Demonstrating the process of community innovation: the Indian Country Methamphetamine Initiative.
Article Type: Report
Subject: Methamphetamine (Laws, regulations and rules)
Indian country (United States) (Health aspects)
Substance abuse (Prevention)
Substance abuse (Care and treatment)
Authors: Walker, R. Dale
Bigelow, Douglas A.
LePak, Jessica Hope
Singer, Michelle J.
Pub Date: 10/01/2011
Publication: Name: Journal of Psychoactive Drugs Publisher: Taylor & Francis Ltd. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 Taylor & Francis Ltd. ISSN: 0279-1072
Issue: Date: Oct-Dec, 2011 Source Volume: 43 Source Issue: 4
Topic: Event Code: 930 Government regulation; 940 Government regulation (cont); 980 Legal issues & crime Advertising Code: 94 Legal/Government Regulation Computer Subject: Government regulation
Accession Number: 278880920
Full Text: 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.

Keywords--best practices, culture-based interventions, methamphetamine, Indian Country Methamphetamine Initiative, nationwide initiatives in Indian Country

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History, epidemiology, pharmacology, health and social consequences, and interventions for the methamphetamine abuse (MA) problem were overviewed by Gonzales, Mooney and Rawson (2010) of the University of California, Los Angeles's Integrated Substance Abuse Programs (ISAP) as part of their large literature on MA. The National Institute on Drug Abuse has summarized some of this information in a fact sheet (NIDA 2006). Methamphetamine is a powerful stimulant that releases the neurotransmitter dopamine in the brain, yielding the sensation of pleasure and ameliorating negative feelings generated by grinding poverty, victimization, and historical trauma. Like most stimulants, there is a dramatic difference between low- and high-dose effects and repeated use changes brain anatomy, causing addiction with major effects on health and social functioning.

The National Congress of American Indians (NCAI) described the unique epidemiology and consequences of MA in Indian Country. MA exists on Indian reservations throughout the U.S., in rural areas and in urban Indian clinics (NCAI 2006). Indications of MA are encountered in schools, emergency rooms, clinics, community gatherings, and employment settings. The opportunity for high profit and low risk of being caught has made trafficking in this drug prevalent and difficult to prevent on reservations.

Although a great deal is known about MA and many are aware of MA being a significant problem needing a serious policy response there is also a great deal that is not known about its epidemiology and about effective interventions, especially about interventions appropriate to local and cultural context.

PURPOSES OF THE ICMI

Elevated rates of crime, violence, suicide, home contamination, land pollution, and neglected and maltreated children throughout Indian Country have been attributed to methamphetamine abuse. Discussion of the MA epidemic in Indian Country dominated the National Congress of American Indians (NCAI) Executive Council Winter Session of February 2006. NCAI President Joe Garcia issued a "call to action" requesting White House and Congressional support. Committee Chairman Senator John McCain held an Oversight Hearing in April of 2006 at which NCAI First Vice-President Jefferson Keel stated that services needed to integrate traditional values (i.e., be culture-based). In the fall of 2006, the U.S. Department of Health and Human Resources announced the first one million dollars toward addressing the meth epidemic and the Indian Country Methamphetamine Initiative (ICMI) was proposed. The ICMI was planned in the summer of 2006, funded in late 2006, implemented in 2007, and concluded in 2010. Ten tribes and five national organizations participated in the four-year project. The project was funded by the Office of Minority Health and administered under a cooperative agreement by the American Association of Indian Physicians (AAIP). Participant and other information is available on the AAIP webpage (http://www.aaip.org/?page=ICMI). Descriptions of participant projects are presented in PowerPoint (ICMI 2009).

ICMI Demonstration Questions

1. Were multilevel, multisector coalitions formed? How did they work? Did they produce comprehensive community needs assessment and plans? Did they drive collaborative implementation of those plans?

2. Were culture-based innovations in methamphetamine abuse prevention and treatment innovated and did they work?

3. Were generalizable best practices identified in a form that could be disseminated and "taken to scale" throughout Indian Country?

