1. Very Simple Discussion
HEALTH PROMOTION PRACTICE / April 2002 The “In-Between People”: Participation of
Community Health Representatives in Diabetes Prevention and Care in American Indian
and Alaska Native Communities Respected members of American Indian and Alaska Native
communities are a critical resource in helping communities mobilize efforts in diabetes
prevention and care. Possessing cultural and historical knowledge and training in health
promotion and social support, community health representatives (CHRs) are uniquely
equipped to broker the needed relationship between a world shaped by culture and history
and the world of conventional scientific knowledge. Grounded in principles of social
support and interpersonal communication, as well as an understanding of their
community’s strengths and history in health protection, CHRs are bridges distinctively
positioned to connect these two worlds. With additional training and mentoring in diabetes
care and prevention, CHRs, in their self- described roles as “in-between people,” can serve
both as caring and knowledgeable community members and valuable members of the
health care team. Dawn Satterfield, RNC, PhD, CDE Chris Burd, RN, PhD Lorraine Valdez,
BSN, MPA, CDE Gwen Hosey, MS, ARNP, CDE John Eagle Shield T ype 2 diabetes was rare in
American Indian and Alaska Native (AI/AN) communities throughout the United States until
after World War II, when the prevalence of the disease began to climb (Joe & Young, 1994;
Krakoff & Wilson, 1999). In the past 50 years, diabetes has become one of the most common
and serious illnesses among people of many AI/AN nations (Narayan, 1997). The age-
adjusted prevalence of diagnosed diabetes among AI/ANs older than 20 years is almost
three times (10.9%)—and up to four times (15.9%) in the Plains tribes—that for non-
Hispanic Whites (3.9%) (Centers for Disease Control and Prevention [CDC], 1998). These
rates are based on available Indian Health Services (IHS) data; only about 60% of AI/ANs
seek IHS services, so these rates are probably underestimated. Health Promotion Practice /
April 2002 / Vol. 3, No. 2, 166-175 ©2002 Sage Publications 166 Downloaded from
hpp.sagepub.com at UNIV OF SOUTHERN CALIFORNIA on September 20, 2012 Satterfield et
al. / DIABETES PREVENTION AND CARE Type 2 diabetes has emerged not only as an
epidemic among AI/AN adults but also among younger people. The appearance of this
“middle-aged” disease among youth, now emerging in all North American populations, was
first reported as a case series in 1979 among American Indian teenagers (Mazur, Joe, &
Young, 1998) and First Nations youth beginning in 1984 (Dean & Moffatt, 1988). From 1988
to 1996, the age-adjusted prevalence of diagnosed diabetes in the 12 IHS service areas
increased 54% among those aged 15 to 19 years from 2.9 to 4.5 per 1,000. Among Akimel

2. O’odham youth in this age group, 50.9 per 1,000 have type 2 diabetes, identified by active
population screening (Fagot-Campagna et al., 2000); this represents a two- to threefold
increase during the past 30 years (Dabalea, Pettit, Jones, & Arslanian, 1999). Fagot-
Campagna and colleagues (2000) observe that type 2 diabetes may be the “first
consequence” of the obesity epidemic reported in North American youth from all
populations and in all age groups. Currently being reported in countries around the world,
including Japan, Libya, Hong Kong, Bangladesh, Australia, and New Zealand, juvenile rates of
type 2 diabetes are, like those of adults, associated with rapid industrialization and related
societal trends. Diabetes-related end-stage renal disease (ESRDDM), requiring outpatient
hemodialysis two to three times per week or a kidney transplant, is six times more common
among AI/AN adults than among U.S. adults overall (Narva, 1999). From 1990 to 1996, the
rate of Native Americans with diabetes who began treatment for ESRD-DM increased 24%
to about 580 per 100,000, compared to about 380 per 100,000 people in the overall
population with diabetes (CDC, 2000). The rising trend in type 2 diabetes among AI/AN
communities, whose members may perceive it as an “outside” or “unnatural” disorder
(Huttlinger, 1995; Joe & Young, 1994; Wing, 1998) or a “white man’s sickness” (Garro &
Lang, 1994), is a relatively new threat to these communities. National initiatives that
address diabetes, particularly in terms of reducing racial and ethnic disparities, are
providing some support for locally generated efforts to address the challenges. The
Balanced Budget Act of 1997 made possible a number of new programs, including the
authorization of IHS grants for the prevention and treatment of diabetes among AI/ANs
during a 3-year period (Indian Health Service, 1998). Prevention and treatment initiatives
have since been undertaken by 333 tribes, tribal consortia, and urban Indian programs;
these initiatives 167 integrate traditional views and practices with conventional health care.
