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There is a need for Indigenous-centered research to appraise culture’s role in wellness. Researchers described the development and validity of the Native Wellness Assessment (NWATM). The NWA has culture-as-intervention at its apex. Wellness, culture, and cultural intervention practices (CIPs) are explored from an Indigenous perspective. Indigenous clients completed matching self-report and observer versions of the NWA at three time points during addictions treatment. Statistically and psychometrically, the NWA content and structure performed well, demonstrating that culture is an effective and fair intervention for Indigenous peoples with addictions. The NWA can inform Indigenous health and community-based programs and policy.
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Journal of Ethnicity in Substance Abuse
ISSN: 1533-2640 (Print) 1533-2659 (Online) Journal homepage:
Honoring Indigenous culture-as-intervention:
Development and validity of the Native Wellness
Carina Fiedeldey-Van Dijk, Margo Rowan, Colleen Dell, Chris Mushquash,
Carol Hopkins, Barb Fornssler, Laura Hall, David Mykota, Marwa Farag & Bev
To cite this article: Carina Fiedeldey-Van Dijk, Margo Rowan, Colleen Dell, Chris Mushquash,
Carol Hopkins, Barb Fornssler, Laura Hall, David Mykota, Marwa Farag & Bev Shea (2016):
Honoring Indigenous culture-as-intervention: Development and validity of the Native Wellness
, Journal of Ethnicity in Substance Abuse, DOI: 10.1080/15332640.2015.1119774
To link to this article:
Published online: 15 Mar 2016.
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2016, VOL. 00, NO. 00, 1–38
Honoring Indigenous culture-as-intervention:
Development and validity of the Native Wellness
Carina Fiedeldey-Van Dijk
, Margo Rowan
, Colleen Dell
, Chris Mushquash
Carol Hopkins
, Barb Fornssler
, Laura Hall
, David Mykota
, Marwa Farag
, and
Bev Shea
ePsy Consultancy, Toronto, Ontario, Canada;
Rowan Research and Evaluation, Ottawa, Ontario,
Department of Sociology & School of Public Health/Canadian Centre on Substance Abuse,
University of Saskatchewan, Saskatoon, Saskatchewan, Canada;
Department of Psychology and
Northen Ontario School of Medicine, Lakehead University, Thunderbay, Ontario, Canada;
(National Native Addictions) Partnership Foundation, Bothwell, Ontario, Canada;
Department of
Sociology & School of Public Health, University of Saskatchewan, Saskatoon, Saskatchewan, Canada;
Centre for Humanities Research and Creativity, Laurentian University, Greater Sudbury, Ontario;
Department of Educational Psychology and Special Education, College of Education, University of
Saskatchewan, Saskatoon, Saskatchewan, Canada;
School of Public Health, University of Saskatchewan,
Saskatoon, Saskatchewan, Canada;
Clinical Epidemiology Program, Ottawa Hospital Research Institute,
Ottawa, Ontario, Canada
There is a need for Indigenous-centered research to appraise
culture’s role in wellness. Researchers described the develop
ment and validity of the Native Wellness Assessment (NWA
The NWA has culture-as-intervention at its apex. Wellness,
culture, and cultural intervention practices (CIPs) are explored
from an Indigenous perspective. Indigenous clients completed
matching self-report and observer versions of the NWA at three
time points during addictions treatment. Statistically and
psychometrically, the NWA content and structure performed
well, demonstrating that culture is an effective and fair
intervention for Indigenous peoples with addictions. The NWA
can inform Indigenous health and community-based programs
and policy.
Addiction; assessment;
cultural intervention
practices; culture; fairness;
Indigenous peoples;
intervention; Native
wellness; NWA; reliability;
treatment; validity
Setting a study context
Individuals with past or present addictions working to recover and heal in
broad social determinants of life critically need social and educational sup
port, outreach, and engagement efforts in overall wellness. This is especially
relevant for Indigenous peoples where indicators of well-being are notoriously
lower than those of other population groups. In Canada, First Nations, Métis,
and Inuit comprise 4.3
the Canadian population. On average, differences
between Indigenous and non-Indigenous populations indicate that the former
CONTACT Carina Fiedeldey-Van Dijk ePsy Consultancy, 144 Tamarac Trail,
Aurora, Ontario, L4G 5TI, Canada.
© 2016 Taylor & Francis
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group is 12.9 years younger, grows at a faster rate by 14.9%, and has fewer
children aged 14 and under living in a family with both parents by 26.4%.
Canada’s colonial history and ongoing efforts at colonization has led to its
Indigenous peoples having a higher risk than the general population of low
income due to higher school dropout rates by 4.3%, higher household food
insecurity by up to 20%, and more admissions to sentenced custody by
23.6%. Indigenous peoples have more diagnoses of chronic health conditions
(e.g., obesity, diabetes) by 8%(Statistics Canada, 2011, 2015). A 2015 review
of available Canadian data and reports likewise “revealed a disproportionate
burden of substance use and harms” (Firestone, Tyndall, & Fischer, 2015,
p.11). These statistics show the need to support wellness for Indigenous
peoples through initiatives that reflect the community’s unique lived experi
ences and that highlight culturally appropriate modes of enhancing wellness,
including the development and validation of wellness measurements.
Framing the role of indigenous culture and cultural intervention
Culture is a necessary part of prevention of and healing from traumatic events
and addictions for Indigenous peoples (Chong, Fortier, & Morris, 2009; Mental
Health Commission of Canada, 2009; Mussel, Cardiff, & White, 2004; Rowan
et al., 2014; Royal Commission on Aboriginal Peoples, 1996). Native denotes
the collectivistic cultures of all Aboriginals or Indigenous peoples. Indigenous
culture is protective for well-being, particularly in light of the social and histori
cal oppression and colonization experienced by Indigenous peoples (Kirmayer,
Gone, & Moses, 2014;
Snowshoe, Crooks, Tremblay, Craig, & Hinson, 2015).
Indigenous people shield and maintain culture by resisting Euro-Canadian
dominance (Berry, 1999). A body of social research (see Phinney, 1990) put for
ward a multidimensional conceptualization that identification with Indigenous
culture is (a) closely linked to strength of self-concept (“who am I really”) and
(b) implies a sense of distinguished, sought-after attachment (“where do I
empathically belong”). How Indigenous people think of themselves and where
they socially, ethnically, geographically, and historically place themselves
provide a certain knowledge/perception and evaluation/affect that define and
sustain culture (Berry, 1999
and form the guidelines whereby Indigenous
culture is symbolized and expressed (Gans, 1979; Gone & Alcántara, 2007).
The sweat lodge ceremony (Gossage et al., 2003; Schiff & Pelech, 2007) and
traditional teachings (Edwards, 2003; Stone, Whitbeck, Chen, Johnson, &
Olson, 2006) are two examples of cultural interventions that have long been
practiced in Indigenous treatment programs. Such practices play an important
role in a decolonization agenda (Gone, 2013; Gone & Calf Looking, 2015). In
recognition of cultural suppression and forced assimilation of Indigenous
peoples, cultural intervention practices serve a critical function to express
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collective identity and address imbalances in health and well-being within and
among Indigenous peoples (Kirmayer et al., 2014). Combined cultural recla
mation and cultural practices can be effective therapeutic interventions or
treatments in substance abuse and toward wellness (Gone, 2011
which may
be captured and tracked through measurement rooted in Indigenous culture.
Diverse traditional practices that involve singular or combined incorpor
ation of “plant, animal and/or mineral medicines, spiritual therapies, manual
techniques and exercises to treat, diagnose or prevent illness” are defined
by the World Health Organization (WHO, 2002,
p. 1) as traditional
medicines, which are regularly applied as culturally appropriate intervention
strategies to promote healing and wellness (Bassett, Tsosie, & Nannauck,
2012). The latter authors reported that, according to the healers they
interviewed, “culture is the primary vehicle for delivering healing” (p. 25).
Culture-based, Indigenous means of treatment may include any or all of spirit,
ceremonies, language, values and beliefs, stories and songs, land-based activi
ties, food, relations, nature, and history, among others. To date, what little pub-
lished information is available to measure and facilitate the effect of culture
and cultural intervention practices on Indigenous peoples as the vehicle toward
Native wellness relies on anecdotal evidence or is based on small samples and,
while promising, rarely can be generalized (Rowan et al., 2014).
In 2011, representatives of the National Native Addictions Partnership
Foundation (NNAPF
), the Assembly of First Nations (AFN), and Health
Canada First Nations and Inuit Health Branch (FNIHB) consulted with the
National Native Alcohol and Drug Abuse Program (NNADAP) and the
Youth Solvent Abuse Program (YSAP) to develop a comprehensive approach
to mental health and addiction programming in Canada. The two programs
underwent a comprehensive process of renewal culminating in a renewed pro
gram framework (Health Canada, 2011).
Its strengths-based systems approach
addresses substance misuse among First Nations by allotting attention to the
social consequences to health and well-being. The representatives of the three
entities concluded that “culture is vital for healing, although how culture is
defined and practised varies across communities” (NNAPF et al., 2011,
p. 9). They expressed a need to determine whether cultural commonalities
can be identified for wellness purposes. They also called for Indigenous-
centered research to measure and validate the role of culture and cultural
renewal in wellness for First Nations communities, which are poorly under
stood in the Western-directed treatment system (Dell et al., 2011;
Nagel, 1997).
Subsequently, the Canadian Institutes of Health Research (CIHR) funded an
alliance of NNAPF, AFN, the Centre for Addiction and Mental Health
(CAMH), and the University of Saskatchewan to develop and validate a mea
sure of the effectiveness of culture-as-intervention, specifically in Canadian
NNAPF was renamed to Thunderbird Partnership Foundation (TFP) in 2015.
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First Nation’s alcohol and drug treatment programs and in overall wellness.
