ACCEPTABILITY OF WEB-DELIVERED PSYCHOSOCIAL TREATMENT WITH URBAN AMERICAN INDIAN/ALASKA NATIVE CLIENTS ENROLLED IN OUTPATIENT SUBSTANCE ABUSE TREATMENT

Grant Support: NIDA CTN U10 DA13035 (Nunes/Rotrosen), U10

DA013732 (Winhusen), U10 DA015815 (McCarty/Sorensen)

Aimee Campbell, PhD, MSW New York State Psychiatric Institute

Columbia University Department of Psychiatry

Addiction Treatment Technology Summit | Chicago, IL

August 27, 2014

Study Team 2

Ned Nunes, MD Lead Investigator

Aimee Campbell, PhD Co-Investigator

Traci Rieckmann, PhD Co-investigator, Project Manager Western States Node

Dennis McCarty, PhD Co-investigator

Frankie Kropp, MA Project Manager, Ohio Valley Node

Brenda Wood Site PI, City/County, Rapid City, SD

Steve Gilbert Site PI, NARA, Portland, OR

Jennifer Lima, MPH Node Coordinator

Primary Objective 3

To evaluate the acceptability of an interactive, web-based version of the Community

Reinforcement Approach (CRA) with urban American Indian/Alaska Natives (AI/AN)

Study Process

Initial discussions with the CTN AI/AN Special Interest Group and collaborators

Contact with CTN-affiliated treatment programs and initial meetings of interest

Protocol fine-tuning; pre-implementation training and feedback; Portland Area IHS IRB

Post-study sharing of results; interpretation of findings; data checks with program staff and partners

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Overview and Design

Urban AI/AN clients (N=40)

2 Treatment Program Sites

OR: Native American Rehabilitation Association (NARA)

SD: City/County Alcohol and Drug Programs (CCADP)

Pre/post Design (baseline and 1-wk FU)

8 weeks of TES treatment

32 Core TES Modules

No contingency management

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Therapeutic Education System 6

Community Reinforcement Approach

Budney & Higgins, 1998; Hunt & Azrin, 1973; Smith, Meyers, & Miller, 2001

TES comparable to clinician-delivered CRA; enhances outcomes

Bickel et al., 2008; Chaple et al., 2013; Christensen et al., 2014; Marsch et al., 2014

Examples: Core TES Modules

Conducting a Functional Analysis

Effective Problem Solving

Drug Refusal Skills Training

Managing Negative Thinking

Steps for Giving Constructive Criticism

Giving and Receiving Compliments

Communication Skills

Sharing Feelings

HIV and AIDS

Drug Use, HIV and Hepatitis

Increasing Self-Confidence in Decision-Making

How to Express Oneself in an Assertive Manner

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Eligibility

Inclusion Criteria

18 years or older

Enrolled in treatment program

Within first 30 days of treatment

Self-identify as American Indian or Alaska Native

Planned treatment episode of 8 weeks or more

Exclusion Criteria

Insufficient ability to provide informed consent

Insufficient ability to use English to participate meaningfully in TES

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Outcomes: Acceptability

Quantitative Proportion that agreed to participate Number of modules completed Seven acceptability indicators (mean score of < 6 on a 10

point scale would be considered necessary to adapt) 1) interest 2) usefulness 3) New information 4) satisfaction 5) relevance 6) likeability 7) ease of understanding

Qualitative (Participant Interviews & Staff Focus Groups)

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Participant Characteristics (N=40)

Mean age 37.5 yrs (SD=10.9)

48% were female

Primary substance: alcohol (78%); meth (10%); opioids (8%); marijuana (5%)

25% reported < high school education; 57.5% high school or equivalent; and 17.5% > high school

35% full or regular part-time work

55% accessed the internet in the prior month (42.5% at least once per day)

73% lived on a reservation at some point in their lives

48% are familiar with their native language

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Acceptability: Quantitative

68 clients approached; 47 brief screens; 41 baselines

40 enrolled (59% of those approached)

