Interventions for Alcohol Problems in Minority and Rural Populations: The Experience of the Southwest Addictions Research Group Bonnie Guillory Duran Dr.P.H., Associate Professor U. of Washington--School of Public Health and Community Medicine and Indigenous Wellness Research Institute Department of Health Services 1959 NE Pacific St., Room H-680 Box 357660 Seattle, WA 98195-7660 Phone: 206-685-8223
[email protected] Nina Wallerstein, DrPH Professor and Director Masters in Public Health Program Department of Family and Community Medicine MSC 09 5060 1 University of New Mexico Albuquerque, New Mexico 87131 Phone: 505 -272-4173
[email protected] William R. Miller, Ph.D. Emeritus Distinguished Professor of Psychology Center on Alcoholism, Substance Abuse and Addictions University of New Mexico 2650 Yale SE Albuquerque, NM 87106 (505) 925-2378 (505) 925-2379 fax
[email protected]
Introduction: In a pluralistic society such as the United States, behavioral and preventive healthcare pose special challenges. How can services best be delivered in order to meet the needs of a diverse population? American citizens speak many different languages, and carry cultural traditions from a plethora of nations. Native Americans alone comprise hundreds of different tribes with widely varying traditions and histories. No longer feasible, or even desirable, is the idea of America as a melding pot in which these diverse elements are blended to form a new homogeneous identity. Many groups within the United States identify with unique ethnic-cultural heritage while also affirming American citizenship. A “one size fits all” approach to behavioral health services is simply inadequate for a nation that affirms diversity. If not well addressed, the challenges of serving a diverse population are likely to foster health disparities. People from unique ethnic communities or rural area may experience disproportionate difficulty in receiving effective and comfortable services to address health concerns such as alcohol problems. For a variety of reasons including difficulty of access, such populations may also suffer disproportionately high prevalence of health problems. General ethical principles of benevolence and fairness render such disparities unacceptable, but the remedies remain complex and elusive. This situation was the puzzle and motivation behind creation of the Southwest Addictions Research Group (SARG) at the University of New Mexico (UNM). Initially funded by a grant from the National Institute on Alcohol Abuse and Alcoholism, SARG was developed as a collaboration of the UNM School of Medicine and its Institute for Public Health with the UNM Center on Alcoholism, Substance Abuse and Addictions
(CASAA). Its founding mission was to promote research on interventions to address alcohol/drug problems in the Native American, Hispanic and rural populations of New Mexico through supporting the career development of investigators of color interested in this topic. A dozen trainee investigators of color formed the core of SARG, with mentoring from the authors. The trainees participated in a two-year career development seminar covering the subject matter of substance use disorders, their treatment and prevention, as well as related research methodology. Visiting scientists offered monthly colloquia on alcohol/drug health disparities and interventions, and trainees attended and presented at scientific conferences pertinent to the topic. A Community Advisory Board of traditional healers, providers, and community members from the represented populations provided direction on state and regional needs. Modest funding was also provided each year for trainees to conduct developmental and pilot studies to get them engaged in data collection related to the mission of SARG. In combination, these efforts were designed to develop the next generation of investigators at UNM focusing on alcohol/drug interventions with minority and rural populations. Hispanic and American Indian Dynamic Tensions: Protection and Paradox New Mexico’s population is 38% Hispanic, representing a broadly integrated set of very old and newer communities with assets and risks. The Landed Hispanic villages of Northern New Mexico predate “US” Anglo settlements by 150 years and continue many rich agricultural, economic and familial traditions to this day (Meléndez 2001). In the last 20 years, many Mexican, Cuban and other Hispanic immigrant individuals and families have settled in New Mexico adding diversity and complexity to the States health
and social assets and problems. Poverty, discrimination, widespread unemployment, and low educational attainment and opportunity disproportionately affect old and newer Hispanic communities and are conditions conducive to alcohol and drug abuse. Conversely, some Hispanic cultural and family traditions are protective and lead to lower rates of substance abuse and mental disorders. (Vega, Sribney et al. 2004; Warner, Valdez et al. 2006) American Indian tribes have lived in the Southwest from time immemorial. Although Southwestern and New Mexico tribes, in large part, share a history of Spanish and US colonial expansions, there is considerable variability in language, culture, traditions, health beliefs, behaviors and health status between and among populations. For example, southwest tribes in general have low cigarette smoking and intravenous drug use rates compared to the general population. Some US tribes are known to have the highest rates of drinking abstinence and at the same time, high problem drinking rates compared to other races (IHS, 2002). As with their Hispanic neighbors, the tribes of the New Mexico and the southwest share challenges that both help and hinder the development of prevention and intervention programs, such as vast distances between communities and services in rural areas; extremely limited human and financial resources; for tribes, the complex relationships that exist between federal, state, and Tribal agencies; and many social issues including poverty, modernization and assimilation, as well as cultural strengths. They live with cultural and family traditions and contradictions that put them both at risk and that serve to protect them from health problems. Culturally Supported versus Empirically Supported interventions