The study, Honoring Our Strengths: Culture as Intervention in Addiction Treat
ment ran from 2012 to 2015. Applying the concept of “two-eyed seeing” as a
guiding principle, researchers were able, in the words of Elder Albert Marshall,
“to see from one eye with the strengths of Indigenous ways of knowing, and to
see from the other eye with the strengths of Western ways of knowing, and to
use both of these eyes together” (Bartlett, Marshall, & Marshall, 2012
p. 335).
Within this framework, project contributors prioritized Indigenous methods
and ways of knowing alongside Western science (Hall et al., 2015).
Operationalizing Native wellness
A holistic definition of wellness guided this project based on Indigenous culture
conceptualized across the four directions in the Sacred Medicine Wheel and fun
damental to all life, wherein all are considered sacred and equal (Dapice, 2006
the study. Native Wellness is a whole and healthy person expressed
through a balance of spirit, heart, mind and body (McConnery & Dumont,
2010). Central to wellness is relations; that is, the belief in one’s connection to lan
guage, land, beings of creation, and ancestry, supported by a caring family and
environment. This belief shapes the spiritual, emotional, mental, and physical
well-being of individuals and communities (Wilson, 2003).
Jim Dumont, a leading
Indigenous researcher and the project’s guiding Elder, articulated these four quad
rants of wellness, which function inseparably from a position of strength (Dumont
& National Native Addictions Partnership Foundation [NNAPF], 2014):
The spiritual is the quality of being alive in a qualitative way; the reason to
live, giving vitality, mobility, purpose and the desire to achieve the highest
quality of living in the world. Spirit is central to the primary vision of life
and worldview and thereby facilitates hope. Embedded in Indigenous culture,
spiritual strength can contend with challenges concerning loss of religion,
avoidance of ceremonies, hopelessness, and despair.
The emotional is rooted in family, community and within creation as extended
family; the foundation of belonging and relationships. The heart is nurtured by
one’s belonging through interdependent relationships with others and by living
in relation to creation, including beings in creation. Set in culture, emotional
strength can oppose loss of identity, (posttraumatic) stress, anxiety, depression,
and suicide when wellness is severely imbalanced.
The mental is the conscious and intelligent drive to know and activate one’s
being and becoming; having a reason for being, which gives meaning to life.
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The mind operates in both a rational and intuitive capacity. Rooted in
Indigenous culture, mental strength can reduce hampered communication,
ceased contact with elders, and devalued or lost experiential learning. Mental
strength can resist the loss of ability to speak/understand Native language and
even brain damage as a result of substance abuse.
The physical is a way of behaving and doing that actualizes the intention and
desire of the spirit in the world, coupled with the knowledge that the spirit has
something to do in the world, which generates a sense of purpose, conscious
of being part of something that is much greater than people are as individuals.
The body is the most outer part of being and is composed of the most
immediate behavioral aspects of our being. Engrained in culture, physical
strength can overcome body weakness and damage (i.e., a target for [chronic]
illness) and susceptibility to craving (e.g., overeating), misuse (unhealthy
habits, inactivity), and abuse (addictions).
Dumont and NNAPF (2014) emphasized client strength and empowerment
in the quadrants according to a worldview that people are resourceful and resili
ent in the face of adversity, which encourages reflection to enlarge capacities for
healing and well-being (Guo & Tsui, 2010).
Outside of Indigenous culture, lists
of possible challenges to wellness (borrowed from Dapice, 2006) are commonly
referenced in the literature depicting those with addictions as trapped in com
plex connections involving drug use, crime, violence, emotional instability,
financial hardship, low education, deviance, social processes associated with
the crack market, and other factors compounding risk (De La Rosa, Lambert,
& Gropper, 1990
These lists also narrow the focus to individuals as victims,
who are simultaneously responsible for surmounting their addiction individu
ally. As deficiencies the identification and conquering of these challenges point
to evidence
Yet, this approach fails to acknowledge consequence in its omission
of the intergenerational effects of colonization through the residential schools,
sixties scoop, structural inequities across the social determinants of health, and
a lack of access to culture as a way to explain addictions. Indigenous social
service agencies, such as friendship centers, view an individual’s addiction as
a symptom of deeper problems rooted in racism, powerlessness, and cultural
breakdown. This notion sets the tone for the framework whereby a Native
wellness assessment was developed and validated in this study.
The inextricable link among the four directional quadrants in advancing
wellness is consistent in the literature (Dingwall & Cairney, 2010; Thomas,
Cairney, Gunthorpe, Paradies, & Sayers, 2010). It is important to work and
grow culturally in each quadrant relational to the others for balance and
wholeness. Wellness is simultaneously contingent on all four of the spiritual,
emotional, mental, or physical quadrants. Western science emphasizes the
pursuit of consecutive evidence on which to base theory, models, and
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measures. Evidence is derived from a collection of ideas and observations,
some of which have been tested and demonstrated to be valid and reliable
across specific populations of people. In the Indigenous worldview, evidence
is informed by knowledge that emphasizes the integration of physical and
spiritual realities in healing and wellness. It is done such that the manifes
tation of spirit in physical reality is accepted as proof when the understanding
of such manifestation or expression can be tied to cultural teachings and com
munity knowledge passed on from generation to generation. With this tie,
change for the better can occur. This implies that Indigenous well-being
can be measured, followed, and developed, for example, by way of a Native
wellness assessment.
The need for a Native Wellness Assessment
There is a scarcity of appropriate, scientifically validated, and holistic wellness
assessments that have Indigenous culture at their foundation and that
measure and can control for the contribution of culture, as expressed through
cultural intervention practices (CIPs). Rowan et al. (2014) conducted an
extensive scoping review of CIPs to treat addictions among Indigenous
peoples in residential programs as tied to wellness in residential programs.
They found that less than 0.5% of studies used surveys and that these had
been developed in house (56%), were Western based (44%), and/or focused
on alcohol and drug use. Only two instruments—the American Indian Cul
tural Involvement Index (Boyd-Ball, Dishion, Myers, & Light, 2011
the Cherokee Self-Reliance Questionnaire (Lowe, Liang, Riggs, & Henson,
2012)—were oriented to Indigenous culture.
These measures accommodate traditional/cultural healing components by
adding them to addiction treatment (including talking circles, family involve
ment, and incorporation of CIPs) and identify the components at least in part
as the cause for a successful outcome of lower substance/solvent/alcohol
abuse. By comparison, this study focuses on wellness with culture at its apex,
shifting from method to foundation. The project team set out to embed
identification with culture and entrench how culture is practiced in wellness;
improvements in wellness during the course of recovery from addictions are
needed to sustain healing and liberate those who are thinking of deficiencies
The review highlighted that there is an overreliance on Western-based
assessments to evaluate Native wellness as tied to addictions. Pace et al.
) cautioned against using assessments centered on the dominant culture,
as interpretation is outside the context of the profound social, historical, and
political understanding and experience of Indigenous peoples. A progressive
alternative is to develop new Indigenous-specific measures directed and gov
erned by Indigenous peoples and informed by Western-based science. Such a
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process would better ensure cultural relevance and align with the global
movement toward a strengths-based resiliency perspective on alcohol and
drug addiction among Indigenous peoples (Dell, Hopkins, & Dell, 2004;
Graham & Stamler, 2010; Mohatt, Fok, Burket, Henry, & Allen, 2011).
Other studies, including Indigenous-directed research, deconstructed well
ness and focused on developing and validating scales related to isolated
aspects of wellness, such as physical or emotional health (Chong et al.,
Mohatt et al., 2011; Thomas et al., 2010). While there is value in
measuring separate aspects of wellness, in isolation they can misrepresent
wellness in its entirety. A holistic perspective allows researchers to examine
the critical interconnectedness and interdependence of wellness.
The review also revealed that assessments were often disconnected from an
Indigenous worldview, focussing on risk factors, disease processes, and socio
economic problems (Bartlett, 2005)
rather than strengths (Snowshoe et al.,
2015). Culture-as-intervention was not embedded in these instruments, yield
ing measures incongruent with Indigenous conceptualizations and diminished
strength. Differing conceptualizations and worldviews can be addressed using
approaches such as two-eyed seeing (Hall et al., 2015
yet cannot replace
culture as strength at the apex of an Indigenous assessment.
Culture is inescapable and beneficial (Dyck & Kearns, 1995; Lynam &
Young, 2000). For example, Canada benefits notably by more than 600,000
youth who will have entered the labor market by 2026 (Calliou, 2012). The
culturally grounded LE,NONET project at the University of Victoria, which
helps growing numbers of Indigenous students adapt to campus life, honor
their values, and improve their success, reported increases of 100% in
term-to-term continuation and 20% in graduation rates and reduction of
67% in withdrawal rates from 2005 to 2009 (Mason, 2010). Postsecondary
education attainment is associated with improvement in social determinants
(Wells, 2010). Approximately 53 million Canadian dollars were loaned to
more than 800 Indigenous start-up businesses in Alberta by one local
developer over the last 28 years (Calliou, 2012). The Royal Bank of Canada
(RBC) and others reported on Indigenous success stories for businesses,
communities, and individuals. For example, Indigenous peoples are increas
ingly forming partnerships with the corporate sector; are actively involved
in on-reserve mortgage housing and real estate, water issues, oil sands, tele
communication, and entertainment and service industries; enroll in various
education projects and programs; partake in the North American Indigenous
Games; have special advisory and senior managerial input to RBC decision
making; established access to opportunities giving law students legal and
business skills needed; and are formally recognized in diversity initiatives
(Goulet & Swanson, 2013
Kishk Anaquot Health Research, 2007; Royal Bank
of Canada [RBC], 2015). Publicly recognized stories and other anecdotal
reports demonstrate how sustainable prosperity for Indigenous peoples is
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approached through economic development strongly intertwined with
community and social development, employment, training and education,
and cross-cultural trust. These widespread progressions help demonstrate that
strengths lie in culture for Indigenous peoples- the importance of Indigenous
culture cannot be overstated.
