R. Dale Walker

Organization and Financing of Alcohol and Substance Abuse Programs for American Indians and Alaska Natives

OBJECTIVES Although American Indians and Alaska Natives have high rates of substance abuse, few data about treatment services for this population are available. We used national data from 1997-2002 to describe recent trends in organizational and financial arrangements. METHODS Using data from the Indian Health Service (IHS), the Substance Abuse and Mental Health Services Administration, the National Institute on Alcohol Abuse and Alcoholism, the Henry J. Kaiser Family Foundation, and the Census Bureau, we estimated the number of American Indians served by substance abuse treatment programs that apparently are unaffiliated with either the IHS or tribal governments. We compared expected and observed IHS expenditures. RESULTS Half of the American Indians and Alaska Natives treated for substance abuse were served by programs (chiefly in urban areas) apparently unaffiliated with the IHS or tribal governments. IHS substance abuse expenditures were roughly what we expected. Medicaid participation by tribal programs was not universal. CONCLUSIONS Many Native people with substance abuse problems are served by programs unaffiliated with the IHS. Medicaid may be key to expanding needed resources.

The changing influences of self-worth and peer deviance on drinking problems in urban American Indian adolescents

This study explored the changing relations among self-worth, peer deviance, and alcohol-related problems in a sample of 224 urban-dwelling, American Indian adolescents. Data were collected annually at 7 time points to test a proposed mediational model. As expected, peer deviance mediated the relation between low self-worth and alcohol-related problems in younger adolescents; however, this relation did not hold as participants became older. In older adolescents, low self-worth and peer deviance directly and independently contributed to alcohol problems. Possible explanations for and implications of these findings are discussed in terms of developmental changes during adolescence.

The effects of parental diagnosis and changing family norms on alcohol use and related problems among urban American Indian adolescents.

This study investigated the role of parental diagnosis of alcohol abuse/dependence and perceived family norms for adolescent drinking on alcohol use and alcohol-related problems among urban American Indian youth. A total of 251 urban, American Indian youth and their parents/caregivers were followed from ages 13 to 18. Perceived family norms against alcohol decreased and alcohol use increased from ages 13 to 18. Relative to no parental diagnosis, youth with one or two parents diagnosed with alcohol abuse/dependence were less likely to perceive family norms against alcohol use. Youth with two parents diagnosed were more likely to report alcohol-related problems at age 18 compared to no parental diagnosis. Faster rates of decrease in perceived family norms against alcohol use were associated with faster increases in alcohol use over time. Higher rates of perceived family norms against alcohol use protected youth from high rates of use at age 13, but higher rates of alcohol use at age 13 predicted more alcohol-related problems at age 18. These results suggest that both family history and family behaviors in the form of communication of norms for adolescent alcohol use are likely to impact both rates of use and eventual alcohol-related problems. 

A Constructive Indian Country Response to the Evidence-Based Program Mandate

Abstract Over the last 20 years governmental mandates for preferentially funding evidence-based “model” practices and programs has become doctrine in some legislative bodies, federal agencies, and state agencies. It was assumed that what works in small sample, controlled settings would work in all community settings, substantially improving safety, effectiveness, and value-for-money. The evidence-based “model” programs mandate has imposed immutable “core components,” fidelity testing, alien programming and program developers, loss of familiar programs, and resource capacity requirements upon tribes, while infringing upon their tribal sovereignty and consultation rights. Tribal response in one state (Oregon) went through three phases: shock and rejection; proposing an alternative approach using criteria of cultural appropriateness, aspiring to evaluability; and adopting logic modeling. The state heard and accepted the argument that the tribal way of knowing is different and valid. Currently, a state-authorized tribal logic model and a review panel process are used to approve tribal best practices for state funding. This constructive response to the evidence-based program mandate elevates tribal practices in the funding and regulatory world, facilitates continuing quality improvement and evaluation, while ensuring that practices and programs remain based on local community context and culture. This article provides details of a model that could well serve tribes facing evidence-based model program mandates throughout the country.

Demonstrating the Process of Community Innovation: The Indian Country Methamphetamine Initiative

Abstract In 2007 the federal Department of Health and Human Services, Office for Minority Health, collaborating with other federal agencies, sponsored the Indian Country Methamphetamine Initiative (ICMI). ICMI was undertaken to create community-driven, culture-based best practices in methamphetamine prevention and treatment which could then be disseminated throughout Indian Country. The ICMI ultimately involved ten tribes and five national organizations. Each tribe established a coalition of community government, nongovernment agencies, and elements of civic society to develop a comprehensive assessment, plan, and then to implement the plan. Each tribal coalition planned a complex array of activities including treatment programs, public education and mobilization, law enforcement strategies, and other intervention strategies, each intervention described within a logic model. These interventions focused on logic modeling; coalitions; capacity development and service system optimization; law enforcement and justice; individual and family treatment; public information, awareness, and education; community mobilization; and a very popular ICMI strategy, cultural renaissance. It was concluded that worthwhile activities were conducted under ICMI sponsorship, but that the specific aim of demonstrating community-driven, culture-based innovations in a manner suitable for dissemination was achieved only to a limited extent. Based on this outcome together with similar experiences, recommendations for future initiatives are suggested.

Initiation of Alcohol Use Among Urban American Indian Youth: A Discrete Time Hazards Model

This study uses data collected over 8 time periods to examine time-varying and time-invariant predictors of alcohol initiation among urban American Indian youth, an understudied population. Similar socialization risk and protective factors were found to be related to initiation as other American youth. However, a nuclear family was not found to be protective against initiating alcohol use and living with a father only and having an alcoholic father significantly increased initiation odds. In general, these urban Indian youth are much like other American youth in their initiation of alcohol use, although they may initiate alcohol use at slightly lower rates.

Predicting an alcohol use disorder in urban American Indian youths

This study examines predictors of alcohol use disorders (AUDs) among an urban American Indian cohort who were followed from approximately age 11 to age 20. Approximately 27% of the sample had a lifetime diagnosis of alcohol abuse or dependence. The results indicated that externalizing, but not internalizing, behaviors, family conflict, and school liking served as significant predictors of an AUD. Neither having an alcoholic mother nor an alcoholic father was found to be significantly predictive of an alcohol use disorder at ages 19 and 20. Finally, early alcohol initiation was a substantial predictor of an AUD and acted as a partial mediator.

Residential substance abuse treatment for Urban American Indians and Alaska Natives

The present study examined costs of two residential substance abuse treatment programs designed for urban American Indians and Alaska Natives (AI/ANs). Costs for one agency were well within national norms, while costs at the other program were less than expected from nationwide data. Economies of scale accounted for much of the difference between observed and expected costs. Culturally specific residential substance abuse treatment services can be provided to urban AI/ANs within budgets typically found at mainstream programs.