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Documenting tribal community readiness to support substance abuse prevention
Abstract
Documenting community readiness to support substance abuse prevention in tribal communities is needed to maximize the impact of prevention programming. Semi-structured interviews with 26 tribal community members from Montana and Wyoming served as the primary data source for this evaluation. The Community Readiness Assessment was used to guide the interview process, analysis, and results. This evaluation found that community readiness was vague, meaning most community members recognize it as a problem, but there is little motivation to do anything about it. There was a significant increase in overall community readiness between 2017 (pre) and 2019 (post). Findings underscore the need for continued prevention efforts targeted at a community's readiness to address the problem and move them to the next change stage.
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An integrative model of change was applied to the study of 872 Ss (mean age 40 yrs) who were changing their smoking habits on their own. Ss represented the following 5 stages of change: precontemplation, contemplation, action, maintenance, and relapse. 10 processes of change were expected to receive differential emphases during particular stages of change. Results indicate that Ss (a) used the fewest processes of change during precontemplation; (b) emphasized consciousness raising during the contemplation stage; (c) emphasized self-reevaluation in both contemplation and action stages; (d) emphasized self-liberation, a helping relationship, and reinforcement management during the action stage; and (e) used counterconditioning and stimulus control the most in both action and maintenance stages. Relapsers responded as a combination of contemplaters and people in action would. Results are discussed in terms of developing a model of self-change of smoking and enhancing a more integrative general model of change. (14 ref)
Cancer disparities continue among American Indian and Alaska Native (AI/AN) populations while they have decreased among other racial and ethnic groups. No studies were found that utilized the Community Readiness Model (CRM) to ascertain the readiness of Tribal and American Indian organizations to participate in cancer research and cancer prevention and control initiatives. The Partnership for Native American Cancer Prevention conducted an assessment of the status of American Indian communities’ readiness to implement activities for prevention, early detection, and treatment to improve AI/AN cancer rates. The assessment was a component of the Community Outreach Core of the grant. Thirty-four key Informants participated in the interview process. The Community Readiness Assessment (CRA) provided a baseline assessment of community partners’ readiness to participate in cancer research and programming. Despite years of cancer intervention programs, the communities were classified as being in the early stages of readiness [1–5] of the nine-stage model. Additionally, findings showed low levels of awareness of previous or ongoing cancer research. The findings in prevention and control efforts indicated a need for technical assistance and funding to support community projects in prevention and control. This supported the implementation of a community grants initiative. They also indicated that communities were not ready to conduct research, despite ongoing cancer related research in at least two communities. Communication tools and social media methods and messages were developed to increase awareness of cancer as a health concern and cancer research in the community. The CRM informed these and other engagement activities to meet the appropriate stage of readiness for each Tribe/community, and to build their capacity to participate in cancer research and programming activities.
Importance
American Indian adolescents attending schools on or near reservations are historically at high risk for substance use.
Objective
To compare rates of substance use among reservation-based American Indian adolescents vs rates among national US youths.
Design, Setting, and Participants
Population-based survey study of 8th-, 10th-, and 12th-grade students attending participating schools on or near reservations, stratified by region, during the 2016-2017 school year. Substance use rates were compared with those of a national sample of comparably aged students from the Monitoring the Future study.
Main Outcomes and Measures
Lifetime and last-30-day self-reported use of alcohol, marijuana, and other drugs, using relative risk (RR) ratios with 95% confidence intervals to compare American Indian student rates with Monitoring the Future student rates.
Results
Participants included 570 students in eighth grade (49.6% girls; mean age, 13.5 years), 582 in 10th grade (50.0% girls; mean age, 15.4 years), and 508 in 12th grade (53.5% girls; mean age, 17.4 years). American Indian students reported substantially higher lifetime and last-30-day substance use rates compared with the Monitoring the Future students, with greatest disparity at eighth grade: last-30-day substance use RRs for grade 8 were 2.1 (95% CI, 1.4-3.0) for alcohol, 4.2 (95% CI, 3.1-5.8) for marijuana, and 2.4 (95% CI, 1.7-3.3) for other illicit drugs. Compared with 2009 to 2012 data, the RRs between American Indian and Monitoring the Future students for lifetime alcohol and marijuana use did not change substantially from the 2016-2017 school year (alcohol: RR, 1.5 [95% CI, 1.4-1.6] vs RR, 1.3 [95% CI, 1.2-1.4], respectively; marijuana: RR, 2.0 [95% CI, 1.8-2.1] vs RR, 2.1 [95% CI, 1.9-2.3], respectively), but increased substantially for other drugs (RR, 1.8 [95% CI, 1.7-1.9] vs RR, 3.0 [95% CI, 2.9-3.2], respectively).