Building on Indigenous success stories, in this project researchers coopera
ted cross-culturally by implementing cultural ways of knowing inherent to the
cultural target group—Indigenous peoples. In the introductory discussion,
researchers specified the context within which the measure needs to be
developed and validated and reviewed the theoretical underpinning behind
the wellness dimensions. The scoping review and trends described above
underscore the need for closing the gap in measurement of culture-based
approaches. Native wellness was defined in alignment with enablement of
communities and individuals to “actualize their potential spiritually, emotion
ally, physically and intellectually,” which Kishk Anaquot Health Research
, p. 5) provided as success criteria. The project goal was to develop a
valid assessment to measure culturally embedded wellness among Indigenous
peoples whereby the NWA contributes to Indigenous success. In the remain
der of the article, researchers focus on the empirical piloting of the NWA and
describe its development, its psychometric reliability and validation, and its
intended function and utility, adhering to the fundamental importance of
culture-as-intervention in wellness.
During piloting in Year 2 of the study, 55 treatment centers in the NNADAP/
YSAP system across Canada were operational and were targeted as practical
and relevant data collection locations and invited to participate in the
research. These treatment centers which primarily serve members of First
nations, Métis, and Inuit populations, are located across Canada and pre
dominantly in Ontario and the four western provinces that house the largest
Indigenous populations (Statistics Canada, 2011
Funded service availability
at these treatment centers was about 865 beds and another 200 beds sourced
elsewhere per annum, with 80%average occupancy rate as reported to Health
Canada, offered to in- and out-patients in continuous and/or block formats,
with accommodation of physical disabilities (93%), pregnant women
(82%), court referral or correctional clients (85%), clients on methadone/
Suboxone (25%), and clients on other psychoactive medications (64%).
Access to a psychologist was available for 45%of the centers via direct service
and 33%via clinical supervision.
On average, treatment centers were run by 6.38 full-time staff members,
71%of whom were certified addiction counsellors. Program length in days
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ranged between 7 and 180 days and offered concurrent disorder capability
(67%), residential schools (51%), on-the-land programs (44%), gender-
based programs (49%), family treatment (24%), child counseling (33%),
and couples counseling (38%). Together the centers equally admitted male
and female clients, of whom about two thirds completed the program.
Participating clients ranged widely with respect to gender (male, female,
other), age in years, Indigenous ethnicity, work, and cultural experience:
1. Clients ranged from 13 (youth) to 63 (adult) years with an average age of 30
years and 9 months.
2. Males (47.3%) and females (53.7%) were fairly equally distributed in both
gender-specific and coed programs offered at treatment centers.
3. The average treatment program length was 8.63 weeks, ranging from 4 to
16 weeks.
4. Participating clients returned for treatment an average of 2.11 times,
ranging from the current treatment being the first time (for 51.4% of
clients) up to 11 times (second to fifth time for 44.6%of clients).
5. Clients reported widely varying proficiency in their Native language; a rudi
mentary measure of adeptness put Native language competence at about
strength compared to other languages (predominantly English).
6. Male clients reported a higher dominance in their Native language over
another comparative language (e.g., English) than did female clients.
Data collection
Twelve treatment centers (21.82%) self-selected participation in the project by
accepting the invitation. This response was workable; treatment center staff
members are taxed on their time demand and clients are given priority. These
participating centers placed wellness at the forefront of addiction treatment
from a Native cultural perspective; almost all centers offered access to an Elder
(98%) and cultural practitioner (75%). Self-selection naturally ensured that
participating treatment centers subscribed to the philosophy of the project
and were engaged in assessment development by and for Indigenous peoples.
Data were collected over a period of 6 months in Year 3 of the study.
Projections of a 50%participation rate from participating treatment centers
based on the above annual intake numbers enabled rudimentary projection
based on cluster sampling. Clusters represented different regions, Indigenous
cultures, and client groups with respect to gender and age. The NWA vali
dation sample comprised m ¼177 volunteer clients from 12 treatment centers
and a 26%average
response rate based on original projection of the maximum
possible sample size. Plausible reasons for the realized response rate were as
follows: one treatment center had to close for building repair during the data
collection period; it was impossible to align the 6-months data collection per
iod perfectly with the treatment cycle of every treatment center; occupancy
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rates were rarely 100%—some clients arrived days after the planned
intake date and dropouts were common; out-patients living off-site were less
accessible than clients in residence in the data collection period; and adminis
tration enabling repeat assessments required additional time commitment.
The response rate was smaller than projected yet reflected circumstances
realistically. Regardless, the piloted sample composition was diverse and met
statistical sample requirements for exploring NWA validation.
A composite sample character equipped to handle parametric statistics
based on a minimum size of 100 respondents with approximation of a normal
distribution curve lends credibility to research findings as it enables appraisal
of test fairness and minimizes bias from known causes when it accurately
represents the target population; in this case, Indigenous peoples (American
Educational Research Association [AERA], American Psychological Associ
ation [APA], & National Council on Measurement in Education [NCME],
Schield, 1994).
During the data collection period, the NWA was completed at different
stages of client treatment, allowing for repeat assessments of the same clients.
This intentional design enabled researchers to test the NWA’s effectiveness in
reporting changes in wellness over time. Data collection allowed for 0–3 sur
vey completions based on self-report forms and observer forms as completed
by the client and/or a staff member, for a maximum of six possible iterations
per client. Most clients self-completed the NWA multiple times and/or were
assessed by staff members. This repeated effort resulted in an iteration-depen
dent sample of size n ¼471 completed surveys (Table 1). Only 10 of the 177
participating clients in the independent sample did not self-complete at least
once; a staff member completed on their behalf.
The NWA was developed to provide feedback on a person’s state of wellness
from the perspective of Indigenous culture. The NWA may be completed at
specific points in time: on entry (P1), midway (P2), and at exit of treatment
(P3). The NWA consists of a self-report form (S version) and a parallel
observer form (O version)—the first of its kind specific to Indigenous peoples.
When mental, physical, language and/or educational background constraints
prevent an individual from self-completing the survey, the parallel O version
can be completed by a staff member of the treatment center or someone close
to the client, such as a relative or a friend. Provision is made for verbatim
comments at the end of the form. The NWA takes about 15 minutes to com
plete. Flesch reading ease of the NWA statements for the S and O versions are
75.3 and 65.7 (easily understood by a 12-year-old and easily understood by a
14-year-old, respectively), and Flesch-Kincaid grade levels 5.6 and 7.3,
respectively (Flesch, n.d.). The NWA consists of statements and cultural
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intervention practices (CIPs). Together they expand the existing knowledge
base of wellness; apart they serve as controls and encouragement for each
The NWA contains 66 randomly ordered, concurrence-oriented cultural state-
ments, such as “My Native culture fuels my desire to live a good life,” “I go to
Elders to learn about our Native ways,” and “The client practices traditional
forms of sharing.” Respondents rate statements using a Likert-type scale
ranging from disagree (0) to strongly agree (4). Respondents are allowed to
opt for a don’t know option as a built-in validity indicator; during NWA devel
opment and item refinement, researchers worked to limit reasons for choosing
this option. Other built-in validity indicators with interpretational guidelines
in the NWA report are response inconsistency and social desirability.
Cultural intervention practices
NWA respondents are asked about their education or experience with a list of
common CIPs. Indigenous peoples from diverse treatment centers, nations,
and tribes identified the CIPs during NWA development by honoring the
cultural evidence base held within their tradition. A CIP can be described
as observable expressions of culture through language, speech, food and
medicines, rituals, rites, customs, teachings, and traditions, whereby cultural
values, beliefs, sentiment, relations, existence, and wisdom may be demon
strated and regeneration occurs in forms of healing, restoration, and renewal
toward wellness. The listed cultural interventions are not exhaustive; those
included in the NWA (Table
3) were practiced 15%–95%of the time before
assessment at P1–P3.
The NWA design can also accommodate completion following treatment
to examine long-term outcomes in wellness or in contexts not associated with
treatment. There is no technical limit to how often the NWA can be adminis
tered to an individual, although practically a minimum interval of three weeks
is recommended to allow for a treatment effect (if one exists) and to maintain
good test reliability. This suggested time interval maximizes the range and
average length of most treatment programs, minimizes carryover effects
Table 1. Breakdown of pilot data sample. Assessments were completed at different points in
treatment: P1¼ on entry; P2¼ midway; P3¼ at exit.
P1 (Entry) P2 (Midpoint) P3 (Exit) Subtotal S/O
S (Self) 91 102 88 281
O (Observer) 55 64 71 190
Subtotal P1–P3 146 166 159 471
Note. m ¼177 clients completed: n ¼471 surveys, either self or via observers, across three different points in
treatment. S ¼self-report form; O ¼observer form.
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from a previous completion (U.S. Department of Education, n.d.), and
accommodates a context in which measured change as a result of
treatment is desired in short order while allowing clients time to improve
their wellness.
For individuals, the Addictions Management Information System (AMIS)
enables automated scoring and direct reporting online. AMIS is a national
data management system available to a network of 55 NNADAP/YSAP addic
tion treatment programs in Canada, generally used for screening, assessment,
referral, and case management. Having the NWA in this national database
ensures centralized data collection for ongoing validation and reporting. A
paper version of the NWA versions is also available; responses can be cap
tured post facto for scoring and reporting. Plans are under way to provide
greater Indigenous community-based access to the NWA and standardize
the NWA according to growing national Indigenous norm groups in 2016/17.
Table 3. NWA cultural intervention practices (CIPs): NWA’s 39 CIP groups according to frequency
of practice among clients in the pilot study.
Group 1 (≥70%practiced) Group 2 (50%–69%practiced) Group 3 (<50%practiced)
Smudging Fishing/hunting Shaker/hand drum making
Prayer Spiritual teachings Naming ceremony
Sweat lodge ceremony Water as healing Water bath
Talking/sharing circle Use of sacred medicines Blanketing/welcoming
Nature walks Community cultural activities Cultural events/marches
Meaning of prayer Fire as healing Dream interpretation
Use of drum/pipe/shaker Storytelling Land-based/cultural camp
Sacred medicines Culture-based art Ghost/memorial feast
Use of natural foods Pipe ceremony Hide making/tanning
Ceremony preparation Sacred places Fasting
Cultural songs Use of Native language Horse program
Creation story Other taught/participated
Cultural dances/pow wow Other (name): ________________
Receiving help from traditional
Gardening, harvesting
Giveaway ceremony
Table 2. NWA structure formation: Distribution of the 66 statements in the NWA across the
quadrants of wellness and their subthemes.
