PhD Dissertation Defense Beverly Patchell, RN, MS, CNS September 27, 2011

PhD Dissertation Defense

Beverly Patchell, RN, MS, CNS

September 27, 2011

NEW MEXICO STATE UNIVERSITY SCHOOL OF NURSING

Dr. Mary HokeDr. Leslie Robbins

Dr. John LoweDr. Iris Mullins

Dr. Kathleen Chinn

DISSERTATION COMMITTEE

NATIVE AMERICAN INDIAN ADOLESCENTS:

RESPONSE TO A CULTURALLY TAILORED, SCHOOL-BASED

SUBSTANCE ABUSE INTERVENTION

SignificanceAims

MethodResults

Discussion Next Steps

OVERVIEW OF THE PRESENTATION

Substance abuse with Native American Indian tribes in the U.S.

• number one health concern for Native American Indians (NAI)

• Substance abuse among NAI adolescents

correlates with higher incidence of associated problems

(Substance Abuse Mental Health Services Administration, 2008)

BACKGROUND

• 2008 state statistics show the economic cost at $6 B/year

• personal cost is greater •85% of all homicides•80% of all prison incarcerations•65% of all child abuse cases•55% of all domestic assaults

• NAI are 9% of the general population, but >25% of the OK prison population.

(Oklahoma Department of Mental Health and Substance Abuse Services, 2008)

OKLAHOMA PROBLEM

• Beauvais et al. (2004) looked at patterns over the past 25 years and found substance abuse to be the primary contributor to health issues among NAI

• Clarke (2002) looked at the emotional issues related to the incidence of substance abuse

• SAHMSA and the Indian Health Service have written extensively about the health issues

LITERATURE REVIEW

• Prevention efforts have previously focused on protective factors such as parent-teen communication, decision-making skills, use of role models, and individual coping styles (Beebee et al., 2008; Chiong, Bry, & Johnson, 2009)

• Use of Native American Indian rituals and traditions has primarily been used in inpatient or residential treatment (Novins et al., 1996; Jacobs, 2002)

• The Cherokee Self-Reliance Theory and Model has demonstrated success based on a culturally tailored approach used with Cherokee adolescents (Lowe, 2006)

LITERATURE REVIEW

GAPS IN THE RESEARCH

• substance abuse treatment for NAI adolescents focuses on the inpatient and residential components of treatment

• education and early prevention focused on school-based education efforts, with poor to mixed results (Segal,

2003)

• there is a need for culturally adapted models and documentation of that adaptation (Domencech Rodriguiz, Baumann & Schwartz, 2011)

• Developed through research into Cherokee culturally-protective factors as described by Cherokee people (Lowe, 2002)

• Utilized theoretical concepts to determine if strengthening the cultural components of a substance abuse prevention model would influence decisions about substance use and abuse (Lowe, 2006)

CHEROKEE SELF-RELIANCE THEORY

CHEROKEE TALKING CIRCLE INTERVENTION

BEING RESPONSIBLE

• Substance Abuse Education • Recognition and Acknowledgement of Personal Substance Use Problems• Identification of High-Risk Situations• Relationship Building• Family Conflict Resolution• Social Support

BEING DISCIPLINED

• Self-Monitoring • Commitment Generation • Alternatives to Substance Use

BEING CONFIDENT

• Acceptance of Personal Strengths • Practicing Resistance/Refusal • Coping with Stress• Abstinence Violation Effect

• Based on the general world view of Native American Indian people

• The natural world is inherently circular and spiral, with ordered flow and movement

• Health requires order and ill health is a result of interrupted flow and dis-order

• Fibonacci sequence is recognized by Western science as the mathematical foundation of life and creation

CIRCULAR MODEL FOR CULTURAL TAILORING

• The tribes of the Great Plains Area encompasses many tribes and sweeps across the United States in the region between the Mississippi River and the western coastal states

• The tribes were historically rovers and hunters, nomadic and loosely organized

• Their prowess was in hunting, raiding, and war

POPULATION

Original Inhabitants of Oklahoma Land Area

1890’s Map of Oklahoma

Current Map of Oklahoma

ELDER’S TRANSFORM THE MODEL

BEING RESPONSIBLE• Substance Abuse Education• Recognition and Acknowledgement of Personal Substance Use Problem• Identification of High-Risk Situations• Relationship Building• Family Conflict Resolution• Social Support

BEING DISCIPLINED• Self-Monitoring • Commitment Generation • Alternatives to Substance Use

BEING CONFIDENT• Acceptance of Personal Strengths• Practicing Resistance/Refusal • Coping with Stress• Abstinence Violation Effect

(Adapted with permission from the Cherokee Talking Circle, Lowe, 2006)

NATIVE TALKING CIRCLE INTERVENTION

• adapt an existing culturally competent Cherokee theoretical model and school-based intervention targeting substance abuse prevention and intervention for use with Native American Indian adolescents in southwestern Oklahoma

• examine the impact of the adapted Native American Indian Self-Reliance Substance Abuse Intervention tool on cultural protective factors associated with substance abuse involvement by Native American Indian youth from Native American Indian Plains tribes.