Conclusions and Relevance
Reservation-based American Indian students are at high risk for substance use compared with US youths in general, making prevention efforts critical. Cultural and value-based characteristics unique to American Indian populations may provide beneficial targets for prevention, but there is limited evidence on how cultural factors work to prevent risky behaviors. Without increased attention to these disparities, the costs to American Indian youths and their communities will remain high.
Objective:
The main objective of this systematic review was to determine how TBPs are implemented and shared in the context of tribal substance use prevention. The second objective was to document TBP examples from three tribal communities involved in a 5-year substance use prevention initiative.
Methods:
A systematic review of published and grey literature was conducted using funding agencies websites, EBSCO Host and national registries. Three tribal communities involved in the initiative documented current TBPs to highlight characteristics of TBPs, costs, and approval processes.
Results:
TBPs are very limited in the literature. Despite tribal use for thousands of years, TBPs are underrepresented and misunderstood. This review found that the terminology used to describe TBPs is not consistent across agencies, publications, websites, or reports. There is also variation in how TBPs originate in substance use prevention contexts and there is not a primary resource or protocol for sharing TBPs. Continued efforts are needed to support the use and dissemination of TBPs in substance use prevention.
Background:
A systematic review characterised and synthesised applications of the Community Readiness Tool (CRT) and synthesised quantitative results for readiness applications at multiple time points.
Methods:
Eleven databases in OvidSP and EBSCHOhost were searched to retrieve CRT applications. Information from primary studies was extracted independently by two researchers.
Results:
Forty applications of the CRT met inclusion criteria focussing on 14 different health and social issues. The community of interest was most often defined solely on the basis of its geographical location (52.5%). Most studies used the CRT to plan (85%) and/or evaluate programs (40%). The CRT protocol was modified in 40% of studies. Six applications evaluated readiness at multiple time points, however limited reporting in primary studies precluded any synthesis of results. Applications identified methodological rigour, contextual information and community engagement as strengths, and time and resource costs as limitations.
Conclusions:
The CRT is well suited for planning and evaluating complex community health interventions given its flexibility to accommodate diverse definitions of community and issues. CRT applications would benefit from improved reporting; reporting recommendations for use of the CRT are outlined.
Researchers occasionally have to work with an extremely small sample size, defined herein as N = 5. Some methodologists have cautioned against using the t-test when the sample size is extremely small, whereas others have suggested that using the t-test is feasible in such a case. The present simulation study estimated the Type I error rate and statistical power of the one- and two-sample ttests for normally distributed populations and for various distortions such as unequal sample sizes, unequal variances, the combination of unequal sample sizes and unequal variances, and a lognormal population distribution. Ns per group were varied between 2 and 5. Results show that the t-test provides Type I error rates close to the 5% nominal value in most of the cases, and that acceptable power (i.e., 80%) is reached only if the effect size is very large. This study also investigated the behavior of the Welch test and a rank-transformation prior to conducting the t-test (t-testR). Compared to the regular t-test, the Welch test tends to reduce statistical power and the t-testR yields false positive rates that deviate from 5%. This study further shows that a paired t-test is feasible with extremely small Ns if the within-pair correlation is high. It is concluded that there are no principal objections to using a t-test with Ns as small as 2. A final cautionary note is made on the credibility of research findings when sample sizes are small.