Wellness quadrants and subthemes (66 statements)
Physical (body), creates purpose (18) Spiritual (spirit), creates hope (16)
Way of being (6) Belief (7)
Way of doing (9) Identity (6)
Wholeness (3) Values (3)
Mental (mind), creates meaning (17) Emotional (heart), creates belonging (15)
Intuition (6) Attitude (4)
Rational (4) Community (4)
Understanding (7) Family (4)
Relationship (3)
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Validation model
Cronbach (1988) and Messick (1988) argued for the importance of values,
which form a basis for assigning meaning and resulting in action, to be
infused in classical validation of psychometric assessments. In this study,
value derives from Indigenous culture. The terms value and valid share the
same Latin root, which means to be strong and is in support of a
strengths-based approach. Validity is mainly concerned with evidential verifi
cation of the meaning and implications of a measured construct, such as well-
ness. Validity is unitarily focused on justifying the construct being measured
(i.e., construct validation), accomplished through integration of complemen
tary forms of evidence (Messick, 1988).
Researchers viewed validation from a
unified framework as suggested by Gregory (1992) and Messick (1995) and
jointly endorsed by the AERA, APA, and NCME (1999).
In the 1980s this pragmatic framework was expanded from the classical vali
dation model described by Cronbach and Meehl (
). The unified model
denotes validation as an integrated evaluative process of gathering evidence
(following the classical validation model) about an assessment underpinned
by theory, to argue for and support the adequacy and appropriateness of
interpretation and applications based on assessment findings; i.e., to consider
their consequences also (Cronbach, 1982, 1988; Messick, 1989; Strauss &
Smith, 2009). The validation framework guided researchers to employ an inte
grated evaluative judgment of six aspects as much as possible through NWA
development, beta testing, and piloting. These six aspects conjointly function
as general validity criteria or standards for all educational and psychological
1. Content relevance and representation: soundness in construction of the
NWA attributes and their dimensionality (i.e., quadrants, subthemes,
descriptors) in terms of relevance to and representation of the Native well
ness domain. Does the NWA content appear to be measuring wellness and
can it do so consistently?
2. Response processes and regularity: empirical verification and strength of
the substance contained in the NWA through an appropriate sampling of
statements and CIPs as they relate theoretically and structurally to wellness.
Is the theoretical foundation—culture—underlying wellness sound as pro
filed by NWA scores?
3. Score structure: rational consistency in NWA quadrant and subtheme
scoring and results presentation with what is postulated about the wellness
construct domain. Do the interrelationships of the NWA attributes—
quadrants, subthemes, descriptors—correlate with each other and with
overall wellness?
4. Generalizability and fairness: provision of representative coverage of well
ness through the NWA among Indigenous peoples with present addictions
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and in recovery of addictions, with potential for wider identified applica-
tions. Does the NWA generalize across different groups, settings, and
5. Relation to other variables: appraisal of the degree to which the low, high,
and interactive NWA attribute scores are mirrored by external indicators of
wellness, whether assessed or nonassessed yet implicit. Does the NWA have
convergent, discriminant, and predictive qualities?
6. Intended and unintended consequences: enablement and accrual of positive
implications as a result of NWA use as well as evidence that adverse conse
quences and test bias are minimal. Does the NWA have merit despite poten-
tial risks if scores are invalid or inappropriately interpreted?
In answering these six criteria, researchers provided essential empirical
validation evidence including content and construct validity under the classi
cal model as detailed in the next sections and a dimensionally sound scientific
basis for accurately interpreting NWA scores and considering their implica
tions. These extensive criteria are backed by strong scientific argument for
addressing all of them in test development and validation.
Cizek, Rosenberg, and Koons (
) conducted a review of the BUROS
Sixteenth Mental Measurements Yearbook sourcing validity evaluations
for 283 published measures (many of which were longstanding), focusing
on conformity to traditional versus modern validity theory and sources of
validity evidence typically reported. They found that evidence sourced
specifically by construct, concurrent and content validity (i.e., aspects 3,
4, 5, and 1) featured roughly half the time; with consequences and evidence
sourced as related to response processes (i.e., aspects 6 and 2) appeared
close to 1%and 2%of all cases. Sources from the classical model of vali
dation were routinely favored above others, likely because more test authors
followed that model in years past, and many test authors may have been up
against practical constraints such as higher cost and time associated with
getting long-term cooperation from people and organizations and reliance
on others for gathering data sourced from multiple samples. Furthermore, it
is difficult to synthesize empirical evidence with theoretical rationales
founded in values and meaning (Cizek, Bowen, & Church, 2010
on the first plausible reason, Cizek et al. (2010) replicated this
study. They used two data sources: 1,007 more recently published articles
in eight esteemed applied measurement and testing journals and 326 articles
published at the last two annual meetings from the AERA, APA, and NCME
at the time. In 1999, these associations jointly published 264 distinct standards
for validation based on the unified framework. The authors arrived at the
same conclusion as their colleagues.
Since Messick’s (1989) influential chapter on the topic, evidence based on
assessment consequences was tacitly ignored or largely underreported for 25
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years. Researchers have long advocated for addressing validation in a unified
manner, placing the responsibility in both academic and applied settings. The
persistent disparity in validation practices can be addressed by detailing evi
dence and considering consequence in all test development and validation
steps and continuing scrutiny of intended and unintended implications of
testing in longer-term planning and publication of ongoing validation
research. This call for action also requires innovative approaches to the num
ber and types of sources used for validation, especially when health and social
consequences are at stake (Hubley & Zumbo, 1996;
Messick, 1989).
Project researchers used the standards nonprescriptively in response to the
evolving field since the classical validation model was described by Cronbach
and Meehl (1955). It is hoped that this article will encourage more research
ers to use and integrate complementary forms of evidence to construct vali-
dation in efforts to break current trends in validation practices. The AERA,
APA, and NCME (1999) cautioned that evaluation of the acceptability of an
assessment and its application “does not rest on the literal satisfaction of
every standard and acceptability cannot be determined by using a check
list” (p. 4). Application of fragmented, unitary approaches to scientific devel-
opment and validation of psychometric assessments that are unified in the
context of consequences is helpful (Fairchild, 2013).
The next sections
provide opportunity for traditional psychometric appraisal, expanded by
judgments about practical relevance and utility of the NWA for user cost
benefit. Evidence and consequence of measured wellness underpinned by
cultural values are offered within rational organization of NWA development
and validation.
Statistical validation of the NWA piloted data comprised a range of standard
descriptive, inferential, and multivariate analyses assuming an asymptotic (i.e.,
closely) normal distribution, using SAS software. Chi-square contingency
associations were computed to display the demographic character of the sam
ple. These were followed by Student t tests for variables with two categories (e.
g., male and female) and general linear modeling (ANOVA) with Sheffé’s post
hoc analysis for variables with multiple categories to explore potential test bias
while accommodating unequal sample sizes. Significance of p < .05 was used
as guideline for interpreting differences in comparative scores. Responses to
statements were treated at the interval scale level of measurement to allow
adding, subtracting, and weighing in scoring. The six iterations were analyzed
separately. Select findings at overall, quadrant, and subtheme levels are dis
cussed here. (Detailed results are available upon request.) Possible implica-
tions of every step in NWA development were scrutinized by a diverse
project team member base and by the communities involved.
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Content relevance and representation in NWA development
The project team included project and territory Elders, Indigenous knowledge
keepers and users, experts in the field of addictions and/or Indigenous
culture-based treatment across Canada, and contractors (Figure 1), ensuring
a rich and relevant knowledge base in both academic and applied settings.
Research principles were established at the first large group meeting in Year
1, ensuring endorsement of self-determination practices throughout the pro
ject. Ownership, control, access, and possession remained with Indigenous
peoples through rigorous sequential timelines (Crooks, Snowshoe, Chiodo,
& Brunette-Debassige, 2013;
Streiner & Norman, 2008). Researchers followed
rigorous assessment development practices by incorporating justified pro
gression in statement generation and refinement, with continuous input from
treatment center staff and clients along the way.
Construct scoping
The primary source of information for initial statement development was
generated through environmental scan focus groups with 12 NNADAP/YSAP
treatment centers across Canada. The two-day focus groups took place over 4
months in Years 1 and 2 and involved treatment center staff, community
participants, and Elders. The project Elder led these sessions, beginning with
the Creation Story as a platform to facilitate in-depth conversation about the
meaning of wellness and about cultural interventions toward wellness. The
Figure 1. Research project outline: Three-year outline specifying the project timeline and role of
main collaborator groups.
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conversations were founded on Indigenous values of giving before asking. This
ensured the interactions were mutually beneficial at all times while adhering to
Indigenous community standards grounded in traditional knowledge advocated
by Gone (2012). A wealth of stories and topics was offered by community-based
researchers and community members from each participating treatment center.
Numerous CIPs used in treatment centers across Canada were gathered along
with their meaning of origin to help grasp culture-as-intervention. No data were
captured on the rituals or the process for conducting cultural interventions in
recognition that cultural practices come from a spiritual foundation. CIPs were
linked to their story of origin or cultural society to qualify as Indigenous. Part
icipants had an opportunity to verify the data captured during focus groups.
Domain identification
A smaller, core Indigenous knowledge group (IKG) of researchers sorted this
information first in emergent, inductive fashion, followed by a deductive
approach grounded in the project definition of wellness. The IKG worked
with another group of project researchers who independently coded the
focus-group information using NVivo qualitative data analysis software
(Miles & Huberman, 1994) to inform the themes that emerged from the
IKG work and establish construct validity in NWA development from the
perspective of two-eyed seeing. Each small work group represented research
ers with either subject-matter expertise or direct project involvement, or both.