STUDY AIMS

• Following implementation of the adapted NativeAmerican Self-Reliance Intervention:

• there will be a significant increase in self-reliance (α ≤ .05) • there will be a significant decrease in reported substance

abuse (α ≤ .05)

• there will be significant decrease in perceived stress (α ≤ .05)

• Design: Pre-test/post-test quantitative study

RESEARCH HYPOTHESES/DESIGN

• Institutional Review Boards at New Mexico State University and the University of Oklahoma.

• Support letter from the Comanche Nation

• Certificate of Confidentiality from the National Institute on Drug Abuse.

• Permission of superintendents and principal's of the high schools.

• Parental permission and student assent

HUMAN SUBJECTS PROTECTION

Convenience sample obtained using two rural high schools in SW Oklahoma with high populations of Plains tribal adolescents; i.e., Comanche, Kiowa, Apache, Wichita, Lenape, Caddo

Sample size • N = 44• Power

Inclusion Criteria:• Self-identified member of one of the Plains tribes of SW

Oklahoma.• Attending one of the designated schools, in grades 9-12.• Between the ages of 16-19• Referred by a counselor due to being at risk for substance use or

abuse

SAMPLE

• Demographic Questionnaire • Adapted Cherokee Self-Reliance

Questionnaire• Global Appraisal of Individual Needs-

Quick (GAIN-Q)• Written Stories of Stress using the

Linguistic Inquiry Word Count (LIWC)

INSTRUMENTS

• 3 GROUPS• 8.5 WEEKS• 10 HOURS OF INSTRUCTION• GROUP RULES• ADAPTED TOPIC CONTENT

NATIVE TALKING CIRCLE INTERVENTION

Obtained informed consent/assent

Pre-intervention data collection• occurred at first session

• Demographic questionnaire• Native Self-Reliance• GAIN-Q• Written Stories of Stress

Post-intervention data collection• demographic questionnaire was omitted

DATA COLLECTION

• Descriptive statistics

• Paired t-test

• Cronbach alpha

• SPSS

• LIWC

DATA ANALYSIS

Age• 16 = 26 (59)• 17 = 12 (27)• 18 = 6 (14)Gender• M= 20 (45)• F=24 (55)Grade• 10th = 30 (68)• 11th = 9 (20)• 12th = 5 (11) Tribe• Comanche = 32 (73)• Kiowa = 8 (18)• Apache = 4 (9)

Living Situation• Parent(s) = 40 (91) • Extended = 23 (52)Siblings• Yes = 42 (95) • No =2 (5)Drug Use• Alcohol = 11 (25)• Marijuana = 4 (9)• None = 29 (66) Team/School Activities• Yes = 28 (64)• No = 16 (36)

Participant Demographics

• Pre-test baseline mean of 86.23 (SD=23.40) increased to a post-intervention mean of 92.20 (SD=18.46), SE = .369, medium effect size

• Supporting the hypothesis that self-reliance would increase post-intervention

NATIVE SELF-RELIANCE QUESTIONNAIRE

  Baseline Post Intervention

Paired Differences 

Indices

M SD M SD M SD t df p value

General Life Problems (N=41)

9.536 7.504 7.415 5.723 2.122 5.887 2.308 40 .013

Internal Behaviors(N=44)  

3.636 4.098 2.023 2.937 1.614 3.452 3.101 43 .002

External Behaviors Internal Behaviors(N=42)  

4.357 4.477 3.310 3.453 1.048 4.884 1.390 41 .086

Substance Problems Internal Behaviors(N=34) 

2.265 4.266 1.265 2.968 1.000 3.162 1.844 33 .037

GAIN-Q Indices at Baseline, Post-Intervention and Paired T-Test Results

Baseline  Post Intervention

 Paired Differences

Dimensions of Words

M SD M SD M SD t df p

Positive Emotion 

4.431 2.653 3.600 2.075 .8311 2.955 2.308 25 .082

Negative Emotion  

5.120 1.929 6.037 2.430 -.9165 3.319 3.101 25 .086

Social 

9.411 3.329 10.860 4.024 -1.448 4.505 1.390 25 .057

LIWC WORD USE RESULTS AT BASELINE, POST-INTERVENTION, AND PAIRED T-TEST

(N=26)

• Groups were facilitated by a Native American Indian woman with extensive adolescent group experience

• The intervention was flexible enough to allow the participants to express themselves in multiple ways

• Convenience sample• Self-identified tribal members• Self-reporting of substance use could

be biased

STRENGTHS AND LIMITATIONS

This study:• addresses a significant problem for

Native American Indian adolescents and the specific tailoring of a successful intervention to meet the needs of the participants

• demonstrates the effectiveness of specific tailoring using traditional and contemporary life experiences

• provides a template/model for use in future studies

DISCUSSION

• Native Talking Circle Intervention requires replication of the study with larger sample sizes and longitudinal studies to address long term effectiveness

• Validation of the effectiveness of the CMCT as a timely cultural tailoring model across subsets of Indigenous cultural groups

RECOMMENDATIONS FOR FURTHER RESEARCH

QUESTIONS?

Thank You

Wado!

TO THE AUDIENCE