Acceptability of a Web-based Psychosocial Intervention Among American Indian/Alaska Native Substance Users: Implications

1. Acceptability of a Web-based Psychosocial Intervention AmongAmerican Indian/Alaska Native Substance Users: Implications for Dissemination • Aimee N. C. Campbell, Ph.D.1,2, Gloria M. Miele, Ph.D.1, Frankie Banta Kropp, M.S.3, Michelle Moore4, Traci Rieckmann, Ph.D.5, Edward V. Nunes, M.D.1,2 • New York State Psychiatric Institute, (2) Department of Psychiatry, Columbia University, (3) CinARC, University of Cincinnati, (4) City/County Alcohol and Drug Programs, (5) School of Medicine, Oregon Health & Science University RESULTS CONCLUSIONS & IMPLICATIONS ABSTRACT • Findings suggest that core TES content is acceptable among a diverse AI/AN client population who agreed to participate; one module, “Functional Analysis” received <6 on the indicator “easily understood” and may require modification. • Initial, lower acceptance rates (and lower use of the internet in the last month) may indicate that web-based interventions need more comprehensive introduction. • Although TES was not culturally tailored to a specific racial or ethnic group, adaptation to enhance relative advantage and compatibility (Rogers, 2003) could enhance adoption (e.g., information specific to substance use/abuse among AI/AN; videos and voices of AI/AN actors; use of stories as opposed to “academic” presentations; and references to and inclusion of AI/AN spirituality and ceremonies such as powwows, sweat lodges, dancing, drumming, fire and talk circles). • Minor to moderate adaptation of TES may be sufficient to address concerns raised in this study; future research should focus on a collaborative, community-based adaptation process between intervention developers/researchers, treatment providers, and AI/AN community stakeholders. These efforts should also target key implementation factors such as provider attitudes, funding (including reimbursement for non face-to-face services), and internet access in rural or reservation-based treatment programs. • An evidence based intervention that is web-based and culturally-informed could address barriers to treatment access and dissemination among AI/AN communities, including ease of implementation, limited staff training (given constricted resources), and flexibility in how TES is integrated into program curricula (Novins et al., 2011). Sample Characteristics Each program enrolled 20 participants (N=40); the mean age was 36 years and 53.2% were female. Most reported alcohol as the primary substance of abuse (72.3%), followed by methamphetamines (10.6%), cannabis (8.5%), and opiates/heroin (8.5%). 24.4% had less than a high school education, 58.5% high school or equivalent, and 16.7% more than high school. 53.6% worked at least part time in the prior month. Most had lived on a reservation at some point in their lives (73.2%) and participated Native ceremonies (73.2%). Almost half were familiar with their native language (48.8%). About half (53.7%) accessed the internet in the month prior to study enrollment. Longstanding disparities in substance use and treatment access exist among American Indian/Alaska Native (AI/AN) communities. A web-delivered intervention could address some of the access barriers and improve service delivery. The purpose of this study was to assess the acceptability of the Therapeutic Education System (TES), a web-based version of the Community Reinforcement Approach, among AI/AN men and women enrolled in outpatient substance abuse treatment. AI/AN-identified clients from two programs (located in the Northern Plains and Pacific Northwest) completed a baseline assessment, 8 weeks of TES using onsite computers, and a 1-week follow-up assessment which included an in-depth interview. Acceptability was measured by (a) proportion of participants who agreed to participate; (b) treatment retention; and (c) participant feedback collected after each TES module across seven acceptability indicators. Sixty-eight clients were approached for the study and 40 enrolled (58.8%). Participants completed an average of 19.5 modules. Results indicate high acceptability across seven indicators: interesting (M=8.3), useful (M=8.5); introduction of new material (M=8.3), easy to understand (M=7.4); satisfaction (M=8.5); relevance (M=8.4), and overall likability (M=8.2). Efficacious interventions often require context or population-specific adaptation to maintain effectiveness during implementation. Overall, these findings suggest that