Statement generation
Researchers further established and grounded domain identification through
the quadrants of wellness and the combined efforts from focus-group results.
The construct was comprehensively represented through initial statement
generating following a model of inclusiveness; all emergent ideas were con
sidered equal at this point. Researchers presented a set of culturally rooted
descriptions at a large gathering in Year 2. The IKG grouped the descriptions
that formed the statement pool of 256 self-report statements, with matching
or paired observer statements, into 47 descriptor labels containing 1–12 state
ments each. Organization into the different levels ensured measurable dimen-
sionality within the construct domain of wellness.
Structure formation
The statement pool and descriptor labels provided a solid base for developing
a structure formation in NWA development (Table 2), yielding 13 subthemes
among the quadrants. Attending to assessment length while allowing for a
sufficient number of items to assess the construct, the statement pool was
synthesised into 66 statements of low content redundancy. Statements were
worded in the same direction; their effect on the response set weighed against
the keystone that culture implies strength in wellness. Each item was used
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once only in scoring, which comprises (a) a summative process and (b) con-
version to an interpretable percentage score as an extension of the scaled raw
values that vary in range depending on the number of statements in each.
Percentages set the baseline at 100, which is familiar to most and whereby
scores can be directly compared within and across reports.
A list of CIPs was developed alongside the NWA statements. CIPs that are
both commonly practiced and specific to nation and gender were described
during the focus groups in Year 1. Researchers considered the CIPs from
the perspectives of teaching, participation, and experience in Year 2 to reach
consensus on the list. Nomenclature was standardized with input from treat
ment center directors, staff, and clients as outlined previously. NWA state-
ments and CIPs, as two different systems of inquiry, keep each other in
check and as a consequence bring forward and make visible their underlying
values and assumptions in the NWA structure formation (Moss, 1998
Rational expert judgment
Collaborator team gatherings relied on cultural, practical, psychometric, and
statistical expertise to further refine these 66 statements and address content
validity through five progressive opportunities. These included, among other
1. Fine tuning of psychometric properties of statements and their response
format, incorporating qualitative and quantitative item analysis based on
expert feedback and testing;
2. Initial beta testing and quantitative scrutiny of the responses and verbatim
comments from a sample of 36 clients at different participating treatment
centers as the target population;
3. Simplification of statement wording to address ease of readability; and
4. Relevance of and client identification with statement content.
The process of assessment development and validation is also described in
the NWA user’s manual available from NNAPF
A list of 52 CIPs was piloted; participants were asked to check all cultural
interventions they practiced recently. The list was then further reduced to 39
CIPs and grouped according to frequency (Table 3). Care was taken to
moderate the effect of seasonal CIPs in alignment with treatment cycles across
the three groups. The question format was refined from the dichotomous
check/no-check response to a rating scale of clients’ strength of connection
to each, ranging from weak (1) to strong (3), including a did not practice
response option in closer alignment with the successful response format used
for the statements upon piloting. This permitted greater insight into the effect
of CIPs in wellness.
Related, the NWA is supported by a free step-by-step client activity guide and facilitator’s handbook for service
providers and their clients (
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Empirical testing
The NWA was piloted in Year 3. During piloting, participating clients
were assessed with the NWA only. The statistical examination of statements
and CIPs at six different iterations ([S, O] x [P1, P2, P3]) helped researchers
establish cross-referenced validation evidence for the NWA during a 2-day dis
cussion of a comprehensive technical report of statistical tables (Fiedeldey-Van
Dijk, 2015).
Items were analyzed to establish their psychometric properties,
unimodality, and response distribution; internal consistency, and correlation
to total; structural and content validity; and power to discriminate between dif
ferent demographic groups. Scored items were analyzed at the levels of quad-
rants, subthemes, and descriptors to determine their interpretational feasibility
and comparability (i.e., convergent validity) between self- and observer reports
and divergent validity over time in the context of expected changes as a result of
treatment. The progressive process of assessment development and validation
based on piloted data enabled researchers to refine the NWA where needed
and concluded the project with an edition of NWA including S and O versions
that are fit for use in NNADAP/YSAP treatment centers and beyond.
NWA content relevance and representation demonstrated in reliability
Comparisons of self-report and observer versions
The sample of 471 completed NWA surveys from 177 participating clients
across the three treatment points enabled calculation of Pearson product-
moment correlation coefficients between the S and O versions (Table 4).
Correlations between the NWA-S and NWA-O at P1–P3 treatment points were
statistically significant (p < .001) and moderate, indicating response accuracy
and convergent validity between versions while allowing for discussion of differ
ent perspectives that may incite further learning (Mersman & Donaldson, 2000).
Internal consistency
Using Cronbach’s coefficient alpha, researchers found internal consistency to
be generally high, regardless of the varying number of statements in each sub
theme (
5), averaging at 77.8, 78.6, and 81.1 for the S-version subthemes
across P1–P3, and correspondingly at 84.8, 85.2 and 84.2 for the O-version
subthemes. Subthemes with either a lower (<.70) or higher (>.90) coefficient
led researchers to identify and revise statements in pursuit of a consistent
Table 4. NWA self- and observer correlation over time: Pearson product-moment correlation
coefficients between the self (S) and observer (O) versions of the NWA.
Six iterations Entry (P1) Midpoint (P2) Exit (P3)
Correlation between S and O versions 0.61 0.51 0.61
Note. S ¼self-report form; O ¼observer form. Assessments were completed at different points in treatment:
P1 ¼on entry; P2 ¼midway; P3 ¼at exit.
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correlation with the total across statements (Gliem & Gliem, 2003; Tavakol &
Dennick, 2011), thereby addressing those with comparatively weaker
correlation and those with statistical and conceptual indications that signaled
redundancy between statements.
Intercorrelation matrices
Pearson’s product-moment correlation coefficients were computed among the
quadrants, subthemes, and statements for all six iterations. Given space
restrictions, two of the matrices S_P1 and O_P3 at the quadrant level are
presented in Table 6, representing one of S and O each at the beginning
Table 5. Internal consistency of the NWA: Cronbach’s coefficient alpha for quadrants and
subthemes in the NWA.
Quadrant subthemes S_P1 S_P2 S_P3 O_P1 O_P2 O_P3
Spiritual 0.92 0.91 0.93 0.96 0.96 0.93
Belief 0.87 0.87 0.88 0.93 0.94 0.90
Identity 0.84 0.82 0.88 0.86 0.89 0.89
Values 0.61 0.63 0.59 0.75 0.80 0.62
Emotional 0.91 0.92 0.93 0.95 0.95 0.94
Attitude 0.84 0.84 0.86 0.87 0.88 0.91
Community 0.71 0.82 0.81 0.89 0.83 0.84
Family 0.71 0.70 0.75 0.83 0.88 0.87
Relationship 0.65 0.67 0.75 0.75 0.78 0.85
Mental 0.95 0.95 0.93 0.97 0.95 0.93
Intuition 0.83 0.87 0.84 0.95 0.88 0.88
Rational 0.80 0.84 0.81 0.90 0.85 0.86
Understanding 0.89 0.87 0.89 0.92 0.86 0.79
Physical 0.92 0.93 0.92 0.96 0.96 0.94
Way of being 0.78 0.83 0.82 0.87 0.86 0.82
Way of doing 0.91 0.89 0.89 0.95 0.93 0.91
Wholeness 0.68 0.57 0.77 0.56 0.69 0.81
Note. S ¼self-report form; O ¼observer form. Assessments were completed at different points in treatment:
P1 ¼on entry; P2 ¼midway; P3 ¼at exit.
Table 6. Partial Correlation Matrix of NWA Quadrants Examples of Pearson product-moment
correlation coefficients (r) between the two NWA versions taken at different points across the
quadrants of wellness
Pearson’s r
% Spiritual % Emotional % Mental % Physical
S_P1 S_P1 S_P1 S_P1
S_P1 % Spiritual 1.0000
S_P1 % Emotional 0.8622 1.0000
S_P1 % Mental 0.8997 0.8432 1.0000
S_P1 % Physical 0.8999 0.8613 0.9186 1.0000
% Spiritual % Emotional % Mental % Physical
Pearson’s r O_P3 O_P3 O_P3 O_P3
O_P3 % Spiritual 1.0000 0.9626 0.9661 0.9544
O_P3 % Emotional 1.0000 0.9645 0.9428
O_P3 % Mental 1.0000 0.9501
O_P3 % Physical 1.0000
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and end points of treatment respectively, chosen based on respectable sample
sizes. (All six matrices can be provided upon request.) Overall, very high
coefficients were found at the quadrant level. This suggests that the wellness
quadrants are inseparable. By contrast, intercorrelations at subtheme level
were found to lie on average at approximately r ¼0.50 with considerable
variation. Researchers used correlation coefficients <.30 or >.70 as a guide
in pinpointing specific statements in identified subthemes, which required
further refinement in wording. Statistics of corresponding statements in S
and O versions served as a helpful additional steer for item refinement.
Approximately one third of the statements underwent refinement, reinforcing
the scope and soundness of the NWA structure at quadrant, subtheme, and
descriptor levels and improving item reliability.
NWA response processes and regularities shown in wellness profiling and
treatment effect
Reported states of wellness
Descriptive scores across the six iterations for overall wellness and the CIPs
are outlined in Table 7. Clients scored themselves more consistently around
the reported average of low 80%; observer scores lay at mid-60%on average.
