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Despite advances in prevention science and practice in recent decades, the U.S. continues to struggle with significant alcohol-related risks and consequences among youth, especially among vulnerable rural and Native American youth. The Prevention Trial in the Cherokee Nation is a partnership between prevention scientists and Cherokee Nation Behavio...
Contexts in source publication
Context 1
... Framework Wagenaar and Perry's (1994) comprehensive theoretical framework of drinking behavior guided development of our integrated universal preventive intervention, as shown in Fig. 1. We designed a community intervention that builds directly on the original Communities Mobilizing for Change on Alcohol (CMCA) trial and subsequent disseminated model intervention ( Wagenaar et al. 2000a;Wagenaar et al. 2000b;Wolfson et al. 2012) with additional evidence-based compo- nents. The environmental interventions in the ...
Context 2
... Framework Wagenaar and Perry's (1994) comprehensive theoretical framework of drinking behavior guided development of our integrated universal preventive intervention, as shown in Fig. 1. We designed a community intervention that builds directly on the original Communities Mobilizing for Change on Alcohol (CMCA) trial and subsequent disseminated model intervention ( Wagenaar et al. 2000a;Wagenaar et al. 2000b;Wolfson et al. 2012) with additional evidence-based compo- nents. The environmental interventions in the current trial are community-driven and focus on decreasing physical availability and increasing formal social controls on both access to and consumption of alcohol by youth. Intervention features are hypothesized to affect per- ceived and observed access to alcohol by youth, per- ceptions of enforcement, drinking norms, drinking be- haviors, and alcohol-related risks and ...
Citations
... Finalmente, y desde la concepción CBPR, se promovieron estrategias como la Screening, Brief Intervention And Referral To Treatment -SBIRT de Komro et al. (2015); el proyecto Honoring Ancient Wisdom and Knowledge -HAWK de Raghupathy (2012), que incluye videojuegos; el Keetoowah-Cherokee Talking Circle -CTC-de Lowe (2006), mencionado por Baldwin et al. (2021); el Motivational Interviewing and Culture for Urban Native American Youth (MICUNAY) de Dickerson et al., (2020); y el Nimi Icinohabi Program de Baydala et al., (2014). ...
Introducción: indígenas y víctimas de la guerra son más vulnerables al uso de sustancias y requieren intervenciones especialmente adecuadas a sus necesidades. Objetivo: determinar los factores de riesgo y de protección, y las estrategias para la prevención del uso de sustancias en indígenas y víctimas de la guerra. Método: se realizó una revisión sistemática exploratoria siguiendo las pautas de la guía PRISMA-ScR. Los pasos llevados a cabo fueron: elaboración de la pregunta, objetivos, marco teórico y empírico; establecimiento de criterios de inclusión; delimitación de la muestra; extracción y sistematización de datos de la muestra; reporte y análisis de resultados. Resultados: Se identificaron 1327 estudios, a través de Scopus, Web of Science, Dimensions, la Biblioteca Virtual en Salud, y Google Académico, de los cuales 40 cumplieron con los criterios de inclusión. La desconexión cultural, el trauma, la exposición a la violencia, el estigma y la discriminación son factores de riesgo significativos. Conclusiones: El abordaje desde estrategias diseñadas con la comunidad es más eficaz para la prevención. En ambas poblaciones, los factores involucrados y las estrategias utilizadas coinciden e indican que efectivamente es necesario plantear programas fundamentados culturalmente, que integren intervenciones con evidencia empírica y sus visiones y prácticas culturales.
... The ISF provides a strong model to strengthen access to PrEP care, but it lacks equally robust attention to addressing PrEP awareness and interest. Thus, in this protocol, we innovatively supplemented the ISF with an evidence-based community organizing approach (COA), previously demonstrated effective for addressing underage alcohol use [34,35]. This evidence-based approach can create broader change across the community for any community challenge [36,37]. ...
