Beverly Patchell RN MS CNS September 27 2011 NEW MEXICO STATE UNIVERSITY SCHOOL OF NURSING Dr Mary Hoke Dr Leslie Robbins Dr John Lowe Dr Iris Mullins Dr Kathleen Chinn DISSERTATION COMMITTEE ID: 760347
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Slide1
PhD Dissertation DefenseBeverly Patchell, RN, MS, CNSSeptember 27, 2011
NEW MEXICO STATE UNIVERSITY
SCHOOL OF NURSING
Slide2Dr. Mary HokeDr. Leslie RobbinsDr. John LoweDr. Iris MullinsDr. Kathleen Chinn
DISSERTATION COMMITTEE
Slide3NATIVE AMERICAN INDIAN ADOLESCENTS
:
RESPONSE TO A CULTURALLY TAILORED, SCHOOL-BASED Substance Abuse INTERVENTION
Slide4SignificanceAimsMethodResultsDiscussion Next Steps
OVERVIEW OF THE PRESENTATION
Slide5Substance 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
Slide62008 state statistics show the economic cost at $6 B/year personal cost is greater 85% of all homicides80% of all prison incarcerations65% of all child abuse cases55% of all domestic assaultsNAI 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
Slide7Beauvais et al. (2004) looked at patterns over the past 25 years and found substance abuse to be the primary contributor to health issues among NAIClarke (2002) looked at the emotional issues related to the incidence of substance abuseSAHMSA and the Indian Health Service have written extensively about the health issues
Literature review
Slide8Prevention 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
Slide9Gaps 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)
Slide10Developed 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
Slide11Slide12Cherokee 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
Slide13Based on the general world view of Native American Indian peopleThe natural world is inherently circular and spiral, with ordered flow and movementHealth requires order and ill health is a result of interrupted flow and dis-orderFibonacci sequence is recognized by Western science as the mathematical foundation of life and creation
Circular Model for Cultural Tailoring
Slide14The 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 statesThe tribes were historically rovers and hunters, nomadic and loosely organizedTheir prowess was in hunting, raiding, and war
Population
Slide15Original Inhabitants of Oklahoma Land Area
Slide161890’s Map of Oklahoma
Slide17Slide18Current Map of Oklahoma
Slide19Elder’s Transform the Model
Slide20BEING RESPONSIBLESubstance Abuse EducationRecognition and Acknowledgement of Personal Substance Use ProblemIdentification of High-Risk SituationsRelationship BuildingFamily Conflict ResolutionSocial SupportBEING DISCIPLINEDSelf-Monitoring Commitment Generation Alternatives to Substance UseBEING CONFIDENTAcceptance of Personal StrengthsPracticing Resistance/Refusal Coping with StressAbstinence Violation Effect (Adapted with permission from the Cherokee Talking Circle, Lowe, 2006)
Native Talking Circle Intervention
Slide21adapt 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 Oklahomaexamine 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
Slide22Following implementation of the adapted Native American 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
Slide23Institutional Review Boards at New Mexico State University and the University of Oklahoma. Support letter from the Comanche NationCertificate 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
Slide24Convenience sample obtained using two rural high schools in SW Oklahoma with high populations of Plains tribal adolescents; i.e., Comanche, Kiowa, Apache, Wichita, Lenape, CaddoSample size N = 44PowerInclusion 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 16-19Referred by a counselor due to being at risk for substance use or abuse
Sample
Slide25Demographic Questionnaire Adapted Cherokee Self-Reliance QuestionnaireGlobal Appraisal of Individual Needs-Quick (GAIN-Q)Written Stories of Stress using the Linguistic Inquiry Word Count (LIWC)
instruments
Slide263 GROUPS8.5 WEEKS10 HOURS OF INSTRUCTIONGROUP RULESADAPTED TOPIC CONTENT
NATIVE TALKING CIRCLE INTERVENTION