The average difference of 18.92%across the quadrants at P1–P3 is consistent
with 360-degree comparisons based on formative response scales in general
(Howard, 1980; Tornow, 1993). Average wellness score differences between
S and O versions contain diagnostic utility: Comparatively high average client
scores may signal strong needs to identify with Indigenous culture despite
what observers may evidence. For CIPs, mean scores were found to be low
50% for clients and low 60% for observers across P1–P3, rendering a
Table 7. NWA descriptive statistics of wellness and the cultural interventions practices: Overall
wellness and CIP scores as reported by clients and observers during treatment.
n Mean SD Std error Skewness Kurtosis
Overall wellness
S_P1 %Wellness 91 76.80 18.41 1.93 0.91 0.72
S_P2 %Wellness 102 82.21 17.09 1.69 1.32 1.86
S_P3 %Wellness 88 84.17 16.26 1.73 1.33 1.97
O_P1 %Wellness 55 50.94 24.62 3.32 0.34 0.96
O_P2 %Wellness 64 64.64 21.55 2.69 0.42 0.67
O_P3 %Wellness 71 70.99 22.51 2.67 0.80 0.38
Overall CIPs
S_P1 %CIPs 91 49.75 24.47 2.57 0.05 0.97
S_P2 %CIPs 102 54.92 23.85 2.36 0.16 0.81
S_P3 %CIPs 88 52.41 20.73 2.21 0.09 0.55
O_P1 %CIPs 55 60.72 20.36 2.74 0.49 0.68
O_P2 %CIPs 64 61.46 19.14 2.39 0.32 0.57
O_P3 %CIPs 71 64.84 14.03 1.66 0.30 0.09
Note. S ¼self-report form; O ¼observer form; n¼number of surveys. Assessments were completed at
different points in treatment: P1 ¼on entry; P2 ¼midway; P3 ¼at exit. Std error ¼standard error of the
mean (sampling error); SD ¼standard deviation; CIPs ¼cultural intervention practices.
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10.02%average difference in the opposite direction as before at P1 and P2.
Contextualization of these differences suggests that the two NWA versions
have statistical and practical merit in addictions treatment context, when
applied either separately or together.
Clients achieved slightly lower scores in the physical quadrant than in the
other three (Table 8). Consider that the physical quadrant creates purpose
(Table 2) as captured in three subthemes: ways of being (exercising responsi
bility, learning about the relationship with Spirit, consequential thinking),
ways of doing (balance and health through food, cleansing and being active,
communication, sharing, and expression of gratitude), and wholeness (nur
turing one’s whole being and knowing where one comes from). Lower scores
in the physical quadrant suggest that until the NWA is standardized, users
may need to ease up slightly in assigning literal value and meaning to physi
cal-quadrant scores in comparison to scores of the other three quadrants.
An increase in average scores over time signals that the NWA measures a
positive change in wellness during the course of treatment (Figure
2), as is
desired for clinical utility. Table 8 and Figure 2 illustrate average wellness for
partially independent client groups at each point in treatment, some of whom
may have taken the NWA for the first time at P2 or P3. Since data dependen
cies and potential carryover effects are reduced in this comparison, findings in
Table 8. NWA wellness at quadrant level: Quadrant scores of wellness as reported by clients and
observers during treatment.
Cultural quadrants n Mean SD
S_P1 %Spiritual 91 78.84 18.03
S_P1 %Emotional 91 78.54 18.94
S_P1 %Mental 91 76.73 19.92
S_P1 %Physical 91 74.01 19.53
S_P2 %Spiritual 102 83.66 16.97
S_P2 %Emotional 102 83.66 17.34
S_P2 %Mental 102 82.56 19.10
S_P2 %Physical 102 79.74 17.85
S_P3 %Spiritual 88 86.00 15.02
S_P3 %Emotional 88 83.66 15.95
S_P3 %Mental 88 83.67 18.49
S_P3 %Physical 88 81.64 17.78
O_P1 %Spiritual 55 51.52 24.82
O_P1 %Emotional 55 53.64 24.68
O_P1 %Mental 55 50.24 26.17
O_P1 %Physical 55 48.69 24.63
O_P2 %Spiritual 64 65.77 23.14
O_P2 %Emotional 64 68.43 21.44
O_P2 %Mental 64 63.21 22.31
O_P2 %Physical 64 61.73 21.37
O_P3 %Spiritual 71 72.51 22.64
O_P3 %Emotional 71 73.33 23.67
O_P3 %Mental 71 69.82 23.04
O_P3 %Physical 71 68.81 22.32
Note. S ¼self-report form; O ¼observer form: n¼number of surveys. Assessments were completed at
different points in treatment: P1 ¼on entry; P2 ¼midway; P3 ¼at exit. SD ¼standard deviation.
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Table 8 imply that the NWA can be used at different points during treatment,
expecting average scores to shift upward somewhat with time into treatment.
Significant change in wellness over time
Treatment effectiveness was determined through calculation of differences in
scores (deltas) between P1, P2, and P3 where repeat assessments were com
pleted. Client data with a one-time NWA completion are excluded here with
smaller sample sizes in analysis as a result. A delta of 0
no change
in wellness over time. Patterned Student t-test results (one-tailed, p < .025)
revealed that significant positive change occurred in all four quadrants over
the course of treatment, demonstrating developmental utility. At P2 in parti
cular, observers had already started to see change in wellness where clients
had not. Overall, clients reported an average change in wellness across all poss
ible P1, P2, and P3 deltas of 4.80
, compared to 14.56%for observers. Found
deltas by themselves imply that the NWA is sensitive to change. Note that the
deltas in Table 9 are larger than NWA time-point differences described above
Figure 2. NWA wellness at quadrant level: Visual depiction of wellness as reported by clients
and observers during treatment.
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in relation to Table 8. This latter comparison indicates that the NWA is able to
measure treatment effectiveness.
The delta differences are echoed by an increase in CIPs, as evident by the
statistically significant deltas (p < .025 for increased CIPs on average). Found
significance in CIP deltas were largely attributed to smaller standard deviation
scores with progress in treatment; clients increasingly conformed to practicing
cultural interventions. In other words, clients who practiced cultural interven
tions at the start of treatment did not necessarily increase the number of prac-
tices, but those who did not practice much or at all at P1, increased their
number of practices by P3.
The findings indicate that the increased conformity in CIPs and the
increase in quadrant scores toward wellness from P1–P3 make a strong case
Table 9. Treatment changes in NWA wellness and CIPs over time: Pattern of significant positive
change in quadrants of wellness and cultural intervention practices as reported by clients and
observers during treatment.
n Mean Δ SD t Prob>|t|
Quadrant changes
S P3-P1 Spiritual 46 10.83 15.46 4.75 0.0001**
S P3-P1 Emotional 46 11.10 13.46 5.59 0.0001**
S P3-P1 Mental 46 12.84 14.36 6.06 0.0001**
S P3-P1 Physical 46 13.63 14.52 6.37 0.0001**
S P3-P2 Spiritual 56 0.98 10.82 0.68 0.5018
S P3-P2 Emotional 56 0.17 10.76 0.12 0.9088
S P3-P2 Mental 56 0.04 13.79 0.02 0.9820
S P3-P2 Physical 56 1.79 11.17 1.20 0.2358
S P2-P1 Spiritual 38 2.46 13.11 1.16 0.2548
S P2-P1 Emotional 38 4.01 13.59 1.82 0.0770
S P2-P1 Mental 38 5.24 14.92 2.17 0.0368
S P2-P1 Physical 38 6.32 15.00 2.59 0.0135*
O P3-P1 Spiritual 25 32.53 22.44 7.25 0.0001**
O P3-P1 Emotional 25 29.99 21.11 7.10 0.0001**
O P3-P1 Mental 25 31.95 21.42 7.46 0.0001**
O P3-P1 Physical 25 32.74 22.64 7.23 0.0001**
O P3-P2 Spiritual 44 9.80 19.14 3.40 0.0015**
O P3-P2 Emotional 44 8.50 18.30 3.08 0.0036**
O P3-P2 Mental 44 11.06 19.61 3.74 0.0005**
O P3-P2 Physical 44 11.63 17.46 4.42 0.0001**
O P2-P1 Spiritual 24 19.93 21.80 4.48 0.0002**
O P2-P1 Emotional 24 19.78 23.03 4.21 0.0003**
O P2-P1 Mental 24 17.15 22.28 3.77 0.0010**
O P2-P1 Physical 24 20.78 22.74 4.47 0.0002**
CIP changes
S P3-P1 CIPs 46 9.07 23.16 2.66 0.0109*
S P3-P2 CIPs 56 4.60 15.42 2.23 0.0297
S P2-P1 CIPs 38 1.00 21.44 0.29 0.7758
O P3-P1 CIPs 25 7.93 10.03 3.95 0.0006**
O P3-P2 CIPs 44 2.74 11.39 1.59 0.1185
O P2-P1 CIPs 24 6.01 5.59 5.26 0.0001**
Note. S ¼self-report form; O ¼observer form n ¼number of surveys. Assessments were completed at
different points in treatment: P1 ¼on entry; P2 ¼midway; P3 ¼at exit. Change between two treatment
points is expressed as delta (Δ). SD ¼standard deviation; t ¼Student’s t statistic for testing the hypothesis
that the population mean is 0. Prob, p ¼probability.
*p < .025; **p < .005; specified as one-tailed or directional to test the significance of positive change.
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for claiming that the NWA is able to demonstrate the importance of culture-
as-intervention toward wellness.
NWA score structure exploration
Exploratory factor analysis (EFA)
The factor structure of the NWA was statistically explored through principal
components analysis of the six iterations of data since the cultural underpin
ning for wellness was not used in measurements in general and in the NWA
specifically until now. In light of the subject-to-variable ratio of 177:66 or
2.7:1, interpretative caution was exercised where subsample sizes dip markedly
below 100 (e.g., O_P1 and O_P2). Varimax rotation—an orthogonal (i.e., per
pendicular) process whereby survey statements are optimally set at right angles
—was applied to effectively address correlation between cultural statements
and to aid in interpretation of resulting factors. Results strongly support one
overarching factor—wellness. Both the scree plot and Eigenvalue criterion of
minimum 1.00 suggested an interpretable 9–14 factor solution depending on
the iteration, with factor loadings generally above 0.40 (
Closer inspection of statements within multiple factor loadings disclosed
that they grouped along different cultural concepts. The findings support the
propositioned deeper underlying structure for the quadrants, subthemes,
and descriptors as outlined. This structure formation of wellness serves as
organization for the theoretical foundation of the NWA. The EFA results
suggest Indigenous culture, which lies at the apex of Native wellness, can
be used for measuring and tracking Indigenous peoples’ wellness while in
treatment for addictions. The foundation for a whole and healthy person
as a desired outcome is culture-as-intervention. It is acceptable to use the
quadrants and subthemes for wellness reporting and development because
culture was found to be embedded in every aspect of the wellness structure
Table 10. Stability in the NWA factor structure across S and O versions and time: Consistency in
the number of factors identified from the 66 statements in each iteration and the variance these
factors explain.
