works well

Both health care workers and community members agreed that current alcohol treatment approaches like Alcohol Anonymous meetings, access to recreational activities, engaging in meaningful activities, and sober support groups work well for the community. Health care workers also noted current counseling services, outreach work, prevention programming for youth, holistic treatment approaches, western medicine approaches, and wrap around services offered at the health center as working well. Importantly, both groups highly reported cultural practices working well as alcohol treatment approaches, including: Powwows, snowshoeing, Sacred Fires, Talking Circles, Sweat Lodges, the Sun Dance, fasting, traditional crafts, drumming, storytelling, and Healing Week.

3.4 |. Feasibility: Health care workers

Overall health care workers rated harm reduction strategies to be feasible (M = 6.38, SD = 2.50). Health care workers identified other harm reduction aligned treatment approaches that currently exist in their community, which focus on meeting client’s where they are at (e.g., access to treatment approaches for an individual in the community who uses alcohol and wants to cut down but not stop). This included teaching healthy coping skills, distress tolerance, and goal-setting for individuals who want to reduce alcohol-related harm; offering methadone maintenance; a needle exchange program; offering a choice between both Western and traditional methods of healing; nonjudgmental treatment approaches; helping client engage in meaningful activities; and integrating trauma-informed treatment approaches. Some health care workers noted ways they were already utilizing harm reduction principles with their cultural healing methods. For example, one health care worker explained harm reduction in regard to his Sweat Lodge ceremony:

I know what it’s like to be stuck in that place where you can’t even go one day without any drugs or alcohol. So, in a way with my sweat lodge, I guess you can kinda look at it as a harm reduction because I’ve let somebody drunk into my sweat lodge before. Should I have? Maybe not. I don’t know. I guess I’ll just leave that up to the Creator to answer that. Right? But I made that choice to allow them because to me what people sometimes – it’s their life, right? It’s life or death for them, especially in that community.

Another health care worker noted using a harm reduction approach with regards to Sacred Fires:

I just started gathering firewood, and I let them have their little ceremony around that fire. While they were there, they were talking about healing, because there were other ones that were really sick, were really sick with addictions …. so I’m like, is this a bad thing? I don’t think so, because I didn’t feel bad. I’d seen good. I’d seen healing around that fire.

However, some health care workers reported that cultural ceremonies contrasted with a harm reduction approach. For example, regarding pipe ceremonies, one health care worker explained:

And one of the rules that I’m supposed to follow by is anybody smoking the pipe too should be drug and alcohol free for four days. So that gets kinda hard for me to kinda bend the rules a little but and allow people to still participate, but it does depend on the person. If I feel they’re really ready and they’re really sincere with wanting the change, then I’ll kinda overlook them with them not being clean for four days. But if it continues and they keep on going on and going on, after a while then I have to speak and say enough is enough. You know what the rules are. You have to make more of a commitment here.

Another health care worker explained how drugs and alcohol shouldn’t prohibit someone from engaging in the Pipe Ceremony: “we’re not there to protect ceremony; ceremony is there to protect us. So, it’s not our right to say, oh, you can’t do this; you can’t use this pipe; you can’t do this. No one gave you that right.” However, other health care workers felt that the structure of ceremonies are intentional and should remain rooted in tradition based on how they were intended by ancestors. Though there was agreement by health care workers that they would never exclude individuals from praying with the pipe, they felt it was their jobs as healers to protect the sanctity of their pipes. For example, one health care worker explained:

To be a pipe carrier, you have to be drug and alcohol free. You have to make that commitment. It’s a lifelong commitment to abstain from any drugs or alcohol. So, you have to have abstinence. You can’t have a harm reduction approach with that and same with Sun Dancing too. You can’t have a harm reduction approach to it. And there’s reasons why too. Your mind has to be fully there.

Therefore, harm reduction approaches considered on a reserve community should be carefully evaluated and considered in the context of cultural ceremony.

Several barriers to harm reduction were noted by health care workers: alcohol use preventing people from engaging spiritually in ceremonies, lack of resources (e.g., funding, clinical support, and access to different inpatient treatment centers), and stigma of alcohol use on the reserve. In addition, other barriers to already-in-place alcohol use treatment approaches included lack of funding, limited housing options, limited employment, unmanaged mental health issues, severity of addiction, transportation, limited clinicians, and clients needing to be at a certain level of wellness to seek out treatment from clinical staff. When asked about ways to reduce alcohol-related harm, health care workers noted that education about alcohol-related harm, more access to employment, social workers, and continued access to social supports are ways to reduce harm in the community. Health care workers also noted the importance of encouraging clients to have more sober days than drinking days, as well as not setting abstinent-only related goals. One health care worker explained: “If they set that goal to abstinence of alcohol, then you’re setting them up for failure.”

