Amy Kaucic

HS 490 Health Promotion Interventions Assignment 3

April 12, 2016
Health Topic: Youth Substance Abuse Marijuana
"Change starts with one person and can grow really fast." Tristan
-www.youth.gov
Target: American Indian/Alaska Native Elementary and Middle School
children
Other key individuals: parents, teachers, school staff, peers
Location: Coeur dAlene Tribal School, Desmet, Idaho
1. Intervention Research Website and Link
National Institute of Justice, Bicultural Competence Skills Approach
http://www.crimesolutions.gov/ProgramDetails.aspx?ID=262
APA citation of website:
https://www.ncjrs.gov/App/Publications/abstract.aspx?ID=129853
General Purpose of the Website
The Bicultural Competence Skills Approach is designed to prevent
abuse of tobacco, alcohol, and other drugs by teaching Native American
adolescents social skills. American Indian youths draw on both Native
American and popular American cultures instead of just identifying with only
one culture. Youth adapt, interact and thrive within both cultures. The Social
Learning Theory helps develop problem solving, decision making, non-verbal
and verbal communication, and builds social network. Populations addressed
are Native American adolescents in rural and reservation settings.

Native American values, legends and stories are integrated for an

effective intervention. The communication and coping skills help youth
handle stressful situations, and avoid using substances. The leaders suggest
healthy alternatives to addictions, and help youth find rewards for making
healthful positive decisions. Ten to fifteen 50-minute sessions are led by two
counselors. Both counselors are Native American.
Intervention tools and resources available are the ten to fifteen 50minutes sessions. Cognitive and behavioral methods are made-to-order to
the cultural prerogatives and the lives of participants. Leaders model
positive refusals of offers for substances in a way that their peers, and nonNative friends are not offended. Two 50-minute booster sessions are offered
semi-annually and include developmentally appropriate content with
strategies. Community is brought into the program. Families, schools,
neighbors, law enforcement, and commercial businesses are included in
activities to bring about awareness. Media releases are distributed to
businesses, as well as, flyers and posters.
Attrition analysis identified attrition averaged 9 percent across the
sample at the six-month follow-up, with no dropout differences.
Evaluation Design: Prospective, experimental design with 137 Native
American youths, ages 11-12, were randomly assigned to prevention and
control conditions. Marijuana use was assessed before, immediately
following, and six months after the intervention (Schinke et al, 1988).
Prospective, experimental design with 1,396 Native American, grades 3 thru
5 in 27 elementary schools, were randomly assigned by school-tointervention or control groups. Marijuana use assessed at baseline, and
6,18, 30 and 42 months post-intervention (Schinke, Tepavac & Cole, 2000).
Evaluation Outcome(s): less use of marijuana at six month follow-up
(Schinke et al, 1988) and lower rates of marijuana at 42 month follow-up
(Schinke, Tepava, & Cole, 2000)

Evaluation Studies
Hawkins, Elizabeth H., Lillian H. Cummins, and G. Alan Marlatt. 2004.
Preventing Substance Abuse in American Indian and Alaska Native Youth:
Promising Strategies for Healthier Communities. Psychological Bulletin
130(2):304323.
Study 1
Schinke, Steven P., Gilbert J. Botvin, Joseph E. Trimble, Mario A. Orlandi,
Lewayne D. Gilchrist, and Von S. Locklear. 1988. Preventing Substance
Abuse Among AmericanIndian Adolescents: A Bicultural Competence Skills
Approach. Journal of Consulting Psychology 35(1):8790.
Study 2
Schinke, Steven P., Lela Tepavac, and Kristin C. Cole. 2000. Preventing
Substance Use Among Native American Youth: Three-Year Results. Addictive
Behaviors 25(3):38797.
Prevention Practices in SchoolsApproximately $11 million in new grants
(SAMHSA News, 2010) to 22 school systems over the next 5 years to help
elementary schools implement
the Good Behavior Game, a classroom behavioral management strategy that
has been shown to be successful in children in first and second grades.
Awardees may receive up to $100,000 per year, for a total of $2.2 million
annually for all grantees.
Critical Thinking
1. Intervention activities that are appropriate to my project are the
program components which are instructing and helping youth learn
social skills, and provides a positive model for saying no to a peer
who offers them marijuana or other substances. Substance abuse is
not usually just one substance. It is usually intertwined with more than
one substance. Coping skills that include self-instruction and
relaxation for handling pressure, and helping youth avoid substance