Increased federal support, awarded in 2001, will expand these initiatives. Other efforts are
unfolding as a variety of agencies and organizations strive to address the Initiative to
Eliminate Racial and Ethnic Disparities in Health, which was signed by President Clinton in
1998. In this presidential initiative, diabetes was identified as one of six health issues with
strong potential for disease and disability prevention. Healthy People 2010, a “road map”
set of objectives for improving the health of all persons in the United States through 2010,
focuses on eliminating health disparities, including 17 objectives that specifically address
diabetes and its complications and two process measures are devoted to the establishment
of culturally appropriate and linguistically competent community health programs (U.S.
Department of Health and Human Services, 2000). The importance of social support in
chronic disease prevention and diabetes self-care has been documented in recent years
(Ford, Tilley, & McDonald, 1998; Wang & Fenske, 1996). Related to this the community
health worker model (a social network intervention) is attracting increasing interest among
health program planners (Beam & Tessaro, 1994; Love, Gardner, & Legion, 1997; University
of Arizona, 1998). Community health workers are “community members who work almost
exclusively in community settings and who serve as connectors between health care
consumers and providers to promote health among groups that have traditionally lacked
access to adequate health care” (Witmer, 2000, p. 1055). In many American Indian
communities, community health representatives (CHRs), and in Alaska Native communities,

3. community health aides who serve as physician extenders, fill this role. We discuss the
overall role of these tribal workers, hereafter referred to as CHRs, in the context of the
theoretical basis for the community health worker (CHW) model and social support theory.
These members of the health care team, also respected members in the communities in
which they serve, mediate between health care systems and communities to improve the
health of the people in their communities. DEFINITION Community health workers go by a
variety of titles (e.g., community health advisors [CHAs], lay health workers, lay health
instructors, peer counselors); here we refer to them as CHWs and specifically, in the case of
many AI/AN communities, as CHRs. CHWs are typ- Downloaded from hpp.sagepub.com at
UNIV OF SOUTHERN CALIFORNIA on September 20, 2012 168 HEALTH PROMOTION
PRACTICE / April 2002 ically respected and trusted community network members,
responsive to others’ needs (Heaney & Israel, 1997), and able to serve as “bridges” (Love et
al., 1997, p. 510) and “culture brokers” (McElroy & Jezewski, 2000, p. 193) between
community residents and health care delivery systems. The CHW model of change is
designed to strengthen already existing community network ties and enhance the total
network by enlisting persons perceived by community members as willing and able to
provide advice, emotional support, and tangible aid (Israel, 1985). HISTORY All cultures in
the world have a lay health care system (Leninger, 1991) and there have probably always
been people who were natural helpers, community members whom neighbors turned to for
social support and advice, as well as specific skills such as midwifery and treatment of
illness. In the United States, formal participation of trained workers in this role has been
documented since the 1950s (University of Arizona, 1998), but internationally they have
been utilized more widely. CDC’s database of CHA, or CHW, programs currently number 200
and represent about 10,000 community workers. The National Community Health Advisor
Study, which was conducted in 1996 and 1997, estimated that there are actually more than
600 such programs and at least 12,500 such workers throughout the United States, of whom