37 participants completed at least one module

Mean number of modules = 18.6 (SD=9.2)

Mean acceptability ratings (scale 0-10)

Usefulness 8.54 (SD=1.9)

Satisfaction 8.49 (SD=1.9)

Relevance 8.39 (SD=2.2)

Interesting 8.33 (SD=2.1)

New information 8.26 (SD=2.2)

Likability 8.22 (SD=2.2)

Understanding 7.43 (SD=3.5)

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Acceptability: Quantitative

Highest rated modules

#30 Drug Use, HIV and Hepatitis (M=9.39, SD=1.2)

#32 Triggers for Risky Drug Use (M=9.25, SD=1.4)

#29 Sexual Transmission of HIV/STIs (M=9.25, SD=1.4)

Lowest rated modules

#4 Self-Management Planning (M=7.76, SD=1.8)

#9 Coping with Thoughts about Using (M=7.81, SD=2.0)

#2 Functional Analysis (M=7.84, SD=1.6)

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Acceptability: Quantitative 13

6

6.5

7

7.5

8

8.5

9

9.5

10

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Overa

ll A

ccepta

bility R

ating

Module Acceptability Among Participants with ≤16 vs. >16 Modules Completed

>16 Modules (N=22) ≤ 16 Modules (N=15)

Acceptability: Qualitative (n=26)

Theme 1: TES information was relevant to overall to addiction treatment and recovery (n=21).

“Oh, I think it’s very appropriate for any culture actually just because it deals with the problems that are here and now, you know?”

“The information that it provided, I shared it with other recovering Natives and it was really informative to them.”

“It just kind of went through, it like it took you like step by step, how to overcome your, you know, your urge or triggers to, to use.”

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Acceptability: Qualitative

Theme 2: Although the information itself was relevant, the presentation could be more culturally congruent (n=16).

“For what I’m doing personally right now, I think it’s relevant to me. But when you say culture, I think of sweat lodges, I think of ceremonies, I think of powwows, I think of drumming and singing, I think of speaking […] our language. I think about educating […] our children and ourselves culturally. Culturally, I don’t see it.”

“It’s straight […] college type information, exam type stuff. For Native people, I would make it a little more comfortable or a little more spiritual with the speaking.”

“…Maybe they’ll put it off because they’re thinking it’s another way the White man’s trying to tell you how to do things, but if it’s about Natives, maybe we’ll accept it more and use more of it and take it as a tool…”

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Participant Adaptation Suggestions

Insert humor, Native words or slang, and storytelling

Use Native actors in videos and for voice over

Remove content that might be counter to Native culture

Use references to/depictions of the natural world

Incorporate Native spirituality, especially as it relates to effective coping (e.g., prayer, sweats, drumming)

Include videos that are relevant to AI/AN experience (e.g., returning to the reservation to visit family and being confronted with alcohol and drug use)

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Staff Feedback

Synergy with treatment-as-usual

Empowering for clients

Clients face challenges making it into program

Computer-assisted modality did not appear to be an issue – even among older clients

Presentation was too academic

Increase cultural representation – better reflect the lives and issues facing urban AI/AN

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Conclusions

Findings suggest core TES content is acceptable among a diverse urban AI/AN sample

Clinical staff were enthusiastic and interested in ways TES could be integrated within standard care

Targeted adaptation could address concerns related to cultural representation and relevance

Although TES was not culturally tailored to a specific racial or ethnic group, adaptation to enhance relative advantage and compatibility (Rogers, 2003) could enhance program adoption

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Acknowledgements

Manuscript Co-authors: Michelle Moore, Roz Ringor-

Carty, Eva Turrigiano, Frankie Kropp, Traci Rieckmann, Gloria Miele, Edward Nunes

Participants

Clinical and administrative staff at the treatment programs

Local research teams

Kamilla Venner (Athabascan); Duane Mackey (Santee Sioux) (deceased)

Clinical Trials Network AI/AN Special Interest Group

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Thank you! 20

Aimee Campbell

anc2002@columbia.edu