Despite decades of research as well as concerted efforts to improve prevention and treatment, available information suggests that the prevalence of problematic alcohol and drug (i.e., substance) use has not appreciably changed in most American Indian and Alaska Native (AI/AN) communities. Research and health surveillance activities further document the substantial impacts of substance abuse on the health of AI/AN people at rates that continue to far exceed those of non-AI/ANs.
Fortunately, a number of Evidence-Based Treatments (EBTs) have now been developed that hold substantial promise for improving treatment for AI/ANs with substance use problems, as they do for non-AI/ANs. Anecdotal reports suggest, however, that the use of EBTs in programs that serve AI/ANs is limited. Furthermore, the unique funding mechanisms for programs serving AI/ANs, as well as the sovereign status of AI/AN tribes, mean that we cannot assume that the factors influencing the implementation of EBTs in programs more generally, such as mandates for the use of EBTs in federally-sponsored programs, impact programs serving this special population in the manner in which they were intended. Organizational factors may also operate differently given the severe fiscal and human resource limitations under which these programs operate. In addition, concerns about the cultural appropriateness of some EBTs may discourage their use.
This project utilizes a multi-stage, mixed methods study design.
Stage 1: Initial Advisory Board Meeting
As part of the first stage of this project, we convened an Advisory Board consisting of experts from AI/AN communities, substance abuse treatment programs serving these communities, and researchers to discuss these controversies, how these controversies might threaten this project, and methods to reduce the risks of these threats.
The above figure represents the tensions the Board identified around EBTs. The two Euro-American groups of practices now form the basis of most substance abuse treatments offered in the United States (and between which significant tensions continue to exist despite years of effort to reconcile these approaches), but they do not necessarily relate well to practices emerging from AI/AN traditions. Thus, the practice and policy environments for programs serving AI/AN communities are complex and these tensions make the implementation and maintenance of successful programs particularly challenging.
Please see our Publications page for presentations and papers that have drawn on results of the first stage of the project.
Stage 2: Focused Program Case Studies
We visited a total of 18 substance abuse treatment programs (12 outpatient, 6 residential) clustered in 7 tribes/communities/regional consortiums. We had 22 clinical administrators and 55 front-line clinicians (an average of 1.2 clinical administrators and 3 front-line clinicians per program). We included 7 IHS regions and 7 states.
After a program expressed an interest in participating in the project, the principal investigator worked with the program to complete the local review and approval process, after which a visit was scheduled. At each participating program we conducted one or more key informant interviews with program staff in clinical administrative positions as well as a focus group with program staff in front-line clinical positions. Key informant interviews were scheduled for 60 minutes and focus groups were scheduled for 90 minutes (with additional time set aside to complete the consent process). Visits to individual programs were generally completed in a single day. Project directors were given the option of distributing the interview/focus group guides prior to the research team’s visit. All interviews and focus groups were conducted by the principal investigator. Interviews and focus groups were recorded and detailed notes were also taken as a back-up.
The Advisory Board developed interview and focus group guides designed to generate open-ended conversations about the community served by the program, services provided and how they were developed, the challenges to providing these services as well as the participants’ awareness of and experience with a selected set of EBTs. In addition, clinical administrators were asked about the size, disciplinary and educational backgrounds, certification and licensure, and ethnicity of their staff as well as the program’s quality assurance and program evaluation activities. Front-line clinicians were asked about ongoing training experiences and their preferences in learning about new treatments they might offer.
The interview and focus group guides included a series of open-ended “stem” questions that were used to steer the conversation through the key topics of interest to the research team. These guides also included a series of “probes” for most stem questions that allowed the interview to explore specific issues if these were not spontaneously identified by the interview/group participants (e.g., whether the program felt pressure to provide specific treatments because of accreditation or reimbursement requirements).
Interview and Focus Group Guides may be found on our Study Measures page.
Please see our Publications page for presentations and papers that have drawn on results of the second stage of the project.
Stage 3: Telephone/Online Survey
In the final stage of the project, we asked a representative sample of the Directors of 445 behavioral health programs that serve reservation, rural, and urban AI/AN communities to complete a 45-minute online survey about their program and experience with EBTs. We divided the sampling frame into 5 distinct groups: the 20 largest federally-recognized tribes (by population on reservation or service area), Urban Indian Health Clinics, Alaska Native Health Corporations, other Tribes (federally-recognized Tribes minus the 20 largest and the Alaska Native villages), and other regional programs (including IHS, Tribal Consortia, independent non-profit and for-profit). One-hundred-ninety-two Program Directors completed the telephone/online survey.
The survey is comprised of 4 parts: introduction, a section focusing on background information regarding the program, staff, and community the program serves, a section on perspectives, use, and experiences with specific EBTs, and a section regarding fidelity. The survey is posted on our Project Measures page.
The results of this project will provide the first description of the use of EBTs in wide range of substance abuse treatment programs serving AI/AN communities, much-needed insights regarding the dynamics around the decision to implement such practices, and carefully formulated methods for more effective dissemination.