Background
Most new HIV diagnoses among cisgender women in the United States occur in the South. HIV pre-exposure prophylaxis (PrEP), a cornerstone of the federal Ending the HIV Epidemic (EHE) initiative, remains underused by cisgender women who may benefit. Awareness and access to PrEP remain low among cisgender women. Moreover, improving PrEP reach among cisgender women requires effectively engaging communities in the development of appropriate and acceptable patient-centered PrEP care approaches to support uptake. In a community-clinic-academic collaboration, this protocol applies an evidence-based community organizing approach (COA) to increase PrEP awareness and reach among cisgender women in Atlanta.
Objective
The aim of this study is to use and evaluate a COA for engaging community members across 4 Atlanta counties with high-priority EHE designation, to increase PrEP awareness, interest, and connection to PrEP care among cisgender women.
Methods
The COA, consisting of 6 stages, will systematically develop the skills of community members to become leaders and advocates for HIV prevention inclusive of PrEP for cisgender women in their communities. We will use the evidence-based COA to develop and implement a PrEP-specific action plan to create broader community change by raising awareness and interest in PrEP, reducing stigma associated with HIV or PrEP, and connecting women to sexual health clinics providing PrEP services. In the first 4 stages, to prepare for and develop action plans, we will gather data from one-on-one interviews with up to 100 individuals across Atlanta to capture attitudes, motivations, and influences related to women’s sexual health with a focus on HIV prevention and PrEP. Informed by the community interviews, we will revise a sexual health curriculum inclusive of PrEP and community-centered engagement. We will then recruit and train community action team members to develop action plans to implement the curriculum during community-located events. In the last 2 stages, we will implement and evaluate COA’s effect on PrEP awareness, interest, HIV or PrEP stigma, and connection to PrEP care among cisgender women community members.
Results
This project was funded by the National Institutes of Health and approved by the Emory University institutional review board in July 2021. Data collection began in December 2021 and is ongoing. COA stage 1 of the study is complete with 70 participants enrolled. Community events commenced in November 2023, and data collection will be completed by November 2025. Stage 1 qualitative data analysis is complete with results to be published in 2024. Full study results are anticipated to be reported in 2026.
Conclusions
Through a community-clinic-academic collaboration, this protocol proposes to mount a coordinated approach across diverse Atlanta counties to strengthen HIV prevention for cisgender women and to create a sustainable systems approach to move new sexual health innovations more quickly to cisgender women.
International Registered Report Identifier (IRRID)
DERR1-10.2196/56293
... among Adolescents in the Achterhoek(Jansen et al., 2016); Local Alcohol Policy Project(Holmila et al., 2010;Holmila and Warpenius, 2007); Prevention of Underage Drinking on California Indian ReservationsGilder et al., 2017;Lee et al., 2011;Moore et al., 2012); Prevention Trial in the Cherokee Nation(Komro et al., 2017;Komro et al., 2015;Livingston et al., 2018;Wagenaar et al., 2018); Project Northland Chicago(Komro et al., 2004;Komro et al., 2008); Reducing Youth Access to Alcohol: Oregon(Flewelling et al., 2013); Social Marketing and Community Mobilisation in Australia(Rowland et al., 2018;Rowland et al., 2013); Strategic Prevention Framework( Anderson-Carpenter et al., 2016); Wegschauen ist keine Losung (Looking Away is not a Solution)(Kraus et al.Day-Power Play! (Foerster et al., 1998); Creating Healthy, Active and Nurturing Growing Up Environments(Cohen et al., 2014); Community Nutrition Education CooperativeDollahite et al., 1998); Project FIT(Alaimo et al., 2015;Eisenmann et al., 2011;Paek et al., 2014;Paek et al., 2015) Obesity 4.9 (2) Niños Sanos, Familia Sana(Sadeghi et al., 2017;de la Torre et al., 2013); the Tioga County Fit for Life Project(Gombosi et al.Grant-Petersson et al., 1999;Dietrich, 2000;Dietrich et al., 1998;Dietrich et al., 2000); SunSafe in Middle School(Olson et al.in Rural Towns Project (Hancock et al., 2001;Hancock et al., 1996); Project ACTIVITY(Arora et al., 2010a;Harrell et al., 2016;Arora et al., 2013;Arora et al., 2010b); Project SixTeen(Biglan et al., 2000); the New Hampshire Study(Stevens et al., 1993); Tobacco Policy Options for Prevention(Blaine et al., 1997;Forster et al., 1998) Multiple outcomes 43.9 (18) Be Active Eat WellSanigorski et al., 2008;Swinburn et al., 