use situations. The intervention teaches them how to build networks

of prosocial peers, family and tribal members.
2. Another key component as to why I like this model is the sessions
include Native American values, legends and stories. This program
looks very promising.
3. Health education/promotion resources used are community
involvement. Media releases, flyers, posters are distributed within the
community through businesses, organizations, schools, families, and
law enforcement. I believe the Tribal community might consider
adding the Church as a resource.
4. Youth.gov: I found a wonderful wealth of information/topics through
the website, and it is easy to maneuver. Co-occuring disorders is
linked to mental illness with 60-75% occurring along with substance
abuse. This is very high, and I found this throughout the research
literature. Depression and self-medicating is a problem that is linked to
substance abuse
Grant opportunity: This grant opportunity caught my eye, and
would be useful for my project. The Tribe might qualify. Information
and link follows:
Agencies & Departments : Department of Health and Human Services,
Administration for Children and Families, Administration for Native
Americans
Estimated Post Date: March 14, 2016
Estimated Application Deadline: June 13, 2016
The Native Youth Initiative for Leadership, Empowerment, and
Development (I-LEAD) program will emphasize a comprehensive,
culturally-appropriate approach to working with Native youth. I-LEAD
will specifically focus on the implementation of community programs
that promote youth resiliency, connection to Native culture, and
leadership skills. The project will actively involve Native youth in the
planning and implementation phases of activities.

See more at: http://youth.gov/announcements/forecastedfunding-opportunity-native-youth-initiative-leadershipempowerment-and#sthash.47986A1Z.dpuf

#2 Intervention Research Readings

Health Behavior Theories: I want to use the following two models as I believe
the project fits both health behavior theories.
Socio-Cognitive Model - Personal factors, environmental factors, and human
behavior exert influence on each other.

Reciprocal determinism - a person's behavior can impact the

environment. It is not just that you are influenced by your
environment, but that you also influence the environment around you-each impacts the other.

Behavioral Capability - This refers to a person's actual ability to

perform a behavior through essential knowledge and skills. In order to
successfully perform a behavior, a person must know what to do and
how to do it. People learn from the consequences of their behavior,

which also affects the environment in which they live.

Observational Learning - This asserts that people can witness and
observe a behavior conducted by others, and then reproduce those
actions. This is often exhibited through "modeling" of behaviors. If
individuals see successful demonstration of a behavior, they can also

complete the behavior successfully.

Reinforcements - This refers to the internal or external responses to a
person's behavior that affect the likelihood of continuing or
discontinuing the behavior. Reinforcements can be self-initiated or in
the environment, and reinforcements can be positive or negative. This
closely ties to the reciprocal relationship between behavior and
environment.

Expectations - This refers to the anticipated consequences of a

person's behavior. Outcome expectations can be health-related or not
health-related. People anticipate the consequences of their actions
before engaging in the behavior, and these anticipated consequences
can influence successful completion of the behavior. Expectations
derive largely from previous experience. While expectancies also
derive from previous experience, expectancies focus on the value that

is placed on the outcome and are subjective to the individual.

Self-efficacy - This refers to the level of a person's confidence in his or
her ability to successfully perform a behavior. It is influenced by a
person's specific capabilities and other individual factors, as well as by
environmental factors (barriers and facilitators).

Precede/Proceed Model A target behavior is an environmental condition

such as the
adoption of a substance abuse program for the Coeur dAlene Tribal School.
Phase 1 of the model design is the social diagnosis what is the quality of
life. Phase 2 would be an epidemiological diagnosis of health. Phase 3 is a

behavioral and health diagnosis which would examine the behavior/lifestyle

along with the environment. Phase 4 steps would be to diagnose education
and organization, and find the predisposing, reinforcing and enabling factors.
Phase 5 would be an administrative and policy diagnosis.

Spectrum of Prevention: All six would fit the project.

1. Strengthening individual knowledge and skills by enhancing an
individuals capability of preventing substance abuse.
2. Promoting community education by reaching groups of people with
information and resources to promote health and safety.
3. Educating providers at the school and wellness center as they will
transmit skills and knowledge to others.