4. Was the process of operating a community innovation initiative successful and productive?

METHODOLOGY

One Sky Center (OSC) provided technical assistance in description and model development of ICMI, some of which is contained in a series of presentations available on the internet (http://www.oneskycenter.org/pp/presentations.cfm). This technical assistance did not involve formal evaluation or research. Best practices, and evidence supporting conclusions about what works, begins with specific, observable, and measurable description of practices/programs. Following the well-established practice of RAND (Chinman, Imm & Wandersman 2004), University of Kansas Community Tool Box (2011) and others, OSC developed a logic model to identify and organize the descriptive variables and the theories that make culture-based practices and programs into a credible practice/program. The ICMI logic model was an elaboration of the basic input-outcome sequence: cause/goal; target population; project strategy; theory of action (change); intervention steps (manualized); short- intermediate-, and long-term outcomes. Each box in this logic model can refer to any of the domains: individual, family, community, and culture. In addition to the eight boxes in the ICMI logic model, information was obtained in eight more categories: needs assessment, positive and negative social determinants, strategic plans, success factors, barriers, and lessons learned. A graphical representation was used in ICMI meetings and communications to describe site interventions.

OSC also developed a coalition model. The coalition model is based on many manuals for creating and operating a coalition, in particular, RAND's Getting to Outcomes (Chinman, Imm & Wandersman 2004), Community Anti-Drug Coalitions of America's Handbook for Community Anti-Drug Coalitions (CADCA 2010), and the University of Kansas' (2011) Community Tool Box. The CADCA Handbook describes the mission of coalitions; who should be involved; what coalitions do; skills needed; and coalition procedures. CADCA Primers (2009) provide information on specific coalition tasks: fostering long-term change, cultural competence, analyzing the community, identifying problems and setting goals; building membership, structure and leadership; putting the plan into action; developing a theory of change, logic models and plans; strategic planning; evaluation; sustaining momentum; public relations; and other topics. SAMHSA, a major sponsor of the ICMI, defines and promotes coalitions through its Drug Free Communities program. A graphical representation of the coalition model was used to picture the tribal coalition, sector collaborators, and the contribution of each to the site's comprehensive plan.

An environmental scan was provided for each ICMI project site using the standard text: Tiller's Guide to Indian Country (Tiller 1996). Interviews within the logic model framework described above were conducted with project representatives from each site, either onsite, by telephone, and/or at ICMI meetings. We summarized and interpreted each interview and sent it back for comments and discussion, and then conducted follow-up interviews to correct and elaborate our original notes. Finally, we sorted site interventions into generic strategic approaches which might be suitable for one of the ICMI specific aims: "taking to scale" interventions focused on systems; on law enforcement and justice; on individual and family treatment; on public education; on community mobilization; and on culture.

RESULTS OF ONE SKY CENTER INTERVIEWS WITH ICMI SITES

Elsewhere we reviewed the literature on general and tribal interventions for substance abuse and related ills (Walker et al. 2008). Using results of that review as guidance, we identified eight generic strategic approaches characterizing the ICMI sites. The following descriptions of eight categories include most but not all ICMI site activities.

Logic Models for Specific Interventions

Logic modeling is used in all coalition and system-planning models. All sites used the ICMI logic model to describe their unique interventions. However, some elements of the logic model were stronger than others. Manuals are critical to dissemination. The existence of manuals was noted in only two of the 10 sites. Measured outcomes are critical to demonstrating the effectiveness of practices and programs. Outcomes and outcome measures were noted in only two sites. There was a tendency to see implementation of project activities, per se, as outcomes. Identification of causes/goals is critical to planning programs. Causes/goals were described quite generally in most sites, e.g., "availability of methamphetamine due to proximity or aggressive trafficking" and "ubiquitous prevalence of distress." The target population was usually described as "the entire community with an emphasis on youth." One site targeted enrolled clients; two other sites targeted traffickers among others. Strategies were the most clearly delineated component of the logic model. Underlying those strategies were some common theories of action, especially the idea that "culture can be strengthened and used to provide personal strength, social bonding, and direction" also known as "cultural renaissance."

Coalitions

The coalition approach gains efficacy from a number of factors not available to stand-alone interventions: shared understanding and ownership of the problem; increased assessment information; power of collaboration; collective attack on barriers; flexible recruitment of tangible and intangible resources; momentum and sustainability. In addition to techniques for coalition creation and operation, including needs assessment and comprehensive planning, in communities generally, techniques have also been developed in previous Indian Country initiatives, e.g., White Bison's (2004) Coalition Building Using Clan Knowledge, conducting Comprehensive Needs Assessment (Walker 2005), using the Readiness Model (Tri-ethnic Center 2011; Edwards et al. 2000), and the Strategic Prevention Framework (SAMHSA 2011).