core TES content is acceptable among a diverse AI/AN client population who agreed to participate. Initial, lower acceptance rates may indicate that web-based interventions need more comprehensive introduction. Acceptability may improve for several modules with greater visibility and integration of AI/AN-specific culture. Acceptability Initial Interest: Sixty-eight clients were approached for the study and 40 enrolled (58.8%). TES Retention: All but three participants completed at least one module; M=19.5 (range=0-33). Feedback: Participants reported the following mean ratings for each acceptability index: 8.33 (SD=2.1) interesting; 8.54 (SD=1.9) usefulness; 8.26 (SD=2.2) new information; 8.49 (SD=1.9) satisfaction; 8.39 (SD=2.2) relevance; 8.22 (SD=2.2) likability; and 7.43 (3.5) understanding. No modules received an overall mean rating of less than 6. The lowest rated module was Self-management Planning (M=7.76) and the highest was Drug Use, HIV, and Hepatitis (M=9.39) (see Table 1). Table 1. Bottom 3 and top 5 rated modules with means on each acceptability indicator and overall module mean (standard deviation) METHODS REFERENCES Bickel, W. K., Marsch, L. A., Buchhalter, A., & Badger, G. (2008). Computerized behavior therapy for opioid dependent outpatients: A randomized, controlled trial. Experimental and Clinical Psychopharmacology, 16, 132-143. Budney, A., & Higgins, S. (1998). Therapy manuals for drug addiction, a community reinforcement plus vouchers approach: Treating cocaine addiction.Rockville, MD: National Institute on Drug Abuse. Novins, D. K., Aarons, G. A., Conti, S. G., Dahlke, D., Daw, R., Fickenscher, A., et al. (2011). Use of the evidence base in substance abuse treatment programs for American Indians and Alaska Natives: Pursuing quality in the crucible of practice and policy. Implementation Science, 6, 63. Rogers, E. M. (2003). Diffusion of Innovations (5th edition). New York: Free Press. The study was conducted in 2011 at two sites affiliated with the NIDA National Drug Abuse Treatment Clinical Trials Network (CTN). Sites were located in the Pacific Northwest (AI/AN-specific program) and Northern Plains (program serving a majority of AI/AN clients). Clients were approached by research staff, briefly informed of the study, and asked if they were interested in participating. Interested participants completed a brief screening to assess eligibility (with verbal consent), followed by study consent and a baseline assessment. Eligible participants were men and women, 18 or older, who self-identify as AI/AN, and within the first 30 days of treatment. Participants were asked to complete 8 weeks (32 modules; approximately 4 per week) of TES using onsite computers followed by a 1-week post intervention assessment which included a short, in-depth interview. Two example module screen shots are displayed in the next panel. Participants rated each individual module on the computer immediately following completion. Seven acceptability indicators were measured using Likert-type scales (range = 0-10): 1) interest, 2) usefulness, 3) information novelty, 4) satisfaction, 5) relevance, 6) likeability, and 7) ease of understanding. Modules with overall mean ratings of < 6 would be considered necessary to revise or adapt. GRANT SUPPORT & CONTACT INFORMATION • Relevance to AI/AN Culture – In depth Interview Preliminary Themes • Information is relevant to treatment and maintaining sobriety: “The information that it provided, I shared it with other recovering Natives and it was really informative to them.” • Relevant to the individual; but not to AI/AN culture: “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, you know, our language. I think about educating, you know, our children and ourselves culturally. Culturally, I don’t see it.” • Presentation should be more culturally congruent: “It’s straight, you know, 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.” This research was supported by grants from the National Institute on Drug Abuse (NIDA) Clinical Trials Network: U10 DA13035 (Edward V. Nunes & John Rotrosen); U10 DA013732 (Eugene Somoza); and U10 DA015815 (Dennis McCarty & James Sorensen), as well as NIDA K24 DA022412 (Edward Nunes). We acknowledge and thank the effort of research staff at participating treatment programs, and the 40 participants who took part in the study. The authors have no conflict of interest to report. Inquiries should be directed to the lead author: Aimee Campbell, Ph.D. | Phone: 212-740-3503 | Email: anc2002@columbia.edu