4. Fostering coalitions and networks by convening groups and

individuals for broader goals and greater impact.
5. Changing organizational practices by adopting regulations and
shaping norms to improve health and safety.
6. Influence policy and legislation by developing strategies to change
policies at the school and in the community to influence outcomes.
Predisposing, enabling and reinforcing factors
Predisposing factors for the project are the students knowledge of the
dangers of marijuana use, the students beliefs toward marijuana (e.g. they
believe what their peers may tell them), and how do they feel about
themselves. Students may have low self-esteem and have poor coping skills.
Family functioning may be a factor.
Enabling factors important to the topic are the availability of a
curriculum at the school. Does the school have a policy in place to teach
substance abuse curriculum. It must be developmentally appropriate and
the content must connect culturally and also include non-culture. Students
need to have a positive peer mentor to help them make healthy choices.
Reinforcing factors are environmental conditions of the neighborhoods.
The community housing is rental properties with low SES in the community.
There is a link between housing and health
(http://www.humanimpact.org/downloads/san-pedro-st-area-hia-full-report,
2016 Pew Charitable Trusts). Housing, economics, education, social support,
built/natural environment are factors that determine the health of a
community. (Community Health Needs & Strengths Assessment, December
2013).
#3 Research Articles Peer Reviewed
APA Citation
Dononvan, D.M., Thomas, L.R., Sigo, R.L.W., Price, L., Lonczak, H., Lawrence,
N., Ahvakana, K., Austin, L., Lawrence, A., Price, J., Purser, A., & Bagley, L.

(2015). Healing of the Canoe: Preliminary results of a culturally tailored

intervention to prevent substance abuse and promote tribal identity for
Native youth in two Pacific Northwest tribes. American Indian and Alaska
Native Mental Health Research, 22(1), 42-76. doi:
10.5820/aian.2201.2015.42
Participants/Population reached: Suquamish and Port Gamble SKallam Tribal
youth
A culturally, social skills intervention was designed to promote an
increase in being part of the culture and prevent substance abuse among
Tribal youth. The Canoe Journey metaphor was connected to hope,
optimism, self-efficacy, and reduced substance abuse.
The Canoe Journey/Lifes Journey curriculum was developed. Holding
Up Our Youth includes sessions to help urban Native American identify and
utilize healthy, appropriate social skills and lifestyle choices to prevent
initiation of substance abuse, and reduce the potential for addictions. The
curriculum may be used for our cultural communities. A sea-going canoe is
the traditional method of transportation, and the journey stops at tribal
communities along the way to dance, drum, sing and share stories. A
weeklong potlatch is a celebration.
The overall findings shows support for the curriculum, and participants
demonstrated high levels of hope, optimism, and self-efficacy. Reduced
substance use from baseline until the end of the year was reported. The
curricula appears to have been effective in addressing youth substance
abuse and use. Community-driven, culturally driven prevention interventions
using the beliefs and values of the specific tribe/culture are more acceptable,
and have the potential to be more effective than non-native evidence-based
practices.
The team that developed the intervention used social-cognitive
behavioral life skills that were grounded in culture, and tribal specific

teachings, practices and values to target substance use/abuse. Cultural

identity and belonging were promoted. Community members worked with
the Healing of the Canoe team.
The conclusion of the authors is that larger samples are needed.
Present findings show the curriculum holds promise. Positive youth
development and tribal-specific components of culture, traditions and values
within the curriculum potentially could reduce substance use. Different
tribes could tailor the delivery format, and help their youth navigate lifes
journey.
I learned that the best practice intervention includes culture, and must
include tribal community input. It is best to tailor the intervention to the
tribe, and honor the ancestry, values and traditions. A community-based
curriculum review and development group includes the elders to adapt the
curriculum. The intervention must be adapted to the Coeur dAlene Tribal
community. I like how the intervention can be made for each tribe.
APA Citation
Okamoto, S. et al. The implications of ecologically based assessment for
primary prevention with indigenous youth populations. The Journal of
Primary Prevention. Vol 27. No 2. March 2006. DOI: 10.1007/s10935-0050016-6
Participants or population reached: Indigenous Youth populations
The American Indian Youth Pilot project examines the substance use
and drug resistance strategies, pertaining to Southwestern American Indian
youth, using a person-in-environment concept. The unique approach
emphasizes individuals within situations. Other programs focused instead on
youths personal attributes. Culturally grounded-school based drug
prevention for Indigenous youth provide the foundation for social and
ecological foundation.