3.5 |. Feasibility: Community members

Community members rated harm reduction as somewhat feasible (M = 5.00, SD = 2.60), specifically when used as a path to sobriety. Community members identified some harm reduction approaches that they believed may be useful, such as meeting people where they are at, acceptance into ceremony, finding safe ways to use alcohol (e.g., ride services), using tools to reduce alcohol-related harm, and goal-setting. Community support and connecting with fellow community members around treatment goals was noted as important. One community member explained how their community has helped them reach their treatment goals and reduce alcohol-related harm: “and what do they give me? A diet Coke. Because they knew I no longer drank. And they had a respect enough for me to, you know.” Another community member noted: “if you have somebody from your community that you see as – could be a family member, somebody like a regular person, someone who’s like you. And you see them make a change and step up, that’s a huge inspiration to everybody from your community, everyone.” Attending church was also noted as a way to reach treatment goals and reduce alcohol-related harm. One community member explained: “well they used to use the church, like, take a pledge to quit. So, when you did that, it was, ‘Well, you’re not gonna drink.’”

In addition, community members named several barriers to healing from alcohol-related harm, including: strict sobriety rules to engage in cultural ceremony, fear of being judged, lacking courage to change, the fear of losing friends, needing strength to stay sober, the drinking environment (e.g., “no social drinkers”) and modeling of others from growing up on the reserve (where many individuals use alcohol), access to mental health education, lacking community resources, stigma towards those who use substances, and lack of employment.

4 |. DISCUSSION

The aim of this mixed-method study was to understand perceptions of community and culturally specific alcohol-related harm as well as to assess the acceptability and feasibility of harm reduction treatment approaches for one NAI reserve community. Our results aid in identifying alcohol-related health inequities experienced by NAI individuals and ways to culturally adapt harm reduction treatment approaches to NAI reserve communities.

4.1 |. Community and culturally specific alcohol-related harm

NAI individuals experience unique and disproportionate alcohol-harm, including from historical trauma related to colonization (Wiechelt et al., 2012). Existing measures of alcohol-related harm include consequences from alcohol use that may not fully capture the unique ways that alcohol may impact NAIs. Harm reduction strategies may help to reduce the alcohol-related health disparities that NAI face, however, a necessary first step is to more fully understand unique community and culturally specific alcohol-related harms. Both health care workers and community members noted loss and disconnection from culture, racism, and trauma as alcohol-related harm experienced by members of the community. Since the introduction of alcohol during colonialization, some NAI individuals have struggled with harmful alcohol consumption and disproportionate rates of negative consequences due to alcohol use (Landen et al., 2014; Spillane et al., 2015; Swaim & Stanley, 2018). Members of this reserve community reported difficulty navigating the duality between alcohol and traditional healing methods given that alcohol was not a part of Indigenous culture before European contact. Perhaps one of the most notable alcohol-related harm discovered from this study was the separation from and loss of culture due to alcohol use. Health care workers have been putting forth efforts to ameliorate this burden on themselves and community members, while also struggling to maintain the sanctity of traditional healing methods that were passed down from ancestors, which require abstinence from alcohol. Furthermore, trauma was prominently noted as an alcohol-related harm, and empirical studies have found high rates of alcohol use resulting directly from acculturative stress and indirectly from historical trauma (Lane & Simmons, 2011; Myhra, 2011; Whitesell et al., 2012b). Our finding aligns with research that underscores the role of historical trauma stemming from a history of genocide, forced removal from lands, and the destruction of culture in contributing to substance use and mental illness within NAI communities (Evans-Campbell, 2008; Heart, 2003; Ross et al., 2015; Wunder & Hu-DeHart, 1992).

Both health care workers and community members noted physical and mental health as alcohol-related harm experienced by individuals in their community. This finding aligns well with research that purports an alcohol-related health disparity among NAI communities (Collins, 2016; Griffith et al., 1996; Indian Health Service, 2019; Landen et al., 2014; Welty, 2003). In addition, several types of alcohol-related harm may be related to living on a rural reserve. For example, limited housing, employment issues, money problems, isolation, boredom, and long wait times for health services on the reserve. Indeed, housing crises, job scarcity and lack of economic opportunity are known difficulties with living on a rural reserve community (Native American Aid, 2021). The community and culturally specific alcohol-related harms identified in this study should be taken into consideration when working with an NAI reserve community. Interventionist should pay special attention to the harms identified in this study to properly identify, assess, treat, and ameliorate the alcohol-related health inequities that exists among NAI communities. Perhaps a harm reduction approach could assist in bridging the gap of reducing alcohol-related harms noted in this study.