Communities are at many different stages of readiness for implementing programs, and this readiness is a major factor in determining whether a local program can be effectively implemented and supported by the community. The Community Readiness Model was developed to meet research needs, (e.g., matching treatment and control communities for an experimental intervention) as well as to provide a practical tool to help communities mobile for change. The model defines nine stages of community readiness ranging from "no awareness" of the problem to "professionalization" in the response to the problem within the community. Assessment of the stage of readiness is accomplished using key informant interviews, with questions on six different dimensions related to a communitys readiness to mobilize to address a specific issue. Based on experiences in working directly with communities, strategies for successful effort implementation have been developed for each stage of readiness. Once a community has achieved a stage of readiness where local efforts can be initiated, community teams can be trained in use of the community readiness model. These teams can then develop specific, culturally appropriate efforts that use local resources to guide the community to more advanced levels of readiness, eventually leading to long-term sustainability of local community efforts. This article presents the history of the development of the model, the stages of readiness, dimensions used to assess readiness, how readiness is assessed and strategies for change at each level of readiness.
The Community Readiness Model is an innovative and widely embraced approach to determining a community's stage of readiness to address a particular community issue and match that stage with an appropriate intervention. The current study used this approach in five communities experiencing cancer health disparities. In each community, leaders were interviewed and their qualitative data scored to determine the community's stage of readiness. Two methods of triangulation, investigator and interdisciplinary, were used to increase the scoring process's rigor. In order to gain a deeper understanding of the consensus portion of the scoring process, these meetings were content analyzed. The results have important implications for scoring team composition, provide insight into consensus reaching strategies, and offer recommendations for addressing potential challenges.
Significant health disparities exist among culturally diverse minority populations in the United States. The ways in which healthcare providers recognize and respond to this issue is critical. Methods must be effective, culturally appropriate, and engage the community if they are to be utilized, and they also need to be sustainable to make a significant impact. American Indians and Alaska Natives face many unique health disparities and challenges and they confront many barriers when seeking care and treatment. These obstacles make it essential for healthcare professionals to engage the community in the development of culturally appropriate strategies with which to address health issues. This article describes a community-based participatory approach that was executed successfully by the Choctaw Nation of Oklahoma. By utilizing the Community Readiness Model, it effectively built on the culture and resiliency that exists in each of 10 communities to more successfully implement community-responsive health prevention and treatment. This article discusses the experience of the Choctaw Nation in its assessment and engagement of the community in addressing cardiovascular disease. Data are presented that reflect the successful use of the Community Readiness Model and discussion is provided. This article emphasizes the use of an effective community-based participatory method, Community Readiness, that enabled the Choctaw Nation to make strong "inroads" into its respective service area through successful community engagement.
An assessment of community readiness for drug use prevention in rural communities indicated that most rural communities are at relatively low stages of readiness. Minority communities were particularly low in readiness, with only 2% having functioning drug prevention programs. Rural communities at different levels of readiness require different types of programs to increase readiness, i.e., communities at the no awareness stage require analysis of the historical and cultural issues that support tolerance of drug use, those at the denial and vague awareness stages need specific information about local problems, and communities at the preplanning and preparation stages need information about effective programs, help in identifying resources, and assistance with staff training. In addition, building and maintaining effective programs requires continued evolution of readiness through the stages of initiation, stabilization, confirmation and expansion, and professionalization. Revised and updated scales and methods for assessing community readiness are provided.
Community readiness is a research-based theory that provides a basic understanding of the intervention process in communities. This theory allows us to accurately describe the developmental level of a community relative to a specific issue or problem. In order to move the community toward implementing and maintaining efforts that are effective and sustainable, community mobilization must be based on involvement of multiple systems and utilization of within-community resources and strengths. Successful local prevention and intervention efforts must be conceived from models that are community-specific, culturally relevant, and consistent with the level of readiness of the community to implement an intervention. The community readiness model is an innovative method for assessing the level of readiness of a community to develop and implement prevention programming. It can be used as both a research tool to assess distribution of levels of readiness across a group of communities or as a tool to guide prevention efforts at the individual level. This tool has proven useful in addressing a gamut of problems ranging from health and nutritional issues to environmental and social issues. The model identifies specific characteristics related to different levels of problem awareness and readiness for change.