Redirecting the conversation away from drug offers, avoiding or

leaving the situation, and refusing the drugs (say No), according to the
author are not unique but non-confrontational strategies may be unique to
Native youth. Cousins played an important role in the decision to use drugs.
The multiple-systems, school, on the reservation, in the community,
connects youth to their cousins. Risk and protective factors can intensify
when they encounter their cousins. A risk would be having a cousin offer
them marijuana. Cousins could be a protective factor by watching out for
them.
Attention to pre-prevention is argued in the paper. Primary Prevention
is needed especially for indigenous youth. The meso-level is the best place
for primary prevention efforts. Culturally-grounded drug prevention is most
important. Youths relationship to the offerer is a very important unit.
The Keepin it R.E.A.L. program has shown limited effectiveness.
Research found that the youth had a significantly steeper trajectory of
marijuana and alcohol use from pre-intervention stage to post-intervention
stage. The findings indicate in order to be effective for Native American
youth the curriculum must be culturally specific. Programs need to be
tailored to their environmental contexts in order to address their specific
views and behaviors. Non-confrontational drug resistance strategies, and
finding ways to deal with family members, cousins, and peers that may be
offerers are three strategies that youth need to practice.
Ecologically-based assessment is based on ecological and contextual
theories. The behavior of an individual is environmental. Persons
knowledge, habitat, and the systems interaction. The research stressed the
importance of the social ecology on the youths behavior. A sense of
belonging at a school was seen to provide protection from drug use in Native
American youth. Sisters, brothers, and cousins of the youth played a
significant role in the decision to use substances.

The Tribe would provide a foundation for prevention programs through

the use of ecologically-based assessment, and putting it into practice. The
authors stressed that a critical aspect is the receptivity of the community to
prevention efforts for youth. Populations have unique social structures,
norms and values. The community must accept and be ready to participate.
The authors strategic implications taught me to base the intervention
components on the Tribes population needs and abilities, programs most
responsive to the youth and the community, and are specific in cultural
contexts. I would have to make sure the community was accepting where
there would be no mistrust of the program, and make sure it is culturally
acceptable. The intervention would be tailored made to fit the Coeur dAlene
Tribal School students.

APA Citation
Barnes, J et al. First steps: study for a randomized controlled trial of the
effectiveness of the group family nurse partnership (gFNP) program
compared to routine care in improving outcomes for high-risk mothers and
their children and preventing abuse. 2013.Vol 14. P285
Participants or population: Native American high-risk mothers and children
A home-based program that extends from early pregnancy to 24
months of age to reduce the risk of abuse and neglect throughout childhood.
A group context is offered for a shorter time, up through 12 month old
infants. The U.S. Department of Health and Human Services found the
program to be effective for increasing parenting practices. Ecological, selfefficacy and attachment theories fall under the Ecological theory model.
Nurse-Family partnerships have been shown to be effective in reducing
adolescent drug use and related problems in disadvantaged communities.
Targeting risk and protective factors as early as the prenatal period and

infancy is an important for reducing adolescents drug use and related

problems (www.drugabuse.gov/about-nida/noras-blog/2014/09/substance).
Suboptimal parenting of babies is a major health issue. Caregiving
during the 1st year of life is vital for promoting optimal child outcomes since
the brain is developing rapidly and is vulnerable to not positive influences.
Trauma and adverse parenting interactions elevate cortisol which is related
to stress. This can lead to attachment difficulties, hyperactivity, anxiety, and
impulsive behaviors. Follow-up of the partnership suggests a 48% reduction
in abuse and neglect by age 15.
The ecological theory was identified in the research. The importance
of interactions between the individuals characteristics and their contexts.
Self-efficacy theory focused on a persons beliefs that they can be successful
in carrying out the behavior for good outcomes. The attachment theory is
important for early childhood interactions between the child and their
caregiver.
The programs cornerstone is the therapeutic nurse-client relationship.
Improved school readiness, improved prenatal health, fewer injuries in
childhood, and less pregnancies are beneficial outcomes for preventing
substance use, abuse and addiction. Nurse-Family Partnership benefit clients
with low psychological resources- lower intelligence, mental health problems,
and low self-efficacy.
I learned that the community needs to be a part of the team
implementing an intervention. The Family Nurse Partnership (Gfnp) involves
the nurse and the mother during pregnancy, and after birth up to age 2. The
students have a better outcome if they have a healthy start in life, and this
means getting the best care as possible. Early childhood interventions are
effective and cost-effective strategies. I would want to involve the Benewah
Medical and Wellness Center, community and other health organizations.