Informed, in part, by the inherent contradiction in protection and risk factors found in Native American and Hispanic life worlds, an important organizing concept of the SARG was to promote the dual approaches of culturally supported and empirically supported Interventions (Hall 2001). Culturally supported interventions (CSI’s) are those that emerge organically out of the grass roots, educational and social service programs of Hispanic, Native and other communities of color. These interventions are aimed at reducing social and health problems, including alcohol abuse and addictions, and are often based on revitalizing cultural principles and traditions of local communities or on validating new emerging social identities and networks. Many of the cultural traditions and ceremonies that were lost during colonization had embedded in them the social norms and sanctions that provided for a coherent, stable community life. New forms of social identity and solidarity have emerged in response and resistance to assimilation into mainstream culture, ideology and politics. Culturally supported interventions are rarely circulated in the academic literature or tested with western scientific methods. They do, however, fit within the values and social service systems of local communities, and are highly utilized, supported and sustained over time (Smith 1999; Chavez, Duran et al. 2003; Duran and Walters 2004). Recently, many CSI’s have been based on a shared identity of colonization and on the cultural, economic and social changes and conditions wrought by globalization (Alexander 2003; Alexander 2004; Reed and Alexander 2007). Some examples of CSI in Native Communities are the American Indian sobriety and wellness movements, the concept of Cultural Trauma as the bases for individual and community mental health treatment and a revitalization of Native religious and social ceremonies such as sweat lodges, youth societies, coming
of age ceremonies, etc. Empirically supported interventions (ESI) on the other hand, are those scientific evidence-based interventions that are currently hegemonic in the fields of addictions research and public health that often do not consider issue of race or place. Evidence based interventions are often prioritized in University academic settings as they involve randomized controlled trials, manuals and replicated studies that mirror laboratory science methodologies and seek to test effectiveness, with a focus on internal validity. An emerging critique however is their lack of attention to external validity, especially in economically disadvantaged communities of color (Glasgow, Green et al. 2006; Persaud and Mamdani 2006). The approach of the SARG starts from the assumption that the state of the field of addictions disparities research warrants two separate but interrelated approaches. This method “starts from both ends of the spectrum” to develop culturally appropriate interventions by: (1) translating and testing empirically supported interventions (ESIs) with the target communities, while also (2) documenting and assessing outcomes of culturally supported interventions (CSIs) widely used and accepted in communities of color. (Hall 2001) This duel approach serves the outcomes of testing translational effectiveness, sustainability, cultural reproduction, sovereignty and control. It is by definition a hybrid approach balancing the goals of effectiveness and fiscal accountability with cultural acceptability, sustainability and translation. The methods of community based participatory research are useful in accomplishing these goals. Community Based Participatory Research (CBPR) Methodology:
To identify CSI values, beliefs, and practices, and to integrate these into clinical and preventive interventions from the ESI perspective, the emerging CPBR research paradigm becomes critical. Community based participatory research is a relatively new phenomena in health interventions, though action research has been part of social psychology in the United States since the 1940s. Its counterpart, participatory research, which has a more radical transformation agenda has been part of Latin American, African, and Asian social sciences since the 1970s (Wallerstein & Duran, 2003) Defined by the Kellogg Foundation (2001), CBPR is a “collaborative approach to research that equitably involves all partners in the research process and recognizes the unique strengths that each brings. CBPR begins with a research topic of importance to the community with the aim of combining knowledge and action for social change to improve community health and eliminate health disparities” (Minkler & Wallerstein, 2003, pg. 4). For treatment and prevention interventions, the community and its community partners can be defined in multiple-level ways, ie., the patient within his or her extended family and community circles; the group of patients who are seen in the clinic for substance disorders; the participants of addictions support groups; the clinicians who are implementing evidence-based treatments, but who recognize and want to integrate the beliefs and practices that come from people’s cultural worlds; the curanderos, curanderas, medicine men or other traditional and spiritual healers who people turn to when they are in trouble; and population groups defined by age, race, sexual orientation, as members of a church, employees at a worksite, or other self-identified community definitions.