This paper presents results from an application of the Community Readiness Model (CRM) as part of a multi-stage community mobilization strategy to engage community leaders, retailers, parents, and school personnel in preventing youth use of inhalants and other harmful legal products in rural Alaska. The CRM is designed to assess readiness to address a single social problem, based on a limited set of key informant interviews. In this study, researchers conducted 32 baseline and 34 post-intervention community readiness assessment interviews in four rural Alaskan communities. These interviews with key informants from the communities were coded and analyzed using CRM methods to yield readiness scores for each community. The aggregate results were analyzed using hierarchical linear modeling (HLM), and the individual community scores were analyzed in the context of the overall study. Significant positive changes in community readiness were found across six readiness dimensions as well as for the overall readiness score. Variation in the degree of changes in readiness across the four communities is attributed to differences in the intervention's implementation. The implications of these results include the potential for CRM assessments to serve as an integral component of a community mobilization strategy and also to offer meaningful feedback to communities participating in prevention research.
Community members have identified second-hand smoke exposure among young women and children within First Nations communities as a concern. As part of a community-based research project, we analyzed experiences related to establishing smoke-free public spaces and the challenges related to smoking and bingo. The purpose of this study was to a) describe and compare community smoking at bingo in First Nations communities, and b) draw implications for assessing and supporting community readiness for comprehensive tobacco control policies (TCPs). Data were collected using individual interviews, group discussions, and observations in the community. The establishment of smoke-free public spaces in communities evolved out of concern by people traditionally responsible for the well-being of the community. Despite close proximity and similar socioeconomic contexts, readiness to extend these successes to bingos held in community halls was influenced by three main factors: a) economic drivers, b) the smoking majority, and c) grassroots support. Although models for assessing community readiness provide a useful starting point for understanding local TCP development and implementation in First Nations communities, other factors also need to be considered. Using a comprehensive approach to assessing community readiness has the potential to increase success in extending TCPs and practices in First Nations communities in ways that are culturally relevant, address local conditions, and build on existing efforts.
Introduction
The community readiness model (CRM) is a stage-matched assessment protocol to assess community readiness to address a public health issue. To identify appropriate, culturally sensitive, and community-specific intervention strategies for preventing obesity in children, researchers, and community members formed a partnership to address childhood obesity within one American Indian Reservation.
Methods
The CRM guided 30 interviews in five communities to direct the team’s efforts in addressing obesity among children residing on the reservation. Interviews were scored across six dimensions on an anchored scale of one through nine; scores were then averaged to determine an overall readiness score for each community. A thematic analysis of interview responses aided in interpretation of the readiness scores and identified areas for prevention planning and intervention development.
Results
The overall community readiness score for the communities was 2.9 (SD = 0.5), which falls between 2 (denial/resistance) and 3 (vague awareness) on the anchored rating scale. The thematic analysis resulted in a hierarchal classification scheme with six broad themes that corresponded to the CRM dimensions and 13 sub-themes.
Discussion
The low readiness scores directed the team to implement corresponding strategies to increase awareness, while the thematic analysis suggested that action-based approaches might also be appropriate. The narrow range of scores suggest that community-wide assessments may be sufficient unless specific information is needed for each region of the community. The CRM may be an effective way to assess community readiness to address childhood obesity on an American Indian Reservation.
American Indian youth substance use is a major public health concern. To date, there has been limited evaluation of American Indian youth substance use prevention programs. Evaluation of prevention programs is necessary to understand the aspects of programming that are effective or not effective. This mixed-methods evaluation focuses on select outcomes of a 3-year culturally-based prevention program located in six American Indian communities in the Rocky Mountain Region. The goals of the prevention program are to reduce binge drinking by 30% and increase community readiness by 1-point over a 5- year period. In the first year of the program, community members worked with program staff to develop an evaluation plan that would measure the following outcomes: lowering substance use, increasing community readiness, and increasing the reach of prevention messaging through culturally based prevention. The primary research questions this outcome evaluation sought to answer were as follows: 1) Are there differences in American Indian youth who participate in culturally-based prevention activities compared with American Indian youth who do not participate in these activities? 2) Was the prevention program effective in increasing community readiness over a 3-year period? 3) Did community involvement in prevention activities increase overtime? Results from this evaluation indicate that substance use was similar among intervention (n = 200) and non-intervention youth (n = 369). This was somewhat surprising because Intervention youth reported higher levels of social support and community connections than non-intervention group youth. Community readiness decreased -.81 point from 2015 to 2017. The reach of prevention activities increased 365% from 2015 to 2017. We provide lessons learned that may help other communities as they document outcomes related to prevention efforts. Substance use is a multi-faceted problem facing our communities, families, schools, and nation. Innovative, effective, culturally-based prevention programs like the one highlighted in this paper underscore the need for primary prevention strategies.