4.2 |. Acceptability of harm reduction approaches

Overall, health care workers found harm reduction to be an acceptable approach. In fact, health care workers identified several ways they were currently utilizing harm reduction approaches to address substance use broadly in their community (e.g., needle exchange program). In addition, both health care workers and community members agreed that a pro of harm reduction strategies included that they allow people who use alcohol to connect more to culture and traditional ceremonies as a way of healing from alcohol-related harm. Furthermore, one community member described wishing they them self had taken more of a harm reduction verse abstinence only approach. Perhaps harm reduction would allow community members to have more self-compassion towards themselves, which we know to be protective against alcohol-related harm among NAI populations (Spillane et al., 2021).

However, overall community members mainly articulated acceptability of harm reduction if understood in the context of helping individuals working towards goals of sobriety. Given the discrepancy in perspectives of acceptability of harm reduction approaches between health care workers and community members, perhaps this speaks to the prevalence of the firewater myth. It is possible that the firewater myth is perpetuated among community members and may speak to a reluctance to go with a harm reduction approach. In fact, one study found that greater belief in the firewater myth among NAI college students was associated with lower self-efficacy for the use of harm reduction strategies among more people who engage in more frequent heavy episodic drinking (Gonzalez & Skewes, 2018). Perhaps community members see alcohol-related harm as an all-or-nothing phenomenon given a belief in a biological predisposition to experience alcohol-related harm when drinking any amount of alcohol. Thus, it is possible that considering ways to reduce alcohol-related harm while continuing to drink does not seem plausible among community members. Given this, it is worth further exploring if reluctance of harm reduction approaches is situated in the context of the Firewater myth within this community.

4.3 |. Feasibility of harm reduction approaches

Overall harm reduction strategies were acknowledged as feasible for this community by health care workers (e.g., meeting people where they are at with alcohol use during cultural ceremonies). However, there were mixed attitudes about whether harm reduction strategies were consistent with Indigenous cultural traditions and values. Feasibility issues related to harm reduction merging with traditional healing methods were noted. For example, some health care workers explained that there is a challenge in engaging NAI individuals who currently use alcohol with cultural healing given that 4 days of sobriety is expected before engaging in one cultural ceremony. Though some health care workers expressed willingness to bend the 4-day sobriety rule, it was expressed that ideally individuals healing from alcohol use would be working towards living a sober life. Similarly, community members articulated how the ultimate goal of sobriety for individuals in their community is expected, especially when considered in the context of cultural ceremonies. Therefore, caution should be utilized by interventionist to ensure harm reduction strategies align with community-centered goals and traditional healing methods.

4.4 |. Limitations

Limitations of the present study include restricted geographic representation of the sample. There is great variability between NAI communities; thus, results may not be applicable to communities in other geographic regions, to other Indigenous groups, or to NAI individuals living off reserves. Future research should consider assessing community and culturally specific alcohol-related harm and harm reduction acceptability and feasibility in other NAI reserve communities, as well as NAI people from urban areas and across different geographic locations. Additionally, our utilization of snowball sampling recruitment has limitations. It is possible that utilization of a community consultant to assist in recruitment through snowball sampling may have not included a representative sample of the entire reserve community. Thus, theoretical saturation may have only been perceived by researchers, and perhaps new concepts may have arisen from a larger, more heterogeneous sample. Further, while we believe use of a mixed methods approach is a strength of our study, there are potential limitations. Though qualitative researchers argue that no research can be generalized beyond the sample studied in the given time and context for which the content was discussed, a critique of qualitative research is that it is not as generalizable as quantitative methods that make use of larger sample sizes and inferential statistics (Lincoln & Guba, 1985). Our study utilized focus groups to gather qualitative data. While studies have found that sensitive disclosures—essential to generating themes on sensitive topics—are more likely to occur from focus groups than in individual interviews (Guest et al., 2017), focus groups may push participants to conform and express more socially desirable and stereotypical answers (Acocella, 2012), and may, thus, be less effective than individual interviews at generating a broad range of results (Guest et al., 2017). That said, this study is the first to document harm reduction acceptability and feasibility on an NAI reserve community and thereby provides an important foundation for subsequent studies.