All ten sites established some kind of coalition consisting of one or more of the following: oversight committee; departmental planning committee; multi-agency committees; tribal task force under Council leadership; agency-and-community coalition; and previously established strategic planning groups. These coalitions clearly generated information sharing and coordination among stakeholders in the methamphetamine effort. In some cases, the coalitions actually conducted collaborative activities.

While some sites referred to needs assessment and comprehensive plans, documented assessments and plans were generally not available.

Capacity Development and Optimizing Service Systems

In some ICMI sites, particular attention was given to increasing the capacity of the service systems to deliver services through service system configuration, improved governance, and personnel development. Because additional resources are difficult to obtain, a more productive approach involves enhancement of tribal governance, administration and service delivery systems. The system enhancement model has been championed and operationalized in Portland State University's Institute for Tribal Government Tribal Leadership Forum; (http://www. tribalgov.pdx.edu/); Harvard University's Project on American indian Economic Development (http://hpaied. org/about-hpaied/overview); University of Arizona Native Nations Institute (http://nni.arizona.edu/), etc. Such enhancement includes reorganizing service systems to eliminate fragmentation and to increase efficiency and effectiveness, i.e., improve capacity with existing resources.

These reorganizations can also apply traditional concepts to organization and operation of service systems delivering contemporary services. The Northern Arapaho Tribe's (no date) Works initiative is a comprehensive systems plan. This approach confronts a common source of inefficiency and ineffectiveness: conflicting purposes, policies, and practices. The Works project implements Multisystemic Family Therapy and critical incident counseling, in addition to creating a comprehensive, collaborative service system. The Northern Arapaho Tribe conducted a needs assessment, received a tribal mandate for the effort, and acquired various funding streams to support collaboration among key players.

Law Enforcement and Justice Models

Some tribes worked with law enforcement and justice systems to strengthen anti-methamphetamine efforts. These included developing cooperative agreements among law enforcement agencies on- and off-reservation to facilitate interdiction; strengthening tribal codes to suppress methamphetamine production; and development of court diversion programs. One tribal council, for example, passed tribal housing codes banning use of methamphetamine in housing. Another created legal authority for collaboration with off-reservation law enforcement agencies enabling cross-border interdiction of drug and human trafficking and kidnapping. A tribal law enforcement agency created a drug task force that has increased its methamphetamine investigatory efforts and also community education in coordination with the tribal meth task force. Extradition agreements were developed by a number of tribes with state and federal authorities to facilitate prosecution and to prevent traffickers from hiding behind jurisdictional barriers.

Individual/Family Treatment Interventions

Tribes are faced with great needs for effective screening, diagnosis, referral, and treatment services. These represent a very large line item in any government's operating budget. The ICMI grant did not provide funding for such direct services, so ICMI activities consisted of identifying and improving established services. Residential treatment services, Matrix model, and other treatment services were obtained from off-reservation providers by some ICMI sites. A Choctaw tribal adventure therapy, Natural Highs, served more than 200 participants, maximizing the effectiveness of recovery interventions through the use of experiential activities along with traditional interventions (ICMI 2009). As a result of the success of this unique intervention, the development of a manual was completed and will be used by other tribes and organizations to facilitate their own adventure therapy program models. This was one of the few documented initiatives appropriate for dissemination.

Interventions Focused on Public Information, Awareness and Education

The largest intervention strategy in the antidrug armamentarium is focused on raising the level of public awareness to facilitate more informed choices and to encourage the development of antidrug norms. Public education and social marketing campaigns use media, posters, lectures, and promotional events to raise awareness of risk, encourage risk avoidance in the general public, and mobilize the community's front-line institutions (schools, churches, workplaces, law enforcement, justice, and corrections) to eliminate risks. One site also utilized social messaging with great success in the form of public service announcements and strategically placed billboards that had culturally relevant messages. Another tribe used social messaging to combat the use of methamphetamine among the tribal community, specifically tribal youth. A tribal meth task force created four television/print public service announcements and strategically placed billboards that have culturally relevant messages, such as "Meth addiction is NOT our tradition" or "Meth users report neglecting their kids--get help!" Preliminary data and statistics from the tribal law and order agency show that since the social messaging took place, there has been a decrease in methamphetamine-related arrests and incidents. This was one of the few outcome assessments.

