Development of a Substance Abuse Prevention/Intervention Program of Research Among Native American Youth

Development of a Substance Abuse Prevention/Intervention Program of Research Among Native American Youth John Lowe, RN, PhD, FAAN Florida Atlantic University (954) 236-1275 jlowe@fau.edu author(s) of presentation ask for permission from author(s) or contact ihartp@uw.edu

ACKNOWLEGEMENTS 10/19/12 2

Where did the thoughts & inspiration come from?

Family and Community 10/19/12 4

ocial, Psychological and Economic Stressors: Highly correlated with substance abuse among Native Americans Causes: Historical Trauma -- genetic memory -- unresolved grief -- soul wounding Forced Removals Boarding Schools Destabilization of Families Economic Disadvantages Etc.

Health Disparities Disparity and dispossession go hand in hand. The massive dispossession that removed Native people from their ancestral lands not to mention genocide and cultural eradication that followed can hardly be imagined by most people. This dispossession is at the root of our health disparities. Michael Bird, 2002 Former President of the Amer. Public Health Assoc. Current Exec. Dir. Of National Native American AIDS Prevention Center

Loss of culture has been the primary cause of many of Native American s existing social problems, especially those associated with alcohol methods to measure Native American cultural beliefs and values have not been well developed. Fred Beauvais, PhD

Master s Thesis: The Social Support that Contributes to the Abstinence from Substance Abuse After Treatment Among Native American Young Adults Funded By: Mennonite Central Committee Community Grant

Findings Cultural protective factors: relationships traditional beliefs respect etc. Publications: Mennonite News

Cherokee Self-Reliance The Cherokee Way Mainstay Ga Du Gi 5-Year Ethnographic Studies to Define and Describe the Concept Funded by SAMHSA EMF at the ANA Endorsed by the Cherokee Nation

The model of Cherokee Self Reliance is formed in a circle indicating the circular holistic worldview of Cherokee culture. The outside circle is green which symbolizes an oak wreath. The orange inner circle symbolizes the sacred eternal fire. The live oak the traditional principal hardwood timber of the Cherokee people, was used to kindle the sacred fire. In connection with this fire, the oak was a symbol of strength and everlasting life. These colors are used in the seal of the Cherokee Nation. The three interlocking circles in intertwining, and interlacing of all of the categories and subcategories of the cultural domain of Cherokee Self Reliance.

Cherokee SelfReliance Questionnaire 24 item Likert scale Test-retest reliability coefficient alpha of.84

Derived from the Native group being studied Native in general Non-Native

Derived from the Native group being studied

MODEL DERIVED FROM A SPECIFIC NATIVE GROUP The model of Cherokee Self Reliance is formed in a circle indicating the circular holistic worldview of Cherokee culture. The outside circle is green which symbolizes an oak wreath. The orange inner circle symbolizes the sacred eternal fire. The live oak the traditional principal hardwood timber of the Cherokee people, was used to kindle the sacred fire. In connection with this fire, the oak was a symbol of strength and everlasting life. These colors are used in the seal of the Cherokee Nation. The three interlocking circles in intertwining, and interlacing of all of the categories and subcategories of the cultural domain of Cherokee Self Reliance.

Native in General

GENERALIZABLE NATIVE MODELS: Indigenist Stress Coping Model (Dr. Karina Walters)

Non- Native

Non-Native Specific Models: Health Promotion Models

Teen Intervention Project Cherokee (TIP-C) A school based intervention study conducted to intervene with early substance abuse among Cherokee/Keetoowah teens Funded By: National Institute on Alcohol Abuse and Alcoholism (NIH). Minority Supplement to R01 AA10246-05S1 Wagner. Endorsed By: Cherokee Nation Tribal School United Keetoowah Band of Cherokee Indians Oklahoma Public Schools

TIP-C Student Manual 10 - week group counseling session conducted in the traditional talking circle format