2014); Community Health Promotion Grants Program(Cheadle et al., 1995;Wagner et al., 1991); Communities that Care(Hawkins et al., 2002;Hawkins et al., 2009;Hawkins et al., 2014;Hawkins et al., 2012;Oesterle et al., 2014;Rhew et al., 2018;Oesterle et al., 2018); Communities that Care: Australia(Toumbourou et al., 2019); Healthy Youth Healthy Communities(Kremer et al., 2011;Waqa et al., 2013); IDEFICS Intervention(Pigeot et al., 2015;De Bourdeaudhuij et al., 2015a;De Henauw et al., 2015;De Bourdeaudhuij et al., 2015b); Isfahan Healthy Heart Program(Sarraf-Zadegan et al., 2003;Sarrafzadegan et al., 2014;Kelishadi et al., 2012;Sarrafzadegan et al., 2006); Massachusetts Childhood Obesity Research Demonstration ProjectBlaine et al., 2017;Taveras et al., 2015;Franckle et al., 2017); Ma'alahi Youth Project(Fotu et al., 2011a;Fotu et al., 2011b); Mebane on the Move(Benjamin Neelon et al., 2015;Martinie et al., 2012); Minnesota Heart Health Program -Class of 1989 ...
Whole-of-community interventions delivered across entire geospatial areas show promise for improving population health for youth cancer prevention. The aims of this scoping review were to synthesize the whole-of-community intervention literature on six modifiable risk factors in youth for cancer prevention (alcohol use, diet, obesity, physical activity, sun exposure, tobacco use) and to develop and apply a typology describing the inclusion of fundamental control system functional characteristics. A systematic search was conducted in PubMed, Cumulative Index to Nursing and Allied Health Literature, Embase, PsycINFO, and Scopus for studies published to the end of 2019. Eligible studies included a geospatially defined whole-of-community intervention; youth 0–18 years; and at least one of the six cancer risk factor outcomes. An iterative process was undertaken to create a typology describing the functions for whole-of-community interventions guided by systems theory, and the typology was used to code the included interventions. A total of 41 interventions were included. Most interventions (43.9%) assessed multiple cancer risk factors. Few interventions provided fundamental functions necessary for community system coordination: sensor, controller, effector. Although communities are a patchwork quilt of microsystems where individuals interact in geographically bounded places nested within larger whole systems of influence, a control systems approach has not been used to frame the literature. Whole-of-community interventions can be characterized by the fundamental system functions necessary for coordinating population health improvement. Future whole-of-community intervention efforts should draw on fundamental knowledge of how systems operate and test whether adoption of the key functions is necessary for whole-of-community population health improvement.
... More recently, two studies have demonstrated that multi-level prevention trials can successfully reduce alcohol use among AI teens (Komro et al., 2017;Moore et al., 2018), opening up the possibility that such programs can be successfully applied more widely to reduce substance-related harm among AIs. One study used a multi-level prevention trial among AI teens in the Cherokee Nation (see Komro et al., 2017;Komro et al., 2015). That study found that the combination of a community organizing intervention targeting alcohol access and a school-based screening with brief intervention was effective in reducing 30-day alcohol use and heavy episodic drinking. ...
We report an evaluation of a combined individual- and community-level treatment and prevention effort to reduce underage drinking by American Indian (AI) youths on rural California Indian reservations. The interventions included: brief motivational interviewing and psychoeducation for Tribal youths, restricting alcohol sales to minors in alcohol sales outlets, and community mobilization and awareness activities. Surveys were collected from 120 adults and 74 teens to evaluate the awareness and effectiveness of the interventions. A high proportion of adult (93%) and youth (96%) respondents endorsed being aware of one or more of the intervention activities, and 88% of adults and 71% of youth felt the program impacted the community in a positive way. Eighty-four percent of adults and 63% of youth agreed that as a result of the activities that they decided to take action to reduce teen drinking in their community. Being aware of more of the intervention activities significantly increased the odds of taking action to change drinking behaviors. This study documents that a significant proportion of the community was aware of the intervention efforts and that awareness caused them to take action to reduce underage drinking. Such efforts may benefit other AI/AN communities seeking to reduce underage drinking.
