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

2. Dr. Mary Hoke Dr. Leslie Robbins Dr. John Lowe Dr. Iris Mullins Dr. Kathleen Chinn

4. SignificanceAimsMethodResultsDiscussion Next Steps

5. Substance abuse with Native American Indian tribes in the U.S. number one health concern for Native American Indians (NAI) number one health concern for Native American Indians (NAI) Substance abuse among NAI adolescents correlates with higher incidence of associated problems Substance abuse among NAI adolescents correlates with higher incidence of associated problems (Substance Abuse Mental Health Services Administration, 2008)

6. 2008 state statistics show the economic cost at $6 B/year 2008 state statistics show the economic cost at $6 B/year personal cost is greater personal cost is greater 85% of all homicides 85% of all homicides 80% of all prison incarcerations 80% of all prison incarcerations 65% of all child abuse cases 65% of all child abuse cases 55% of all domestic assaults 55% of all domestic assaults NAI are 9% of the general population, but >25% of the OK prison population. NAI are 9% of the general population, but >25% of the OK prison population. (Oklahoma Department of Mental Health and Substance Abuse Services, 2008)

7. 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

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

9. substance abuse treatment for NAI adolescents focuses on the inpatient and residential components of treatment 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) 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 there is a need for culturally adapted models and documentation of that adaptation (Domencech Rodriguiz, Baumann & Schwartz, 2011)

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

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

13. Based on the general world view of Native American Indian people Based on the general world view of Native American Indian people The natural world is inherently circular and spiral, with ordered flow and movement 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 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 Fibonacci sequence is recognized by Western science as the mathematical foundation of life and creation

14. 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 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 The tribes were historically rovers and hunters, nomadic and loosely organized Their prowess was in hunting, raiding, and war Their prowess was in hunting, raiding, and war

20. 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)

21. 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 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. 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.

22. Following implementation of the adapted Native Following 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 increase in self-reliance (α ≤.05) there will be a significant decrease in reported substance abuse (α ≤.05) there will be a significant decrease in reported substance abuse (α ≤.05) there will be significant decrease in perceived stress (α ≤.05) there will be significant decrease in perceived stress (α ≤.05) Design: Pre-test/post-test quantitative study Design: Pre-test/post-test quantitative study

23. Institutional Review Boards at New Mexico State University and the University of Oklahoma. Institutional Review Boards at New Mexico State University and the University of Oklahoma. Support letter from the Comanche Nation Support letter from the Comanche Nation Certificate of Confidentiality from the National Institute on Drug Abuse. Certificate of Confidentiality from the National Institute on Drug Abuse. Permission of superintendents and principal's of the high schools. Permission of superintendents and principal's of the high schools. Parental permission and student assent Parental permission and student assent

24. 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

25. Demographic Questionnaire Demographic Questionnaire Adapted Cherokee Self-Reliance Questionnaire Adapted Cherokee Self-Reliance Questionnaire Global Appraisal of Individual Needs-Quick (GAIN-Q) Global Appraisal of Individual Needs-Quick (GAIN-Q) Written Stories of Stress using the Linguistic Inquiry Word Count (LIWC) Written Stories of Stress using the Linguistic Inquiry Word Count (LIWC)

26. 3 GROUPS 8.5 WEEKS 10 HOURS OF INSTRUCTION GROUP RULES ADAPTED TOPIC CONTENT

27. Obtained informed consent/assent Pre-intervention data collection occurred at first session occurred at first session Demographic questionnaire Demographic questionnaire Native Self-Reliance Native Self-Reliance GAIN-Q GAIN-Q Written Stories of Stress Written Stories of Stress Post-intervention data collection demographic questionnaire was omitted demographic questionnaire was omitted

28. Descriptive statistics Paired t-test Cronbach alpha SPSS LIWC

29.  Demographics: Table 2 Participant Demographics GenderAgeGradeTribeLiving SituationSiblingsDrug UseTeam/School Activities 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) TotalsM= 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.

30. Age 16 = 26 (59) 17 = 12 (27) 18 = 6 (14) Gender M= 20 (45) F=24 (55) Grade 10 th = 30 (68) 11 th = 9 (20) 12 th = 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

31. Pre-test baseline mean of 86.23 (SD=23.40) increased to a post-intervention mean of 92.20 (SD=18.46), =.369, medium effect size 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 Supporting the hypothesis that self-reliance would increase post-intervention

32. BaselinePost Intervention Paired Differences Indices MSDM M tdfp value General Life Problems (N=41) 9.5367.5047.4155.7232.1225.8872.30840.013 Internal Behaviors (N=44) 3.6364.0982.0232.9371.6143.4523.10143.002 External Behaviors Internal Behaviors (N=42) 4.3574.4773.3103.4531.0484.8841.39041.086 Substance Problems Internal Behaviors (N=34) 2.2654.2661.2652.9681.0003.1621.84433.037

33. Baseline Post Intervention Paired Differences Dimensions of Words MSDM M tdfp Positive Emotion 4.4312.6533.6002.075.83112.9552.30825.082 Negative Emotion 5.1201.9296.0372.430-.91653.3193.10125.086 Social 9.4113.32910.8604.024-1.4484.5051.39025.057

34. Groups were facilitated by a Native American Indian woman with extensive adolescent group experience 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 The intervention was flexible enough to allow the participants to express themselves in multiple ways Convenience sample Convenience sample Self-identified tribal members Self-identified tribal members Self-reporting of substance use could be biased Self-reporting of substance use could be biased

35. This study: addresses a significant problem for American Indian adolescents and the specific tailoring of a successful intervention to meet the needs of the participants 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 demonstrates the effectiveness of specific tailoring using traditional and contemporary life experiences provides a template/model for use in future studies provides a template/model for use in future studies

37. Native Talking Circle Intervention requires replication of the study with larger sample sizes and longitudinal studies to address long term effectiveness 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 Validation of the effectiveness of the CMCT as a timely cultural tailoring model across subsets of Indigenous cultural groups

39. Thank You Wado!