Contents of the TIP-C Group Sessions Substance Abuse Education: Students are educated about substance use, the development of substance use problems, and the historical perspectives and trends of substance use/abuse of Native Americans. Recognition and Acknowledgement of Personal Substance Use Problems: Students learn to connect current difficulties with substance use. Self-Monitoring: Students commit to reducing or eliminating their own use of alcohol and other drugs. Cherokee traditions relating to being responsible, being disciplined, and being confident are introduced. Commitment Generation: Students commit to reducing or eliminating their alcohol and other drug use. Identification of High-Risk Situations: Students identify high-risk situations for substance use. Alternatives to Substance Use: Students develop alternative behaviors to alcohol use, with emphasis on high-risk alcohol use situations. Cherokee traditional activities are introduced. Coping with Stress: Students learn to recognize stress and develop non-alcohol use strategies for coping with stress. The Cherokee concept of self is discussed. Family Conflict Resolution: Students learn and rehearse ways to manage conflicts within families. Traditional Cherokee family structures and roles are reviewed. Relationship Building: Students are given guidelines for initiating and developing reciprocal relationships with others. Students are given the traditional Cherokee life-way of relationships (Ga Du Gi) within Cherokee tribal communities. Abstinence Violation Effect: To prevent relapse, students learn to anticipate and cope with the negative emotional reaction that is likely to follow a slip. Practicing Resistance/Refusal: Students learn and rehearse ways to manage peerrelated change their alcohol use behaviors. Alcohol use situations: Students review the Cherokee way of being disciplined. Social Support: Students identify groups and individuals who will support their efforts to cope with stress and avoid alcohol and drug use situations.

Cherokee Self-Reliance CSRQ (N=108) 1= pre-intervention 2= immediate post 3= 90-day post 120 Estimated Marginal Means of MEASURE_1 110 Estimated Marginal Means 100 90 80 1 2 3 SR

Substance Abuse DUSI-R (N=108) 1= pre-intervention 2= immediate post 3= 90-day post 25 Estimated Marginal Means of MEASURE_1 24 Estimated Marginal Means 23 22 21 20 1 2 3 DUSIR

Stress PSS (N=108) 1= pre-intervention 2= immediate post 3= 90-day post Estimated Marginal Means of MEASURE_1 44.0 43.5 43.0 Estimated Marginal Means 42.5 42.0 41.5 41.0 1 2 3 STRESS

Other Studies Conducted to Inform and Test Components of the Cultural Intervention Teen Talking Circle for HIV/AIDS and HCV Prevention (Funded By: The Association of Nurses in AIDS Care Bio Tech Research Grant) (Endorsed By: United Keetoowah Band of Cherokee Indians) Native American Nursing Conceptual Framework (Funded By: Johnson & Johnson, Corp.) (Endorsed By: United Keetoowah Band of Cherokee Indians)

Additional Research that has helped to inform the Program of Research: The Transcultural Caring Experience of Nursing Students working with Tribes in Oklahoma. Nursing in the Native American Culture. Native American Nurses Stories. Contributing Factors to Substance Abuse Among the Homeless. Funded By: Florida Atlantic University Research Enhancement Grants, Johnson and Johnson Corporation, and Robert Wood Johnson Foundation.

Conceptual Framework Caring Tradition Respect Connection Holism Trust Spirituality

Model of the dimensions and characteristics of Nursing in the American culture CARING Health Knowledge Relationship Holism NURSING IN NATIVE AMERICAN CULTURE SPIRITUALITY Relationship Healing Unity Balance Honor TRADITIONS HOLIS M TRUST Relationship Values CONNECTION Balance Relationship Relationship Respect Respect Wisdom RESP ECT Relationship Foundation Cultura l Presence Relationship Strength Honor Identity

Expansion of the Self-Reliance Model with other Native American Tribes

Community Partnership to Affect Cherokee-Keetoowah Adolescent Substance Abuse Funded By: The National Institute of Drug Abuse (NIH) R01 DA021714-01A2 Endorsed By: United Keetoowah Band of Cherokee Indians