The community would need to have resources in place for a partnership in

order to fit the Coeur dAlene community.
Pulling It All Together
1. Healthy People 2020: SA-2.2 Increase proportion of at risk
adolescents, ages 12-17, who in past year refrained from using
marijuana for the first time.
2020 Baseline (year): 33.4 (2008)
2020 Target: 36.7
Desired Direction: Increase desired
2. Intervention Type: Bicultural Skills Approach for Marijuana and
Youth/Adolescents (Targeting the School and Community),
www.crimesolutions.gov

Media posted releases, flyers, posters throughout the community for

community involvement
Informational sessions at school with childcare provided
Food provided to participants and families
Intervention groups led by two Native American counselors delivering
ten to fifteen 50 minute sessions that are developmentally appropriate
in content and strategies
Students practice modeling the refusal offers for substance use
(marijuana, alcohol, tobacco, other drugs) from possible peers without
offending their friends, Native and non-native
Students build prosocial networks for strength
Learn coping and communication skills
Native American values, legends and stories are included in all
sessions
Leaders coach, give positive feedback, praise
Semi-annual delivery of two 50-minute boosters

Intervention Type: Behavior intervention at the Tribal School

Reduce risk by having peers for positive interactions/teaching
Keep culture days active
Bring in outside volunteers (Family in Four Seasons with University of
Idaho students)
Keep the culture of the school positive
www.samhsa.gov

Intervention Type: Environmental

Use CATCH program for physical education, health, wellness, nutrition
Curriculum purchased for learning about substances
Policy for teaching substance abuse marijuana and other drugs,
alcohol, smoking
Parental/guardian support
www.ncbi.nlm.nih.gov
3. Potential for Success
The intended approach that I like best is the Bicultural Competence
Skills Approach from the National Institute of Justice as the approach is an
intervention that is designed to help youth with social skills. It draws on
social learning theory, and includes the culture of the Tribe. Integrating
Native American values, legends and stories helps to make it applicable
and favorable for the Tribal School.
The program increases students knowledge of marijuana and other
substances, makes the students feel self-confident by increasing the skill
level, and involves the family and community which is very important.
Peers will be important to provide positive supports. The social support of
the community, Church, businesses, school and the Tribe will benefit all
the participants (http://crimesolutions.gov/ProgramDetails.aspx?ID=262
and http://www.youth.gov).
Sustainability of the intervention plan will continue through grants. A
forecasted opportunity in 2016 is the Native Youth Initiative for Leadership
from youth.gov. An intervention that is positive, and cost-effective will
help keep the best plan in place.

Works Cited:
http://www.cdc.gov/
http://www.youth.gov/
http://www.crimesolutions.gov/
http://www.humanimpact.org/downloads/san-pedro-st-area-hia-full-report/
http://bmcwc.com/
http://ncbi.nlm.nih.gov/
http://www.drugabuse.gov/about-nida/noras-blog/2014/09/substances

SAMHSA. Risk and protective factors associated with youth marijuana use.
SAMHASAs center for the application of prevention technologies. June 2014
Barnes, J et al. First steps: study for a randomized controlled trial of the
effectiveness of the group family nurse partnership (gFNP) program
compared to routine care in improving outcomes for high-risk mothers and
their children and preventing abuse. 2013.Vol 14. P285

Okamoto, S. et al. The implications of ecologically based assessment for

primary prevention with indigenous youth populations. The Journal of
Primary Prevention. Vol 27. No 2. March 2006. DOI: 10.1007/s10935-0050016-6

Dononvan, D.M., Thomas, L.R., Sigo, R.L.W., Price, L., Lonczak, H., Lawrence,
N., Ahvakana, K., Austin, L., Lawrence, A., Price, J., Purser, A., & Bagley, L.
(2015). Healing of the Canoe: Preliminary results of a culturally tailored
intervention to prevent substance abuse and promote tribal identity for
Native youth in two Pacific Northwest tribes. American Indian and Alaska
Native Mental Health Research, 22(1), 42-76. doi:
10.5820/aian.2201.2015.42

Populations
PopulationOkamoto, S. et al. The implications of ecologically based

2003
2004

2005
2006
2007
2008 2
2009
2010
2011
2012
2013
Total
Total
32.4
34.9
35.0
34.0
34.7
34.5
33.4
30.3
29.6
27.6
26.5

24.2