Interventions Focused on Community Mobilization

Community structure and functioning is a source of health and thriving in individuals; whereas structural defects and dysfunction in communities contribute powerfully to methamphetamine, other substance abuse, and related ills. Communities have, to varying degrees, the leadership, organization, and capacity, i.e., the community competence, to improve the quality of life for members, to provide opportunities, and to rise to challenges. Part of community competence is social capital, the fund of trust and reciprocity that exists among members of the community.

Community mobilization, like coalition building, is intended to raise and focus concern and to direct the considerable potential effort of an entire community toward challenges and goals common to most or all members. One tribal coalition provided methamphetamine education, community unity activities such as the Meth Free Walk, and also offered social networking sites for youth regarding methamphetamine education, outreach, and teen interface.

Another tribe mobilized the community using a block party method. Unlike coalition building, the block party technique is conducted more in a social entertainment than a business meeting style. Unlike a social messaging campaign, the block party audience is more directly and actively involved in the process rather than the passive recipient of information and education. The block party provides food, celebration, and anti-methamphetamine messaging to mobilize the local community. A manual was developed for the block party method.

Interventions Focused on Culture and Nation-Building

Rediscovery and reinvigoration of American Indian culture is the underlying theory of action for many of the ICMI site programs. Rediscovering and reestablishing language, arts, ceremonies and identity is part of preserving the strengths of cultures that have been damaged by conquest and other adversities. Reestablishment of institutions and self-government are among the strategies designed to strengthen such cultures. At the same time, envisioning the future, identifying current opportunities for improving health, social and economic status are essential to the health and thriving of Indian Country. "Culture is prevention" means an awareness of (and participation in) the values, traditions, ceremonies, and sense of community per se that improves health and thriving, while preventing methamphetamine, other substance abuse, and related ills.

All sites in the ICMI, and in other practice improvement initiatives, have used a cultural renaissance model, some primarily so. The model is aimed at strengthening cultural identity, language, ceremony, food-related activity, artifacts, spirituality, and traditional healing. Traditional values and principles are applied. Experiential learning is through guided participation in traditional activities (berry-gathering, crafts, and ceremony). There is a deliberate focus on well-being of individual, family, and community--the specifically identified outcome criteria. Elders are called upon to provide leadership and teaching of cultural knowledge and skills. The curiosity and enthusiasm of youth are often paired with the wisdom and leadership of their grandparents' generation.

Nation building consists of the development of protocols, offices and institutions and involves the development of expertise in governance and administration. For example, the ArizonaNative Net (http://www.arizonanativenet.com) houses a sophisticated continuing education program for tribal leaders in governance, law, and the provision of public justice, health, and educational services. Increasing and diversifying the economy, strengthening and increasing the sustainability of the means of production, growing the gross tribal product, and creating employment opportunity are vital, fundamental improvements in the social determinants of health, including the prevention of methamphetamine abuse. Nation building and economic development were only marginally involved in the ICMI, but are worth pointing out because of their importance.

CONCLUSIONS

The ICMI funds were intended to support achievement of the specific aims of ICMI:

1. Establishment of tribal coalitions, demonstrating how they work, generation of comprehensive needs assessment and plans, and driving collaborative implementation of those plans

2. Innovation and demonstration of community innovated, culture-based best programs

3. Preparing these demonstrated programs for dissemination and to "take to scale" throughout Indian Country

4. Demonstration of the process and productivity of community innovation initiatives

Coalitions envisioned in the Drug Free Communities program, CADCA, RAND Getting to Outcomes, University of Kansas Community Tool Box, and other funding or technical assistance organizations are characterized by a high degree of engagement with all stakeholders, thorough data-based needs assessment, and comprehensive plans that drive activities of the collaborating parties. All ICMI sites did establish some form of tribal coalition. Most coalitions engaged in some form of needs assessment and comprehensive planning. However, reports of need assessment and written comprehensive plans were often cited but not readily available. Intermittent participation, limited commitment, and varying degrees of council mandate seemed to be frequent problems for the power of coalitions. In many sites, the productivity of the ICMI seemed primarily due to the energy and vision of the project staff acting largely on their own.