Interpretable factor solution Number of factors Percentage variance explained
S_P1 13 57.11%
S_P2 12 55.46%
S_P3 9 55.79%
O_P1 9 59.76%
O_P2 12 55.64%
O_P3 14 56.78%
Note. S ¼self-report form; O ¼observer form. Assessments were completed at different points in treatment:
P1 ¼on entry; P2 ¼midway; P3 ¼at exit.
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Generalizability and fairness of the NWA
The NWA was statistically analyzed to ensure and confirm fairness among the
different demographics (gender, broad age category, favoring of Indigenous
language, treatment return times, and length of the treatment program) at
the six iterations. Significant differences in average scores for demographic
groups yielded summative insights described later. Differences are best read
against the baseline of total sample mean scores for overall wellness and CIPs
provided in Table 7.
Male clients practiced 5%–10%more CIPs than female clients, and under-
18-year-olds checked fewer CIPs than older age groups. (Some CIPs are
gender and/or age restricted.) Clients with Indigenous-language dominance
checked 7%–11%more CIPs than their counterparts. A similar number of
CIPs were practiced regardless of whether clients were in treatment for the
first time or repeatedly. Clients in longer treatment programs practiced more
CIPs. (Observers noted more CIPs than clients in short treatment programs
specifically.) In scrutinizing demographic fairness when applying the NWA,
foreseeable gender-based exceptions were found in NWA quadrants and sub
themes. Females reported lower emotional community; males reported lower
mental intuition (
3). Another notable exception was that when all
results were considered together, those under18 years of age scored lower
in wellness than older clients. Finally, length of the treatment program mat
tered significantly to change in wellness. Overall, wellness as measured
through the quadrants and subthemes in the NWA rendered no statistically
significant gender, age, or treatment return-time differences. This underscores
the fairness of assessing clients in addiction treatment with the NWA.
Efforts to improve wellness are critical for recovery and healing from addic
tions. Researchers theorized about and empirically demonstrated the role of
Indigenous culture and cultural intervention practices (CIPs) as an underpin
ning for wellness at all levels through the development and validation of the
Native Wellness Assessment (NWA
). The psychometric and utility merits
of the NWA were detailed within the unified validation framework. Specifi
cally, evidence was provided based on (1) relevance and representation of test
content, (2) regularities in survey statement responses, (3) feasibility of the
internal score structure, and (4) generalizability and fairness, with some refer
ences to test consequences as far as the NWA enables users to consider impli-
cations. Comments on evidence based on (5) relation to other variables and
(6) intended and unintended consequences still remain and are offered as lim
itations and suggestions for ongoing research. Researchers showed that the
NWA addresses a gap in the field for an Indigenous assessment that can be
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used and repeated in addictions treatment and other Indigenous contexts as
bolstered by culture-as-intervention.
The power of culture-as-intervention
The results’ repeated emphasis on culture as underpinning for wellness
deserves attention. From an Indigenous worldview, a singular culture does
not exist. Indigenous nations have distinct sacred knowledge, beliefs, and tra
ditions, although commonalities may be similar among them (Lowe, 2002).
these are asserted, they may aid in fostering the renaissance of Indigen
ous culture (Cunningham & Stanley, 2003),
achieve reconciliation, and sup
port the implementation of cultural intervention practices (CIPs) effectively
in treatment and community-based programs. At a communal base, culture
is a way of human life as variously expressed in spiritual, psychological, social,
and material practices in order to create hope, belonging, meaning, and pur
pose in balance. This mirrors the project definition of wellness. Indigenous cul-
ture is embedded in the land, language, and nation of peoples and, most
importantly, in the unique experiences of culture-as-intervention, which
prompts reflection and internalization.
Unified concepts of culture
Taking this base a step further, Dumont (2014) identified primary unified
concepts that describe Indigenous culture. These commonly held cultural
concepts underpin wellness and, upon close inspection, were found to rep
resent some of the factor loadings of this research. They are paramount in
appreciating that
1. Life on Earth is fundamentally seen as centrally bonded though a caring
Spirit, which is in and throughout all life and Creation and so all life is
motivated by Spirit;
2. The circle, more than any other symbol, is most expressive of the Indigen
ous worldview and denotes a continuous flow of life, as is wellness;
3. Indigenous culture is virtuously voiced and transmitted through original
4. All universal things (human and nature) are inclusively relational and con
nected as personhood; and
5. Throughout continuous stages of life, everybody is predisposed to have the
desire to be respectfully harmonious and in balance with Creation.
Indigenous culture-as-intervention was articulated and communicated
through culturally specific spirit-heart-mind-body NWA statements. Grouped
as different subthemes within the four quadrants or directions of the Sacred
Medicine Wheel, these statements can indicate a person’s present or developing
state of wellness. Since CIPs are Indigenous expressions of spirit-heart-
mind-body at work, wellness can be achieved through Indigenous cultural
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intervention practices also. These understandings are critical to the develop-
ment and validation of the NWA as a measure of wellness with cultural
underpinnings. As an Indigenous construct, wellness is an inclusive state or
position of balance, wherein spirit-heart-mind-body work together through
the primary, unified concepts of culture. This renders culture, in and by itself,
as an intervention toward wellness through expressions (CIPs) and behavior
(cultural statements). Hence, culture-as-intervention is written as a hyphenated
phrase to denote one concept at the apex of wellness instead of as three separate
words as one would do in the context of a research experiment. It also implies
that when culture-as-intervention lies at the apex of treatment programs
for addictions, the NWA can be used to facilitate and monitor the process
over time.
Validation insights and strengths
Both the self-report (S) and observer (O) versions brought value to the
NWA and insights about clients in treatment for addictions. Clients consist
ently scored themselves more highly on entry to treatment, which may have
a ceiling effect and could indicate early willingness to self-identify with
Indigenous culture when observers stand more critical toward demonstrable
cultural identification as it pertains to wellness. Observers tended to score
clients higher in wellness during treatment than the clients did themselves,
reporting a greater change more quickly. However, observers’ scores
remained consistently below the clients’ own. Staff’s desire to see positive
change as evidenced in comparatively high R
at P2 may have biased obser-
vers midtreatment, although their experience of client progress in treatment
and quicker perception of signs of progress in wellness may have kept their
observations in check. Self- and observer scores were strongly aligned at exit
from treatment. Differences in S and O scores underscore the importance of
initiating a conversation with clients about differences between their self-
perceptions and staff observations to qualify perspectives, further develop
client self-awareness, and capitalize on another opportunity to learn about
the client. Sharing the results of both versions with clients midway through
treatment could encourage them to see that their wellness is improving, that
they are doing well.
The quadrants of wellness are interconnected and inseparable from within
an Indigenous worldview. One could argue that the reported internal consist
ency and correlations (r >
0.85) do not signal redundancy, but rather indicate
the spirit-heart-mind-body at work interactively. When a cultural practice
helps release the body from the effect of an addiction, the benefit circles fluidly
through the bonded connection of spirit, heart, and mind as well. Culture-as-
intervention simultaneously underpins all quadrants, rendering the reported
high correlations as desirable. Distinguishing between the spiritual, emotional,
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mental, and physical has discerning value but becomes arbitrary when living
one’s life from within an Indigenous worldview. This helps explain and justify
why combinations of all four quadrants and 13 subthemes were interspersed
throughout the cultural factors. The cultural statements as grouped by explora
tory factor analysis (EFA) appeared to subscribe more closely to the primary,
unified concepts that describe Indigenous culture and can be taught and prac
ticed in addiction treatment. Indigenous culture itself is viewed as a continuous
critical intervention in a person’s journey toward wellness via the quadrants,
subthemes, and CIPs.
Culture-as-intervention weaves through all quadrants toward wellness.
Together, the quadrants and CIPs form an intricate balance in pursuit of well
ness through the primary, unified concepts of culture. Reported quadrant,
subtheme and CIPs averages expressed as percentages and mean differences
between them set interpretational guidelines early on when (a) a norm base
is growing and (b) further research is planned, paving the way for standardi
zation of NWA scores in the near future for use in the context of addictions
treatment and for general applications. Quadrants, subthemes, and CIPs
scores can also motivate further land-based activity, instigate longer-term
residential funding, and argue for incentives toward better food quality and
gardening programs at treatment centers, incorporating the inclusion of
Indigenous knowledge and skill of cultural practitioners as necessary in the
workforce addressing substance use.
Limitations and opportunities
NWA validity is well demonstrated through the first four of six aspects of the
unified validation model. The remaining two aspects signal future opportu
nities for ensuring continual NWA validation.
Relation to other variables
More factors were statistically identified than the five named and described in
the project definition of culture (see Dumont, 2014). Results suggest that there
is possibly room to expand the number of primary, unified concepts in the
culture definition through additional careful reflection in collaboration with
Indigenous knowledge keepers and/or further breakdown of the present five
unified cultural concepts. A smaller number than 13 cultural factors may be
considered for appraisal through confirmatory factor analysis (CFA) in
ongoing research.