CBPR, therefore, as an overall research methodology, would engage these communities to ask about their beliefs and practices, and what their “research” questions may be about what facilitates health and healing or reduces risk in this particular community. The distinction of CBPR is that it challenges the traditional roles which divide the researcher and researched. Instead of academic or “scientific” knowledge being privileged, the knowledge from the community is seen as an equal contributor to the partnership, which raises the need to uncover and reflect on issues of power, participation (who is included and who excluded), potential impact of racism (Chavez et al., 2003), and who is leading the knowledge creation agenda (Wallerstein and Duran, 2006). Clinicians for example often tackle research questions about implementing interventions, such as how do they translate an effective treatment modality that has been tested in one population for another very different population; or what are the organizational structures in the practice that may facilitate or be barriers to a successful and sustainable implementation. To answer these questions, there are multiple steps for establishing partnerships with the appropriate constituencies to develop a collaborative research approach, ie., the research design, sampling frame, data collection and analysis (Wallerstein, Duran, et al, 2005). The first step is often developing mutual principles of collaboration, ie., how will we work together to honor each others’ knowledge (Viswanathan et al, 2004; Israel et al, 2003; Israel et al, 2005). CBPR strategies can also embrace the question of the added value of participation of the involved communities in enhancing health outcomes.
Very much within CBPR research is the mandate to build community capacity to address multiple health concerns over the long term, and to enable CSI research directions to emerge directly from community partners. Community capacity has been defined as "the characteristics of communities that affect their ability to identify, mobilize, and address social and public health problems” (Goodman et al, 1998). Community capacity has been articulated as having multiple dimensions: active participation, leadership, rich support networks, skills, ability to bring in resources, critical reflection, sense of community, understanding of history, articulation of values, and access to power (Goodman et al, 1998). In the first operationalization of social capital/community capacity for tribal communities, Mignone, (2003) working with Canadian First Nations peoples, identified specific tribal bonding social capital measures, as well as bridging and linking measures (the ability of tribes to interact well with outside governments and entities; and tribal members to interact outside reservation life.) These dimensions of community capacity and social capital open the door to examining organizational leadership and policy measures that may support new interventions, such as assessment of practice commitment and resources to educational, prevention and screening programs; monitoring patterns of alcohol and drug incidence by population; use of technology to bridge geographic, linguistic and cultural gaps; leadership involvement with community defined problems, and systemwide ability to support children and families (Miller, Bedney et al. 2003; Miller and Shinn 2005).
Whether within tribes or with neighboring Hispanic, poor, and rural communities, understanding the backdrop to health issues requires a broad understanding of the social, cultural and political dynamics of those communities. There is no substitute for understanding the value of CSIs within these contextual dynamics, and the need therefore to engage communities in mutual learning in order to build capacity for all clinical, other organizational, and community partners. Introduction to Articles in the Issue This special issue of Alcoholism Treatment Quarterly represents one product of the first years of SARG which reflect the joint emphasis on evidence-supported interventions (ESIs) and community-supported interventions (CSIs). Dr. Kamilla Venner and her colleagues (xx) discuss issues in the adaptation of evidence-based treatment methods for use with Native American populations, focusing as an example on the collaborative development of a manual for Native American motivational interviewing. Dr. Catherine Baca and Jennifer Manuel (xx) report their early efforts exploring health service delivery to rural and frontier areas via telephone and televideo communication. Drs. Steven Verney and Billie Jo Kipp (xx) review methods for measuring acculturation as a relevant factor in intervention research with minority populations. Dr. William Miller and colleagues (xx) examine issues and research on the ways in which interventions with special populations may need to be different from those developed with the dominant culture. Women represent another special, albeit majority population, in that most alcohol/drug interventions have targeted males, and the need to adapt services for women is explored by Isabel Villarreal (xx). Drs. Irene Ortiz and Eliseo Torres (xx) describe how traditional Mexican folk healers address alcohol problems in practicing