... Details of the trial design and alcohol use outcomes are described elsewhere. 23,24 This article will describe the specific characteristics and implementation of the CONNECT SBI intervention, the universally-implemented, multiculturally-appropriate school-based prevention program. ...
... Two main intervention strategies were employed: (1) SBI with MI implemented by CONNECT coaches within the school setting and (2) a media campaign to reinforce positive social interactions (eg, encourage parent-child communication). Komro et al. 24 detail the trial design. Figure 1 provides a diagram of the intervention implementation components, hypothesized intermediate outcomes, and main outcomes. ...
... The school-based service workers devoted 49% full time equivalent (FTE) as the school's CONNECT coach and 51% FTE as a social service provider linking students and their families to community resources. 24 This model strengthened the partnership between the schools and OKDHS. ...
Background:
There is growing optimism regarding the use of screening and brief intervention (SBI) to identify and reduce risk behaviors during adolescence. However, understanding successful SBI implementation remains unclear. We previously reported the effects of CONNECT, a school-based SBI, on reducing the primary outcome, the rate of monthly alcohol use among primarily American Indian (AI) and White high school students in the Cherokee Nation. In this paper, we describe the design and implementation process for CONNECT.
Method:
CONNECT was designed to reduce alcohol use with 2 key strategies: (1) SBI with motivational interviewing (MI), implemented by a school-based CONNECT coach, and (2) a media campaign.
Results:
Implementation results indicate that during each semester of the 2-1/2 years, between 73% and 100% of eligible students had at least one 15-minute meeting with a CONNECT coach. Postcards and posters with positive communication tips for parents were displayed in CONNECT communities. No statistically significant differences occurred between the CONNECT and control groups on the hypothesized intermediate outcomes.
Conclusions:
We describe implementation of a universal, school-based, culturally adapted SBI that was effective in reducing alcohol use among youth living in the Cherokee Nation. Schools provide an important context for universal delivery of SBI interventions, such as CONNECT, for diverse adolescent populations, including AI youth.
... Studies sometimes emerged from community review of findings from formative research or discussions between researchers and community representatives about community health needs. One study began after researchers were introduced to community representatives through mutual acquaintances [26]; in another, research activities commenced two years after the principal investigator was introduced by a tribal member to the tribal health director [36]. Researchers also used professional networks and preexisting contacts with AIAN communities to identify communities willing to participate in studies. ...
... Community members also helped with staffing issues. In one study, community members were involved in the selection, interview, and hiring of project staff [26]. Other articles reported that CAGs, leaders, and laypersons community were responsible for identifying individuals to fulfill specific project roles based on their experience and skills [32,[46][47][48][49]. Community members contributed to project management by coordinating event logistics; providing translation and information technology services; scheduling and organizing data collection activities; and, facilitating meetings. ...
... For example, in a randomized controlled trial to assess the impact of an intervention to reduce health risks for AI teen mothers and their children, community members advocated for the use of an "optimized" variant of standard care in the control group in order to better address the health needs of participants randomized to control ( [47], p. 506). Another trial used a wait-listed randomized design to ensure that all participants eventually received the intervention [77] and an intervention to prevent underage drinking among AI youth was designed to involve all students in the participating communities in order to prevent stigmatization that could result from singling out AI youth for intervention [26]. ...
A scoping review was conducted to assess the state of the literature on health-related participatory research involving American Indian and Alaska Native communities. Online databases were searched for relevant articles published between 1/1/2000 and 5/31/2017. 10,000+ data points relevant to community-level engagement in and regulation of research, community research capacity and cultural adaptation were extracted from 178 articles. Community engagement varied across study components: 136 (76%) articles reported community participation in research-related meetings and other events and 49 (27%) articles reported community involvement in initiation of research. 156 (88%) articles reported use of community-level tools to guide or regulate research. 93 (52%) articles reported that community members received research-related training. 147 (82%) articles described some type of cultural adaptation. Across all articles, data points on community engagement were not reported in 3061 (40%) out of 7740 cases. Findings suggest a need for increased community engagement in early stages of the research process and for reporting guidelines for participatory research involving American Indian and Alaska Native communities. There is also need to further existing research on the impact of different components of participatory research on process and outcome measures and to develop funding mechanisms that account for the time and resource intensive nature of participatory research.