one fourth serve as volunteers (University of Arizona, 1998). CHRS IN AI/AN
COMMUNITIES The largest and likely the oldest system to formally use the skills of
community workers was established in 1968, when IHS adopted the fledgling Community
Health Representative program from the Office of Economic Opportunity. The program was
designed to bridge gaps between people and resources and to integrate basic medical
knowledge about disease prevention and care with local knowledge (Landen, 1992; Mayer,
Brown, & Kelly, 1998; Yellow Bird, 1998). Designed to “integrate the unique helping of
tribal life with the practices of health promotion and disease prevention” (Indian Health
Service, 1991, p. 12), tribal CHR programs employ tribal members able to foster cross-
cultural understanding through their shared tribal language and experiences. They support
them with guidance and health care and education training. In 1988, the Indian Health Care
Improvement Act Amendment recognized the unique skills of these workers mandating that
“the CHR Program endeavors to provide quality outreach health care services and health
promotion/disease prevention services to American Indians and Alaska Natives within their
communities.” CHR services are managed and carried out by tribal governments,
embodying the precepts and goals of Indian self-determination (Indian Health Service,
1991, 1999a). Currently, about 1,400 CHRs serve in more than 250 tribes in more than 400

4. rural communities. “Deeply involved in promoting health and preventing disease within
their own communities, CHRs provide early intervention and case findings that result in
patients receiving care earlier in the course of their illnesses,” observes the Indian Health
Service. Serving long hours and often on a 24-hour basis, CHRs promote access for their
people to and from the health care system, support delivery of and continuity of care and
culturally relevant education, and provide social support. The emblem of the CHR program
reflects a view of CHRs as “front-line caregivers” committed to providing a high standard of
health care and service to their people. It features an eagle feather standing for courage to
overcome barriers, a circle representing the unity of tribes in striving to create better lives
for all AI/AN people, inner triangles illustrating council fires in which tribal members
discuss their problems and plan together to resolve them, and outer triangles representing
all AI/AN tribes in the United States (see Figure 1). The CHR program reported almost 2.3
million client contacts in 1998, most of which occurred in community (34%) and home
(30%) settings. The two leading detailed activities were case management (22%) and
health education (20%). Many of the efforts reported by CHRs were channeled toward
health promotion and disease prevention (19%) and diabetes care and education (14%)
(Indian Health Service, 1999b). Reports by coordinators of the Special Diabetes Grants
(made possible by the Balanced Budget Act of 1997) indicate that many projects included
participation of CHRs in their plans to prevent and treat diabetes. Training of community
advocates in diabetes care and prevention, including CHRs, for implementation of
interventions is a strategy that is being utilized in at least half of the com- Downloaded from
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al. / DIABETES PREVENTION AND CARE FIGURE 1 Emblem of the Community Health
Representative Program 169 workers or nurse case managers (Gary et al., 2000). The work
of CHRs in accomplishing the diabetes program goals of American Indians (Gilliland et al.,
1998) and community health aides in Alaska Native communities (Mayer et al., 1998) has
also been noted. THEORETICAL CONCEPTS SUPPORTING THE CHW AND CHR MODELS
Theoretical support for the use of the CHW/CHR model is based on social support and social
influence. munity grant programs (Acton, Valdez, Hosey, Vanderwagon, & Smith, 1999).