Slide27Obtained informed consent/assentPre-intervention data collectionoccurred at first sessionDemographic questionnaireNative Self-RelianceGAIN-QWritten Stories of StressPost-intervention data collectiondemographic questionnaire was omitted
Data Collection
Slide28Descriptive statisticsPaired t-testCronbach alphaSPSS LIWC
DATA ANALYSIS
Slide29Demographics:
Results
Table 2
Participant Demographics
Gender
Age
Grade
Tribe
Living Situation
Siblings
Drug Use
Team/School Activities
N
(%)
N
(%)
N
( %)
N
(%)
N
(%)
N
(%)
N
(%)
N
(%)
Group 1
M=4 (25)
F=12 (75)
16= 12 (75)
17= 4 (25)
10
th
=15 (94)
11
th
=1 (6)
Comanche = 12 (75)
Kiowa = 3 (19)
Apache =1 (6)
Parent(s) =16 (100)
Extended = 6 (38)
Yes = 15 (94)
No = 1 (6)
Alcohol =3 (19)
Marijuana = 1 (6)
None = 12 (75)
Yes = 7 (44)
No = 9 (56)
Group 2
M=7 (44)
F=9 (56)
16 =13 (82)
17 =3 (18)
10
th
=14 (88)
11
th
=2 (12)
Comanche = 13 (81)
Kiowa = 2 (13)
Apache = 1 (6)
Parent(s) =12 (75)
Extended = 8 (50)
Yes = 15 (94)
No = 1 (6)
Alcohol = 2 (13)
Marijuana = 1 (6)
None = 13 (81)
Yes = 12 (75)
No =4 (25)
Group 3
M=9 (75)
F=3 (25)
16 = 1 (8)
17 = 5 (42)
18 = 6 (50)
10
th
=1 (8)
11
th
=5 (42)
12
th
=6 (50)
Comanche = 7 (58)
Kiowa = 3 (25)
Apache = 2 (17)
Parent(s) =12 (100)
Extended = 9 (75)
Yes = 12 (75)
No = 0 (25)
Alcohol = 6 (50)
Marijuana = 2 (17)
None = 4 (33)
Yes = 9 (75)
No = 3 (25)
Totals
M= 20 (45)
F=24 (55)
16 = 26 (59)
17 = 12 (27)
18 = 6 (14)
10
th
= 30 (68)
11
th
= 9 (20)
12
th
= 5 (11)
Comanche = 32 (73)
Kiowa = 8 (18)
Apache = 4 (9)
Parent(s) = 40 (91)
Extended = 23 (52)
Yes = 42 (95)
No =2 (5)
Alcohol = 11 (25)
Marijuana = 4 (9)
None = 29 (66)
Yes = 28 (64)
No = 16 (36)
Note. N
= 44. Participants were assigned to one of three intervention groups based on their attended high school and class schedule. M= male. F=female. Age is in years. Living situation is living with parents and presence of extended family members in the home. Siblings are if participant has siblings or not. Drug use refers to self-reported drug of choice. Team/school activities refers to participant involvement in sports and/or group sponsored school activities.
Age16 = 26 (59)17 = 12 (27)18 = 6 (14)GenderM= 20 (45)F=24 (55)Grade10th = 30 (68)11th = 9 (20)12th = 5 (11) TribeComanche = 32 (73)Kiowa = 8 (18)Apache = 4 (9)
Living SituationParent(s) = 40 (91) Extended = 23 (52)SiblingsYes = 42 (95) No =2 (5)Drug UseAlcohol = 11 (25)Marijuana = 4 (9)None = 29 (66) Team/School ActivitiesYes = 28 (64)No = 16 (36)
Participant Demographics
Slide31Pre-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 sizeSupporting the hypothesis that self-reliance would increase post-intervention
Native
Self-Reliance questionnaire
Slide32Baseline Post Intervention Paired Differences Indices MSDMSDMSDtdfp valueGeneral Life Problems (N=41)9.5367.5047.4155.7232.1225.8872.30840.013Internal Behaviors(N=44) 3.6364.0982.0232.9371.6143.4523.10143.002External Behaviors Internal Behaviors(N=42) 4.3574.4773.3103.4531.0484.8841.39041.086Substance Problems Internal Behaviors(N=34) 2.2654.2661.2652.9681.0003.1621.84433.037
GAIN-Q Indices at Baseline, Post-Intervention and Paired T-Test Results
Slide33Baseline Post Intervention Paired DifferencesDimensions of Words MSDMSDMSDtdfpPositive Emotion 4.4312.6533.6002.075.83112.9552.30825.082Negative Emotion 5.1201.9296.0372.430-.91653.3193.10125.086Social 9.4113.32910.8604.024-1.4484.5051.39025.057
LIWC word use results at Baseline, post-Intervention, and paired
T-Test (
n
=26)
Slide34Groups were facilitated by a Native American Indian woman with extensive adolescent group experienceThe intervention was flexible enough to allow the participants to express themselves in multiple waysConvenience sampleSelf-identified tribal membersSelf-reporting of substance use could be biased
Strengths and Limitations
Slide35This study: addresses a significant problem for Native American Indian adolescents and the specific tailoring of a successful intervention to meet the needs of the participantsdemonstrates the effectiveness of specific tailoring using traditional and contemporary life experiencesprovides a template/model for use in future studies
DISCUSSION
Slide36Slide37Native 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
Slide38Questions?
Slide39Thank YouWado!
TO THE AUDIENCE