... Combining these approaches is rare, 16,17 especially for AI/AN youths. 18 However, multilevel interventions have the potential to work synergistically to reduce both supply of and demand for alcohol. ...
Objectives:
To evaluate combined individual- and community-level interventions to reduce underage drinking by American Indian/Alaska Native (AI/AN) youths on rural California Indian reservations.
Methods:
Individual-level interventions included brief motivational interviewing and psychoeducation for Tribal youths. Community-level interventions included community mobilization and awareness activities, as well as restricting alcohol sales to minors. To test effects, we compared 7 waves of California Healthy Kids Survey data (2002-2015) for 9th- and 11th-grade AI/AN and non-AI/AN students in intervention area schools with California AI/AN students outside the intervention area (n = 617, n = 33 469, and n = 976, respectively).
Results:
Pre- to postintervention mean past 30-day drinking frequency declined among current drinkers in the intervention group (8.4-6.3 days) relative to comparison groups. Similarly, heavy episodic drinking frequency among current drinkers declined in the intervention group (7.0-4.8 days) versus the comparison groups.
Conclusions:
This study documented significant, sustained past 30-day drinking or heavy episodic drinking frequency reductions among AI/AN 9th- and 11th-grade current drinkers in rural California Indian reservation communities exposed to multilevel interventions. Public Health Implications. Multilevel community-partnered interventions can effectively reduce underage alcohol use in this population. (Am J Public Health. Published online ahead of print June 21, 2018: e1-e7. doi:10.2105/AJPH.2018.304447).
... We conducted a community intervention trial with quarterly data over 3 years (2012-2015; 12 waves) to examine the effectiveness of 2 alcohol prevention interventions implemented alone or in combination. We purposively selected 6 of 12 potential study communities in the Cherokee Nation in Oklahoma based on similar characteristics and with higher substance use risk profiles compared with other candidate communities 10,11 and randomly assigned them to 1 of 4 study conditions: CMCA only (n = 1 community), CONNECT only (n = 1), both interventions combined (n = 2), and delayed intervention control (n = 2). Details on the theory, interventions, trial design, and data collection were published before outcome data collection. ...
... Nevertheless, we incorporated additional design elements, including intensive longitudinal measurements, to improve causal inference. 11 ...
Objectives:
To evaluate effects of 2 alcohol prevention interventions-Communities Mobilizing for Change on Alcohol (CMCA), a community organizing intervention designed to reduce youth alcohol access, and CONNECT, an individual-level screening and brief intervention approach-on other drug use outcomes.
Methods:
We conducted a community intervention trial with quarterly surveys over 3 years (2012-2015) of high school students living within the jurisdictional service area of the Cherokee Nation in Oklahoma. We used generalized estimating equations and linear probability models to examine intervention spillover effects on other drug use.
Results:
We found significant reductions in drug use other than alcohol attributable to CMCA and CONNECT. CMCA was associated with a 35% reduction in chewing tobacco use, a 39% reduction in marijuana use, and a 48% reduction in prescription drug misuse. CONNECT was associated with a 26% reduction in marijuana use and a 31% reduction in prescription drug misuse.
Conclusions:
Nonalcohol drug use was consistently reduced as a result of 2 theoretically and operationally distinct alcohol prevention strategies. Evaluations of alcohol prevention efforts should continue to include other drug use to understand the broader effects of such interventions. (Am J Public Health. Published online ahead of print December 21, 2017: e1-e3. doi:10.2105/AJPH.2017.304188).
... This trial of the Communities Mobilizing for Change on Alcohol (CMCA) intervention is built on two key strains of theory [5]. The first is the theory of cause-factors influencing rates of youth drinking and alcohol-related problems. ...
... Nevertheless, the theory, hypothesized main outcomes, hypothesized secondary outcomes, and measures were all published before the outcome data were collected and analyzed [5,18]. ...
