Substance Use Prevention for Urban American Indian Youth: A Efficacy Trial of the Culturally Adapted Living in 2 Worlds Program

Abstract

This article describes a small efficacy trial of the Living in 2 Worlds (L2W) substance use prevention curriculum, a culturally adapted version of keepin’ it REAL (kiR) redesigned for urban American Indian (AI) middle school students. Focused on strengthening resiliency and AI cultural engagement, L2W teaches drug resistance skills, decision making, and culturally grounded prevention messages. Using cluster random assignment, the research team randomized three urban middle schools with enrichment classes for AI students. AI teachers of these classes delivered the L2W curriculum in two schools; the remaining school implemented kiR, unadapted, and became the comparison group. AI students (N=107) completed a pretest questionnaire before they received the manualized curriculum lessons, and a posttest (85% completion) one month after the final lesson. We assessed the adapted L2W intervention, compared to kiR, with paired t tests, baseline adjusted general linear models, and effect size estimates (Cohen’s d). Differences between the L2W and kiR groups reached statistically significant thresholds for four outcomes. Youth receiving L2W, compared to kiR, reported less growth in cigarette use from pretest to posttest, less frequent use of the Leave drug resistance strategy, and less loss of connections to AI spirituality and cultural traditions. For other substance use behaviors and antecedents, the direction of the non-significant effects in small sample tests was toward more positive outcomes in L2W and small to medium effect sizes. Results suggest that evidence-based substance use prevention programs that are culturally adapted for urban AI adolescents, like L2W, can be a foundation for prevention approaches to help delay initiation and slow increases in substance use. In addition to study limitations, we discuss implementation challenges in delivering school-based interventions for urban AI populations.

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“…Several studies have shown the efficacy of Environmental Prevention strategies to reduce community alcohol problems, including underage drinking, by reducing commercial alcohol availability (Holder et al, 2000;Treno, Gruenewald, Lee, & Remer, 2007;Treno & Lee, 2002;Wagenaar, Toomey, & Erickson, 2005). However, few investigators have described interventions on alcohol use among AI/AN youths (see Cheadle et al, 1995;Gabriel, Leichtling, Bolan, & Becker, 2013;Kulis, Ayers, & Harthun, 2017;May & Moran, 1995;Usera, 2017;Wagenaar, Livingston, Pettigrew, Kominsky, & Komro, 2018;Whitesell et al, 2012;Williams & Perry, 1998). A few studies have included AI/ANs in the study design but were not powered to test for effects that might be specific to the AI/AN sample (Livingston et al, 2018;Perry et al, 2000;Perry et al, 1996).…”

Preventing Substance Use Among Indigenous Adolescents in the USA, Canada, Australia and New Zealand: a Systematic Review of the Literature

“…The pilot of the adapted program produced beneficial outcomes for substance resistance strategies (Kulis et al 2013). The efficacy trial showed improvements in substance-related knowledge, but no statistically significant improvements in substance resistance strategies or substance use frequency (Kulis et al 2016).…”

“…Cultural adaptation of non-Indigenous programs included translation of concepts into local Indigenous language and concepts, developing cultural images and the adaptation of activities to include cultural activities such as prayer, dancing and circle conversations. Three studies evaluated the Keepin' it REAL program: two were a cultural adaptation of this program called Living in 2 worlds (Kulis et al 2013;Kulis et al 2016), and one was unadapted (Dixon et al 2007). Dixon et al (2007) found iatrogenic outcomes for Indigenous adolescents, namely an increase in cannabis use following the program.…”

A scoping review of school-based indigenous substance use prevention in preteens (7–13 years)

“…This model emphasizes personal self-management skills and the social skills to refuse drugs and to reduce motivation to use drugs. Kulis, Ayers, and Harthun's [52] project, Living in 2 Worlds (L2W), was adopted from the Keeping it Real program (KiR), a universal school-based substance use prevention program that teaches youth skills to resist substance Fig. 1 A flow chart-prisma diagram that illustrates the steps and outcomes of the scoping review use through the refuse, explain, avoid, and leave (R.E.A.L.)…”

“…The L2W [52] project was adapted using a theoretical model of cultural adaptation that entailed adding culturally appropriate language, images, scenarios, and formats for urban Alaskan Indian youth while maintaining the core components of the KiR program. It also integrated three types of information: 1) prior research on substance use risk and protective factors, 2) culturally specific ways urban Alaskan Indian youth encounter and resist substance offers, and 3) Indigenous cultural elements.…”