The ICMI tribal coalitions appeared to be useful but seemed to fall short of the level of engagement and authority envisioned in the Drug Free Communities program, CADCA, and others.

Logical models gain efficacy by clarification, by supporting critical thinking, and, ultimately, by identifying success. All interventions were innovated or selected and adapted in part because of cultural appropriateness. Some of these specific interventions were uniquely culture-based interventions, as envisioned in the original ICMI plan. Innovations in culture-based best practices in methamphetamine prevention and treatment were reflected in tribes' use of logic models. All tribes did adopt the ICMI logic model, as shown in tribal presentations at ICMI meetings. However the ICMI federal project leadership did not emphasize rigorous logic modeling nor did they use the logic model in leading the initiative. With project leadership's encouragement, ICMI funding and activities were comingled with other federally supported projects and with ongoing tribal efforts. While "emergent" and interlaced programmatic activities have their own merit, they do not contribute greatly to demonstration of a particular intervention on the basis of which wider dissemination might be recommended and implemented.

In addition, it must be admitted that logic modeling suitable for program evaluation, dissemination, and taking to scale is quite difficult to do. The epidemiology and etiology of methamphetamine abuse (MA) in tribal communities is imperfectly understood. Imperfectly understandings make it difficult to determine what about the MA problem is likely to change and how these outcomes could be measured are not easily defined. The initiative becomes, by default, a matter of undertaking a number of generally good activities. Similar results were reported by the National Indian Health Board in its Healthy Indian Country Initiative (NIHB 2009) and other national Indian Country initiatives have had similar results. The imprecision of logic models for most ICMI tribal projects, the absence of formal evaluation, and the general lack of "evaluability" precludes success in the ICMI specific aim of innovating and demonstrating interventions to "take to scale" throughout Indian Country.

As with any national initiative, there is a value-for-money question. Activities in ten tribes and four national organizations for up to four years were supported with over $4 million from the Office of Minority Health, supplemented by additional funds provided directly to several ICMI sites by SAMHSA. In addition to the four specific aims of the ICMI, another de facto purpose of ICMI was to underwrite community development and ongoing anti-methamphetamine activity. There was, indeed, a great deal of community development and anti-methamphetamine activity conducted in conjunction with the ICMI.

We conclude that the ICMI achieved reasonable value-for-money in supporting innovative and ongoing community development and prevention services against MA in Indian Country. However, it does not appear that ICMI achieved the specific aims of establishing powerful coalitions that conduct thorough needs assessment, develop comprehensive plans, and drive the multilevel, multisector implementation of such plans. Nor were there many documented and demonstrated community innovated, culture-based best practices to take to scale throughout Indian Country. Because this has also been the outcome of a number of such initiatives, we conclude that either (1) proposals for nation-wide initiatives in Indian Country should not include establishing best practices for taking to scale, or (2) new efforts in more rigorous management of initiatives is needed, as was suggested by NIHB.

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R. Dale Walker, M.D. (a); Douglas A. Bigelow, Ph.D. (b); Jessica Hope LePak, M.S.W. (c) & Michelle J. Singer, B.A. (d)

The authors greatly appreciated the participation and cooperation of the ten tribes and four other national organizations involved in the Indian Country Methamphetamine Initiative. The authors acknowledge the Association of American Indian Physicians, which under cooperative agreement with the Department of Human and Health Services, Office of Minority Health, provided partial financial assistance for this work.

(a) Professor of Psychiatry at Oregon Health & Science University, and Director, One Sky Center, Portland, OR.

(b) Professor Emeritus, Oregon Health & Science University, Portland, OR.

(c) Program Coordinator, Native American Health Center, Family Child Guidance Clinic, Oakland, OR.

(d) Research Associate, One Sky Center, Portland, OR.

Please address correspondence and reprint requests to Douglas A. Bigelow, PhD, Professor Emeritus, One Sky Center, Oregon Health & Science University, Gaines Hall 155, 3181 SW Sam Jackson Park Road, Portland, OR 97239, email: dabelh@frontier.com.

DOI: 10.1080/02791072.2011.629140
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