... We combined multiple design elements to optimize causal inference while meeting the constraints of the setting, number of sites available, and budget (see supplemental Figure 1 for CONSORT information and Komro et al. for additional details) [5]. The two central design features are the combination of a controlled intensively longitudinal or time-series design with random assignment of community to study condition. ...
Aims:
We evaluated the effects of a community organizing intervention, Communities Mobilizing for Change on Alcohol (CMCA), on the propensity of retail alcohol outlets to sell alcohol to young buyers without age identification and on alcohol acquisition behaviors of underage youth.
Design:
Random assignment of community to treatment (n=3) or control (n=2). Student surveys were conducted four times per year for three years; the cohort was in 9th and 10th grades in the 2012-13 academic year. Alcohol purchase attempts were conducted every 4 weeks at alcohol retailers in each community (31 repeated waves).
Setting:
The Cherokee Nation, located in northeastern Oklahoma, USA.
Participants:
1399 high school students (50% male; 45% American Indian) and 113 stores licensed to sell alcohol across 5 study communities.
Intervention:
Local community organizers formed independent citizen Action Teams to advance policies, procedures and practices of local institutions in ways to reduce youth access to alcohol and foster community norms opposed to teen drinking.
Measurements:
Perceptions regarding police enforcement and perceived difficulty of and self-reported actual acquisition of alcohol from parents, adults, peers, and stores.
Findings:
Alcohol purchases by young-appearing buyers declined significantly, an 18 (95% CI: 3, 33) percentage-point reduction over the intervention period. Student survey results show statistically significant differences in the trajectory of perceived police enforcement, increasing 7 (4, 10) percentage-points, alcohol acquisition from parents, decreasing 4, (0.1, 8) percentage-points, acquisition from 21+ adults, decreasing 6 (0.04, 11) percentage points, from <21 peers decreasing 8 (3, 13) percentage-points, and acquisition from stores decreasing 5 (1, 9) percentage-points.
Conclusions:
A community organizing intervention, Communities Mobilizing for Change on Alcohol (CMCA), is effective in reducing the availability of alcohol to underage youth in the USA. Furthermore, results indicate that the previously reported significant effects of CMCA on teen drinking operate, at least in part, through effects on alcohol access.
... The Cherokee Nation is the second largest American Indian tribe in the United States. We conducted a community-randomized trial testing two theoretically distinct alcohol preventive interventions in rural towns within the jurisdictional service boundaries of the Cherokee Nation (Komro et al., 2015. We implemented a community environmental change intervention using community organizing called Communities Mobilizing for Change on Alcohol (CMCA) and a universally implemented individual-level intervention implemented within schools combining brief intervention with motivational interviewing called CONNECT and found that both interventions, alone and in combination, were effective in reducing past month alcohol use, heavy use, and alcohol consequences . ...
... Change strategies were not explicitly defined but included a complex mix of strategies including facilitative, educational, persuasive, and regulatory or power strategies (Harper & Leicht, 2011). In the prevention trial in the Cherokee Nation, the theory of community change was explicitly tested and defined as a process of citizen-led and direct-action community organizing (Komro et al., 2015. The direct-action community organizing process was the standard intervention delivered across communities, yet specific intervention components and their dosage varied based on local contexts . ...
... In comparison, my most recent prevention trial in partnership with the Cherokee Nation in rural Oklahoma included an intervention condition that solely focused on community environmental change (Komro et al., 2015. We implemented CMCA, which uses community organizing strategies to galvanize adults to take actions to reduce youths' access to alcohol through social and commercial sources. ...
For the past 25 years, I have led multiple group-randomized trials, each focused on a specific underserved population of youth and each one evaluated health effects of complex interventions designed to prevent high-risk behaviors. I share my reflections on issues of intervention and research design, as well as how research results fostered my evolution toward addressing fundamental social determinants of health and well-being. Reflections related to intervention design emphasize the importance of careful consideration of theory of causes and theory of change, theoretical comprehensiveness versus fundamental determinants of population health, how high to reach, and health in all policies. Flowing from these intervention design issues are reflections on implications for research design, including the importance of matching the unit of intervention to the unit of assignment, the emerging field of public health law research, and consideration of design options and design elements beyond and in combination with random assignment.