The NWA structure’s convergence and divergence with other measures
of both culture and wellness were not explored during piloting and will be
a valuable addition to ongoing NWA validation endeavors. For convergent
validity, the two measures identified in the scoping review—the American
Indian Cultural Involvement Index (Boyd-Ball et al., 2011) and the
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Cherokee Self-Reliance Questionnaire (Lowe et al., 2012)—may be reason-
able contenders, along with the Orthogonal Cultural Identification Scale
developed by Oetting and Beauvais in 1990–91 (Venner, Wall, Lau, &
Ehlers, 2006
for Native American youth. Western-based cultural assess
ments, or those that are sensitive to particular cultures but not necessarily
Indigenous cultures, may be contemplated for divergent validity, provided
they are of good psychometric standing. Higginbottom et al. (
) offered
13 tools or models that provide further direction for deliberation. In simi
lar fashion, the NWA should be validated against other measures of well-
ness and treatment outcomes also and tried against nonpsychometric
criterion-related appraisals customarily used by treatment center staff
and Health Canada to further compare its discriminatory and predictive
Intended and unintended consequences
Inclusion of a control group of Indigenous peoples not in addiction treatment,
and an experimental group of Indigenous peoples participating in community-
based programs in future validation studies, would test that changes measured
with the NWA result from treatment alone and/or pertain to Native wellness in
a wider context. Returning clients had similar wellness scores to those entering
treatment for the first time, indicating that treatment and NWA assessment are
beneficial to both groups. This finding has a critical implication for treatment
design and its measurement of success. For example, a modified stepped-wedge
design could accommodate return clients as a positive indicator, which involves
trials whereby specific treatment aspects may be sequentially rolled out based
on circumstantial relevance and likelihood of treatment effectiveness.
Differences in NWA scores among age groups necessitate separate youth
and adult NWA norms in the future. Although observers did not report well
ness differences based on language dominance, clients with Indigenous
language dominance consistently reported higher overall wellness, especially
in the Spiritual quadrant. This emphasizes the benefits of language-based
initiatives as an important contributor to culture-as-intervention. The need
for translated versions of the NWA, and subsequently language-based norms,
needs to be assessed. In Canada, translation into French and at least one
Indigenous language such as Nehiyawewin (Cree) or another language where
English proficiency is low, may be a practical starting point. Researchers will
need to ensure that translation efforts meet standards of semantic, content,
and technical equivalence through translation from English by a Native
speaker and back translation into English by an independent Native speaker,
both from the region where the translated version will be dominantly used.
Ongoing research efforts to keep NWA content valid and relevant should
include treatment-center feedback on any recurring language issues based
on educational level, wellness, and addictive states. These efforts should also
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include proportional representation of First Nations, Metis and Inuit popula-
tions as in NWA piloting participants skewed disproportionately toward First
Nations, even when this group dominates in number among Indigenous
populations in Canada.
The NWA provides for gender identification other than male or female
though demographic categorization and gender-inclusive statement wording,
as well as in the conceptualization of wellness and culture-as-intervention
throughout NWA development. Pilot sample sizes did not allow for more
detailed statistical analysis on gender. However, gender is tied to self-identity
and rooted in Indigenous understanding of community and family as inclus
ive of all relations. Gender is an important consideration for the NWA
research agenda going forward (Brotman, 2015)
and for treatment centers
that offer coed programs.
The finding that the length of the treatment program matters significantly
needs to be addressed. CIPs and wellness development showed a meaningful
initial effect, a plateau midway, and a prolonged effect over time. This indi
cates that treatment programs in the approximate range of 7 to 10 weeks
achieve optimal results with culture-as-intervention. Whether particular CIPs
can be accommodated in a concentrated period may matter in wellness and
should be further investigated.
The few demographic differences in NWA scores draw attention to possible
cultural underpinnings that may be differentiating within reasonable explana
tions such as lived experience, role in Indigenous communities, and the reality
that cultural teaching and learning are continuous. Alternatively, client access
to culture may be hindered by dominance of religion in the community block
ing cultural practices, or youth may be living in a non-Indigenous institution
through child welfare or the justice system in Canada.
While the different types of statistical validation reported here solidify the
scientific and Indigenous strength of the NWA, validation of its current
edition with refined statements and improved CIP ratings would need to be
confirmed with new samples. More conclusive regression models of based
on larger samples could offer more insights into the drivers of wellness and
inform treatment programs. Another way to validate the NWA is to consider
the descriptive characteristics of its structure formation with theoretical
underpinning of culture-as-intervention and demonstrated ability to measure
the effect of treatment. Through AMIS, continuing data collection among
growing numbers of clients and involving more service providers is possible.
NNAPF, the national partnership foundation for addressing addictions with
NNADAP/YSAP treatment centers and programs in Canada, is initiating
ongoing validation of the NWA, ensuring its relevance and contributing to
the sustainable offering of effective CIPs.
Under a unified validity theory, validation is an ongoing process, and
the piloted results reported here help regulate and govern NWA
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applications while allowing for change. Developing a validated NWA broke
new ground in effectively linking shifts in experience of CIPs, and scored
responses to the quadrants and subthemes, to wellness through the concep
tion of culture-as-intervention. NWA inferences will need continual vali-
dation updates to ensure the meaning of scores remains pure to wellness
(i.e., having value implications) and suitable to different contexts (i.e., hav
ing social consequences and requiring norms) (Hubley & Zumbo, 2011;
Messick, 1989
). Staff members at treatment centers and community-based
programs are encouraged to use the NWA among Indigenous peoples.
During piloting, treatment center staff reported that the NWA served as
a means for improving their own understanding of Indigenous culture
and directing their focus when observing indicative behaviors in clients.
Anecdotally, the NWA was a good training resource for both Indigenous
and non-Indigenous service providers during piloting, demonstrating
educational utility.
The NWA distinguished itself as a landmark assessment that is ready for
use among Indigenous populations in pursuit of wellness. Continued build
ing of evidence for culture-as-intervention through AMIS will ensure out-
come data can be supported and used effectively to improve client wellness
and program efficacy. NWA reporting combined with accessible client
information will enable stakeholders to better understand and demonstrate
client needs, guide decision making to better respond to those needs, and
improve services and related polices at treatment center and network levels.
The NWA can inform health and community-based programs and policy
for Indigenous youth and adults in addiction treatment in Canada and
Competing interests
The author(s) declare that they have no competing interests.
Authors’ contributions
All authors helped to write, edit, and approve of the final version of the article
prior to publishing within their respective expertize. Specifically, CD and CH
conceived of the Honoring Our Strengths: culture-as-intervention in Addiction
Treatment project; BF managed the data collection and capturing; CFvD per
formed the data verification, statistical analyses, interpretation of empirical
findings involved in validating the NWA and main writing of the manuscript;
MR comanaged the writing of the manuscript and main editing with CM; BS
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formatted the tables; MF organized the references; DM ensured compliance
with author guidelines for writing the manuscript.
Members of the Honoring Our Strengths: Indigenous culture-as-intervention research team
include nominated principal investigator: Colleen Dell (University of Saskatchewan); co-PI: Peter
Menzies (Independent, formerly Centre for Addiction and Mental Health), Carol Hopkins
(National Native Addictions Partnership Foundation), Jennifer Robinson (Assembly of First
Nations; former designate, Jonathan Thompson); coapplicants: Sharon Acoose (First Nations
University of Canada), Peter Butt (University of Saskatchewan), Elder Jim Dumont (Nimkee
NupiGawagan Healing Centre), Marwa Farag (University of Saskatchewan), Joseph P. Gone
(University of Michigan at Ann Arbor), Christopher Mushquash (Lakehead University), Rod
McCormick (Thompson Rivers University, formerly University of British Columbia), David
Mykota (University of Saskatchewan), Nancy Poole (BC Centre of Excellence for Women’s
Health), Bev Shea (University of Ottawa), Virgil Tobias (Nimkee NupiGawagan Healing Centre);
knowledge users: Kasi McMicking (Health Canada), Mike Martin (National Native Addictions
Partnership Foundation), Mary Deleary (Independent, formerly Nimkee NupiGawagan Healing
Centre), Brian Rush (Centre for Addiction and Mental Health), Renee Linklater (Centre for
Addiction and Mental Health), Sarah Steves (Health Canada; former designate, Darcy Stone
adge); collaborators (treatment centers): Willie Alphonse (Nengayni Wellness Centre), Ed Azure
(Nelson House Medicine Lodge), Christina Brazzoni (Carrier Sekani Family Services), Virgil
Tobias (Nimkee NupiGawagan Healing Centre; former designate, Mary Deleary), Patrick
Dumont (Wanaki Centre), Cindy Ginnish (Rising Sun), Hilary Harper (Ekweskeet Healing
Lodge; Acting Director, Yvonne Howse), Yvonne Rigsby-Jones (Tsow-Tun Le Lum), Ernest
Sauve (White Buffalo Youth Inhalant Treatment Centre), Zelda Quewezance (Saulteaux Healing
and Wellness Centre), Iris Allen (Charles J. Andrew Youth Treatment Centre), Rolanda
Manitowabi (Ngwaagan Gamig Recovery Centre Inc./Rainbow Lodge); collaborators (leader
ship): Chief Austin Bear (National Native Addictions Partnership Foundation), Debra Dell
(Youth Solvent Addiction Committee), Val Desjarlais (National Native Addictions Partnership
Foundation; former designate, Janice Nicotine), Rob Eves (Canadian Centre on Substance Abuse;
former designate, Rita Notarandrea), Elder Campbell Papequash (Saskatchewan Team for
Research and Evaluation of Addictions Treatment and Mental Health Services Advisor); contrac
tors (methodology): Elder Jim Dumont (Nimkee NupiGawagan Healing Centre), Randy Duncan
(University of Saskatchewan), Carina Fiedeldey-Van Dijk (ePsy Consultancy), Laura Hall
(University of Saskatchewan), Margo Rowan (University of Saskatchewan); management:
Barbara Fornssler (University of Saskatchewan; former designate, Michelle Kushniruk); article
editing: Marcia Darling (Toronto). This work was inspired by the devotion of Elder Jim Dumont
and the treatment center project partners to walk with First Nations’ people on the path to well
ness guided by culture-as-intervention. With respect to this article, the authors most appreciat-
ively thank Mike Martin for his assistance in facilitating the pilot testing process; Randy Duncan
for his measurement expertise and work with the IKG in helping to revise early drafts of the
instrument; and Roisin Unsworth (University of Saskatchewan) for her work in compiling infor
mation from the literature involving the application and validation of instruments to assess
This work was supported by the Canadian Institutes of Health Research (funding reference
number AHI 120535).
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