COMMUNITY-BASED PARTICIPATORY RESEARCH (CBPR) Stringer (1999) CBPR favors participatory processes that enable people to thoughtfully evaluate their situation and determine solutions that fit their problems which demand consideration of the cultural context. The core quality of CBPR is community-researcher engagement for all phases with the underlying intention of building community capacity and improving community health. Stringer, E.T. (1999). Action Research (2 nd edition). Thousand Oaks, CA: Sage

Specific Aims a. Create a community partnership steering committee; b. Assess the Cherokee-Keetoowah community needs regarding substance abuse; c. Partner with the Cherokee-Keetoowah community to create culturally competent intervention materials and select culturally appropriate outcome measures; d. Evaluate the difference in substance abuse, Cherokee selfreliance, and stress for Cherokee-Keetoowah adolescents who receive the culturally competent intervention and those who receive standard substance abuse education.

Three Phases: 1. Look the researcher engages with the community to clearly articulate the problem, as it exists within the community context. 2. Think community stakeholders views are synthesized to create an inclusive perspective of the problem, which can be addressed with action. 3. Act goals, objectives and tasks are identified and community stakeholders are engaged in the process of affecting the change.

TSSS CTC 23.94 (19.31) SE 25.43 (20.08) Baseline Post-intervention 3-mon follow-up 16.19 (11.91) 10.91 (10.11) 27.33 (23.32) 27.18 (27.21) GLPI CTC 11.84 (8.98) 8.99 (6.64) 6.16 (5.58) IBS CTC 4.46 (4.60) 2.89 (3.14) 1.84 (2.72) SE 5.69 (4.79) 5.52 (5.06) 5.46 (5.71) EBS CTC 4.95 (3.83) 3.39 (3.61) 2.26 (3.11) SE 5.63 (4.48) 5.76 (5.14) 5.22 (5.32) SPS CTC 2.71 (4.47) 1.26 (2.48).65 (1.59) SE 2.44 (4.42) 3.77 (5.65) 3.46 (5.51) SR CTC 89.5 (15.69) 93.07 (16.23) 100.53 (9.98) SE 88.77 (17.03) 85.71 (19.83) 85.18 (19.27) GAIN-Q scores across time and group N=187 Baseline Postintervention 3-mon follow-up TSSS CTC 23.94 (19.31) 16.19 (11.91) 10.91 (10.11) SE 25.43 (20.08) 27.33 (23.32) 27.18 (27.21) GLPI CTC 11.84 (8.98) 8.99 (6.64) 6.16 (5.58) SE 11.73 (8.84) 12.29 (9.93) 13.18 (12.04) IBS CTC 4.46 (4.60) 2.89 (3.14) 1.84 (2.72) SE 5.69 (4.79) 5.52 (5.06) 5.46 (5.71) EBS CTC 4.95 (3.83) 3.39 (3.61) 2.26 (3.11) SE 5.63 (4.48) 5.76 (5.14) 5.22 (5.32) SPS CTC 2.71 (4.47) 1.26 (2.48).65 (1.59) SE 2.44 (4.42) 3.77 (5.65) 3.46 (5.51) SR CTC 89.5 (15.69) 93.07 (16.23) 100.53 (9.98) SE 88.77 (17.03) 85.71 (19.83) 85.18 (19.27)