5 |. CONCLUSIONS AND FUTURE DIRECTIONS

The present study assessed community and culturally specific alcohol-related harm as well as acceptability and feasibility of harm reduction strategies in one NAI reserve community. Findings indicated that members of this NAI reserve community were experiencing alcohol-related harm that may be unique to NAI individuals living on a reserve. Though some feasibility challenges were noted, findings indicated that harm reduction strategies can be used as a tool to help bring people who use alcohol closer to culture and traditional healing methods. Given that NAI communities have called for interventions to be culturally centered since “culture is medicine” (Bassett et al., 2012; Walters et al., 2020) it is important to prioritize culturally centered approaches rooted in NAI epistemologies and their corresponding core values and actions, going beyond simply adding cultural practices into existing interventions (Walters et al., 2020). Thus, future harm reduction interventions targeting alcohol use should be developed within communities to align with their values (Walters et al., 2020), focusing on individual alcohol use while also accounting for community-level influence, context, and support (Dickerson et al., 2016; Jernigan et al., 2020; Whitesell et al., 2020) and strengthening the connection between individuals and cultural reinforcers (Goldstein et al., 2021).

Given that our findings provide support for acceptability of harm reduction approaches for alcohol among this NAI reserve community, an important next step is perhaps considering developing a culturally grounded harm reduction approach that integrates culture with humility. There is a paucity of interventions designed by and for NAI communities. NAI populations have increasingly advocated for health interventions to be culturally grounded (Bassett et al., 2012). Moreover, researchers have advocated for a culturally grounded approach to intervention development in this population (Okamoto et al., 2014). Harm reduction may be a good fit for adapting to a culturally grounded treatment given its diverse set of compassionate and pragmatic strategies, flexible treatment goals that aim to minimize alcohol-related harm and enhance quality of life without requiring or advising abstinence or use reduction (Collins et al., 2011; Marlatt & Witkiewitz, 2010), and malleable treatment target goals that aim to engage people with a predetermined goal of abstinence (Collins et al., 2011, 2019, 2021, 2015). Perhaps utilizing a culturally grounded harm reduction approach may ameliorate the discrepancy in our results between community members views of alcohol treatment when compared to health care workers. Flexible and individualized treatment target goals that allow for client centered goals, whether they be abstinence-based goals, reduced use, or reduced harm, may engage community members by meeting them “where they are at” in their ideas of alcohol treatment, while still integrating cultural healing methods.

Given the problematic history of research in NAI reserve and reservation communities, it is particularly important to use a Community Based Participatory Research (CBPR) framework, where researchers and NAI community members work together to address health disparities. Thus, consistent with culturally adapted treatment in this population, recommendations for next steps include a series of stages that would look at CBPR Methods, to ensure a continued robust collaboration between academics and the NAI community (Simonds et al., 2013; Wallerstein & Duran, 2006). This includes working with a community advisory board to share results from this study and elucidate what the community sees as logical options of what a harm reduction treatment that is culturally grounded would look like. Using this information, researchers could work in collaboration with community members to create a unique version of a harm reduction model that ultimately could lead to a pilot trial testing the efficacy of a culturally grounded treatment model. This type of project, with CBPR as a focus, would include having regular community advisory meetings, conducting focus groups and qualitative analysis, presenting findings, eliciting feedback from the community, and using a community consultant to inform decision making around all aspects of the intervention development.

Findings from this study are an important first step towards developing treatment modalities that are NAI community informed. Perhaps harm reduction strategies tailored to fit traditional methods of healing can assist individuals who use alcohol on a NAI reserve community to connect more to culture. Caution should be taken with implementation to integrate properly with traditional cultural healing.

ACKNOWLEDGEMENTS

The authors thank our participants for their time, contribution, and for sharing this information. We also thank Melissa R. Schick, M.A. for her assistance with data collection, as well as Ben Seebold, B.A., Isabel Nunez, B.A., and Robyn Abernathy, B.A., for their assistance with data analysis. This work was supported by the Society of Addiction Psychology: American Psychological Association Division 50 Student Research Grant awarded to Silvi C. Goldstein. Work on this paper by Silvi C. Goldstein was supported by National Institute on Alcohol Abuse and Alcoholism Grant F31 AA029274. Work on this paper by Tessa Nalven was supported by National Institute on Drug Abuse Grant F31 DA053754. Author Nicole H. Weiss acknowledges the support from the Center for Biomedical Research and Excellence (COBRE) on Opioids and Overdose funded by the National Institute on General Medical Sciences (P20 GM125507).

Footnotes

CONFLICTS OF INTEREST

The authors declare no conflicts of interest.

PEER REVIEW

The peer review history for this article is available at https://publons.com/publon/10.1002/jcop.22859

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Associated Data

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Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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