curanderismo. Finally, Dr. Vanessa Lopez Viets (xx) discusses the adaptation of a family-based intervention developed in New Mexico - the community reinforcement and family training (CRAFT) method - to work with Hispanic families concerned about a loved one with alcohol/drug problems. We hope the articles in this volume illustrate the opportunities provided by the integration of an ESI and CSI framework and provide avenues for substance abuse clinicians, other providers, prevention specialists, researchers and community members to work together to support communities to improve their health. References: Alexander, J. C. (2003). The meanings of social life : a cultural sociology. Oxford ; New York, Oxford University Press. Alexander, J. C. (2004). Cultural trauma and collective identity. Berkeley, Calif., University of California Press. Chavez, V., B. Duran, et al. (2003). The Dance of Race and Privilege in Community Based Participatory Research. Community Based Participatory Research for Health. M. Minkler and N. Wallerstein. San Francisco, Jossey Bass: 81-97. Duran, B. and K. L. Walters (2004). "HIV/AIDS prevention in "Indian country": current practice, indigenist etiology models, and postcolonial approaches to change." AIDS Educ Prev 16(3): 187-201. Glasgow, R. E., L. W. Green, et al. (2006). "External validity: we need to do more." Ann Behav Med 31(2): 105-8. Goodman, R. M., M. A. Speers, et al. (1998). "Identifying and defining the dimensions of community capacity to provide a basis for measurement." Health Educ Behav 25(3): 258-78. Hall, G. C. (2001). "Psychotherapy research with ethnic minorities: empirical, ethical, and conceptual issues." J Consult Clin Psychol 69(3): 502-10. Israel B, Eng E, Schulz AJ, Parker EA, (2005), Methods for Community Based Participatory Research for Health. San Francisco, CA: Jossey-Bass. Israel B., Shulz AJ, Parker EA, Becker A, Allen A., Guzman R. (2003), "Critical Issues in Developing and Following Community Based Participatory Research Principles,
Minkler, M. and N. Wallerstein, Eds.Community based participatory research for health. San Francisco, CA, Jossey-Bass. Meléndez, A. G. (2001). The multicultural Southwest : a reader. Tucson, University of Arizona Press. Mignone, J. (2003). Measuring Social Capital: A Guide for First Nations Communities. Winnipeg, Manitoba, CA, Human Ecology Department of Family Social Sciences, University of Manitoba.
Miller, R. L., B. J. Bedney, et al. (2003). "Assessing organizational capacity to deliver HIV prevention services collaboratively: tales from the field." Health Educ Behav 30(5): 582-600. Miller, R. L. and M. Shinn (2005). "Learning from communities: overcoming difficulties in dissemination of prevention and promotion efforts." Am J Community Psychol 35(3-4): 169-83. Minkler, M. and N. Wallerstein, Eds. (2003). Community based participatory research for health. San Francisco, CA, Jossey-Bass. Persaud, N. and M. M. Mamdani (2006). "External validity: the neglected dimension in evidence ranking." J Eval Clin Pract 12(4): 450-3. Reed, I. and J. C. Alexander (2007). Culture, society, and democracy. Boulder, Paradigm Publishers. Smith, L. T. (1999). Decolonizing methodologies : research and indigenous peoples. London ; New York Dunedin, N.Z. New York, Zed Books ; University of Otago Press ; Distributed in the USA exclusively by St. Martin's Press. Vega, W. A., W. M. Sribney, et al. (2004). "12-month prevalence of DSM-III-R psychiatric disorders among Mexican Americans: nativity, social assimilation, and age determinants." J Nerv Ment Dis 192(8): 532-41. Viswanathan M, Ammerman A, Eng E, Garlehner G, Lohr KN, Griffith D, et al. (2004), Community-based participatory research: assessing the evidence. Evid Rep Technol Assess (Summ) 1–8.
Wallerstein, N. and B. Duran (2003). The Conceptual, Historical and Practical Roots of Community Based Participatory Research and Related Participatory Traditions. Community Based Participatory Research for Health. M. Minkler and N. Wallerstein. San Francisco, Jossey Bass: 27-52. Wallerstein, N., B. Duran, et al. (2005). Initiating and maintaining partnerships. Methods in Community Based Participatory Research. B. A. Israel and et. al. San Francisco, Jossey-Bass. Wallerstein, N., B. Duran (2006). Using Community Based Participatory Research to Address Health Disparities, Health Promotion Practice, 7 (3), July, 2006, 312323. Warner, L. A., A. Valdez, et al. (2006). "Hispanic drug abuse in an evolving cultural context: an agenda for research." Drug Alcohol Depend 84 Suppl 1: S8-16.