SUBSTANCE USE

CHEROKEE SELF- RELIANCE

Publications: Lowe, J. & Struthers, R. (2001). A Conceptual Framework: Nursing in the Native American Culture. Journal of Nursing Scholarship, Third Quarter, 33 (3): 279-283. Lowe, J. (2002). Cherokee Self-Reliance. Journal of Transcultural Nursing, 13 (4):287-295. Struthers, R. & Lowe, J. (2003). Nursing in the Native American Culture and Historical Trauma. Issues in Mental Health Nursing, 24 (3): 257-272. Lowe, J. (2003). The Self-Reliance of the Cherokee Adolescent Male. Journal of Addictions Nursing, 14: 209-214. Lowe, J. (2002). Balance and Harmony Through Connectedness: The Intention of Native American Nurses. Holistic Nursing Practice, 16 (4):4-11. Lowe, J. (2004). Contributing Author. Circle of Harmony. National Native American AIDS Prevention Center. Oakland, CA. Lowe, J. Featured Interview. Healing a Wounded Past. Minority Nurse, Spring 2004, 32-37. Lowe, J. (2005). Being Influenced: A Cherokee Way of Mentoring. Journal of Cultural Diversity, 12 (2): 37-49. Lowe, J. (2005). Assessment. In Be Safe: A Guide for the Cultural Competent Health Care Treatment of Native Americans Living with HIV/AIDS. National Minority AIDS Educ. Center: DC. Lowe, J. (2008). Featured Interview. Lessons from My Father. Minority Nurse, Winter 2008, 40-44. Lowe, J. & Crow, K. (2009).Utilization of a Native American Nursing Conceptual Framework to Transform Nursing Education. International Journal for Human Caring, 13 (3):56-64. Lowe, J. & Archibald, C. (2009). Cultural Diversity: The Intention of Nursing. Nursing Forum, 44 (1): 11-18. Lowe, J. & Gibson, S. (2010). The Substance Use and Abuse Among A Homeless Population Journal of Addictions Nursing. Lowe, J. & Nichols, LA. (2010). Utilization of a Native American Nursing Conceptual Framework: Implications for Practice and Research. Wicazo Sa Review Journal. Patchell, B., Lowe, J., & Robbins, L. (2010). Cultural Tailoring of a Theoretical Framework used to Guide Native American Indian Adolescent's Substance Abuse Prevention/Intervention Programs. Journal of Addictions Nursing. Lowe, J. & Gibson, S. (2011). Reflections of a Homeless Population s Lived Experience with Substance Abuse. Journal of Community Health Nursing, 28 (2): 92-104 Lowe, J., et al (2011). Cultural Competencies for Graduate Nursing Education. Journal of Professional Nursing, 27 (3): 133-139. Lowe, J., Riggs, C., & Henson, J. (2011). Principles for Establishing Trust When Developing a Substance Abuse Intervention with a Native American Community. Journal of Creative Nursing, 17 (2): 68-73.

Presentations: NANAINA SUMMITS AMERICAN NURSES ASSOC. CONVENTIONS AMERICAN ACADEMY OF NURSING CONFERENCES INTERNATIONAL AIDS CONFERENCE INTERNATIONAL SIGMA THETA TAU CONFERENCES NATIONAL NATIVE AMERICAN NURSING EDUCATION CONFERENCES NATIONAL CONGRESS ON THE STATE OF THE SCIENCE IN NURSING RESEARCH CONFERENCES SUMMIT ON AMERICAN INDIAN HEALTH CARE NATIONAL INSTITUTUES OF HEALTH CONFERENCES VETERANS ADMINISTRATION RESEARCH CONFERENCES ALL THINGS ARE CONNECTED NATIVE AMERICAN/ALASKAN NATIVE SUBSTANCE ABUSE, HIV/AIDS, AND DIABETES CONFERENCE GATHERING OUR WISDOM CONFERENCE EMBRACING OUR TRADITIONS CONFERENCE TRANSCULTURAL NURSING CONFERENCES FLORIDA NURSES ASSOCIATION CONFERENCES INTERNATIONAL RESEARCH CONFERENCES SOCIETY OF PREVENTION RESEARCH CONFERENCE ETC.

Testing A Substance Abuse Prevention for Cherokee- Keetoowah Early Adolescents Funded By: The National Institute of Drug Abuse (NIH) R34DA029724-01A1 Endorsed By: United Keetoowah Band of Cherokee Indians

Brief Intervention for Substance Using Native Youth SACRED CONNECTIONS (Spiritual Attention Creates Responsible Destiny) Lowe & Wagner, Co-PIs Funded By: The National Institute of Drug Abuse (NIH) 1R01DA029779-01A1 Endorsed By: United Keetoowah Band of Cherokee Indians

Relationship & Connectedness Giving Receiving 42

Wa Do! Thank you!