Effective community-based actions are urgently needed to combat the ongoing epidemic of opioid overdose. Community readiness (CR) has been linked to communities’ support for collective action, which in turn has been associated with the success of community-wide prevention strategies and resulting behavior change. Our study, conducted in North Carolina, assessed the relationship between CR and two indices of opioid overdose. County-level data included a survey of health directors that assessed CR to address drug overdose prevention programs, surveillance measures of opioid overdose collected from death records and emergency departments, and two indicators of general health-related status. We found that counties’ rates of CR were positively associated with their opioid-related mortality (but not morbidity) and that this relationship persisted when we controlled for health status. North Carolina counties with the highest opioid misuse problems appear to be the most prepared to respond to them.
Purpose
– Effective community-based suicide prevention strategies require culturally relevant contextually driven approaches, validated by community members. Existing literature, funding agencies, and polices do not adequately address the differences in community vs non-community definitions and approaches to suicide prevention. These differences and the process must be articulated to fully understand the complexities of effective American Indian community-based suicide prevention strategies. This paper aims to discuss these issues.
Design/methodology/approach
– This study uses a qualitative methodology to understand the process and meaning of an American Indian reservation's community-based approach to suicide prevention.
Findings
– Seven recommendations emerge. These include: expand the understanding of suicide; plan activities and outreach early; uphold cultural values; build administrative and community capacity; prepare and respond to community needs and situations; anticipate challenges and develop solutions; and recognize the spiritual aspects of the endeavor.
Originality/value
– This study provides new insight about the process in which American Indian communities define, develop and implement suicide prevention strategies that are culturally relevant and community driven. The process and recommendations may be useful for institutions, funding agencies, policy makers, and tribal leaders, and community-based prevention partners.
The ever-increasing numbers of ethnic minority populations in the USA seeking social services suggest that a "multicultural paradigm shift" is underway and gaining speed. This shift will increasingly demand that prevention programs and interventions be more culturally responsive. Interventions that are not aligned with prospective participants' world views and experiences are only minimally effective. Existing models for conducting culturally grounded program adaptations emphasize identifying distinct levels of cultural influences while preserving core elements of the original intervention. An effective adaptation requires competent language translation as well as trained translations of program concepts and principles that will be meaningful to the targeted group, without compromising program fidelity. This article describes how a university research team and curriculum developers worked with American Indian youth and adults in a large southwestern city using a CBPR process to identify cultural elements that became foundational to the adaptation of a prevention curriculum that is a national model program, with the objective of increasing its applicability for urban native youth.
Community-based participatory research in public health focuses on social, structural, and physical environmental inequities through active involvement of community members, organizational representatives, and researchers in all aspects of the research process. Partners contribute their expertise to enhance understanding of a given phenomenon and integrate the knowledge gained with action to benefit the community involved. This article presents key principles of community-based participatory research (CBPR), discusses the rationale for its use, and provides a number of policy recommendations at the organizational, community and national levels aimed at advancing the application of CBPR. While the issues addressed here draw primarily upon experiences in the United States, the emphasis throughout this article on the establishment of policies to enhance equity that would serve both to increase the engagement of communities as partners in health research, and to reduce health disparities, has relevant applications in a global context.
What are the odds? Community readiness for smoke-free bingos in first nation communities
- N Chambers
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- M D Dennis Wardman
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Community readiness: A handbook for successful change: Fort Collins. Tri-Ethnic
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