Transcript Open slide - CTN Dissemination Library

Acceptability of a Web-based Psychosocial Intervention Among
American 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
(1) 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
ABSTRACT
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 indepth 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.
METHODS
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.
CONCLUSIONS & IMPLICATIONS
 Findings suggest that core TES content is acceptable among a diverse
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.
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)
Module Name
New
Satisfaction Relevance Likeability
Info
Understand
Overall
7.41
6.16
7.76 (1.8)
7.71
6.81
7.81 (2.0)
N
Interesting
Useful
Self-Management Planning
32
7.91
8.44
8.22
7.78
8.44
Coping with Thoughts about
Using
31
8.16
8.19
8.00
8.10
7.71
What is Functional Analysis?
33
8.09
8.48
8.48
8.21
8.30
7.91
5.42
7.84 (1.6)
Receiving Criticism
19
8.95
9.47
8.89
8.74
9.32
8.84
9.00
9.03 (1.3)
Manage triggers for Risky Sex
8
9.63
9.63
9.38
9.38
9.00
9.25
7.75
9.14 (1.5)
Sexual Transmission of
HIV/STIs
8
9.38
9.38
9.38
9.38
9.25
9.25
8.75
9.25 (1.4)
Manage triggers for Risky Drug
Use
8
9.50
9.63
9.25
9.50
9.63
9.25
8.00
9.25 (1.4)
Drug Use, HIV, and Hepatitis
8
9.50
9.50
9.50
9.50
9.50
9.50
8.75
9.39 (1.2)
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.”
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 culturallyinformed 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).
REFERENCES
Bickel, W. K., Marsch, L. A., Buchhalter, A., & Badger, G. (2008). Computerized
behavior therapy for opioid dependent outpatients: A randomized, controlled
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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.
GRANT SUPPORT & CONTACT INFORMATION
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: [email protected]