EFFECTIVENESS OF CHWS The use of CHWs in health intervention programs has been
associated with improved health care access, prenatal care, pregnancy and birth outcomes,
client health status, and health- and screening-related behaviors, as well as reduced health
care costs (Brownstein, 1998). A 6-month self-management program for patients with
chronic disease who used lay health instructors resulted in improved health behaviors,
improved health status, and fewer hospitalizations compared with usual care (Lorig et al.,
1999). CHWs have been shown to be helpful in diabetes care as well. Diabetic patients in
Saint Louis, Missouri, who accepted a home health aide to support their self-care efforts for
18 months (N = 44) showed improvements in glycemic control and attendance at eye and
diabetes clinic visits and decreased emergency room visits, compared to a control group
(Hopper, Miller, Birge, & Swift, 1984). Hispanic populations who used community workers
were more likely to complete diabetes education programs, according to two studies
(Brown & Harris, 1995; Corkery et al., 1997). Spanish-speaking persons (N = 109) using
peer educators demonstrated improvements in diabetes education and self-care (Lorig &

5. Gonzalez, 2001). African American patients with diabetes randomized to an integrated CHW
and nurse case manager group had greater declines after 2 years in hemoglobin A1c values,
cholesterol, triglycerides, and diastolic blood pressure than a routine-care group or those
led solely by community Social Support Social support, “the comfort, assistance, and/or
information one receives through contacts from one’s social network” (Wallston, Alagna,
DeVellis, & DeVillis, 1984), typically involves conveying empathy for the difficulties of
adaptation while providing a private setting for repeating and clarifying instructions (Elder,
Guadalupe, & Harris, 1999). Social influence, a key construct in the fields of health
communication and health promotion, includes recognition of the influence of a person’s
and a community’s peer network in making health decisions (Eng, Parker, & Harlan, 1997;
Eng & Young, 1992; Love et al., 1997). The behavioral categories of social support,
according to House (1981), are emotional (e.g., listening, caring, empathy, trust),
instrumental (e.g., tangible aid through resources, transportation), informational (e.g.,
advice, suggestions, referrals, education), and appraisal (e.g., affirmation and feedback) (see
Figure 2). This construct of social support provides a conceptual framework for the CHW
model (Barnes & Fairbanks, 1997; Eng et al., 1997; Eng & Young, 1992; Heaney & Israel,
1997; University of Arizona, 1998) (see Figure 2). CHWs may also be involved in mobilizing
community resources to address the health and social well-being of their people (Berkley-
Patton, Fawcett, Paine-Andrews, & Johns, 1997) and may be instrumental in supporting
preventive services (Love et al., 1997). Social support has been influential among African
American adults striving to control their blood pressure (Ford et al., 1998) and among
overall populations striving to eat healthy diets (Kelsey, Earp, & Kirkley, 1997). This
support factor has also been found to be valuable in predicting diabetes self-care among
older adults (Wang & Fenske, 1996) and in encouraging participation in an AI/AN diabetes
education program (Griffin, Downloaded from hpp.sagepub.com at UNIV OF SOUTHERN
CALIFORNIA on September 20, 2012 170 HEALTH PROMOTION PRACTICE / April 2002
Gilliland, Perez, & Carter, 1999). In a diabetes intervention trial among Pima Indians, social
support influenced glucose control “in ways that extend beyond our current paradigm of
diabetes management” ( Gregg & Narayan, 1998, p. 875; Narayan et al., 1998). In studying
social support as a predictive variable, researchers have identified some problems of
scientific rigor in terms of measurement, including difficulty distinguishing between the
recipient’s social skills and their perception of social support (Cohen, Sherrod, & Clark,
1986; Tillotson & Smith, 1996), the inherent kinship and support based on cultural values in
some communities (Berkman, 1984), and the influence of varying stages of illness and
stress (Wallston et al., 1984). In addition to concerns about measurement, Wallston et al.
(1984) have raised the possibility that too much social support may be harmful in some
interventions, contributing to dependency and low selfesteem. Social Influence and
Relational Communication The role of social influence on behaviors, extending beyond the
realm of social support theory, must also be considered when evaluating the effect of CHW
intervention strategies (Wallston et al., 1984). Self-efficacy is one’s judgment of capability to
accomplish a certain level of performance and is identified as a determinant of behavior
change and maintenance linked to the behavior categories of social support, particularly
appraisal (see Figure 2). Self-efficacy is a concept found in social cognitive theory (Bandura,

6. 1977, 1986), and it has recently been added to the health belief model (Glanz, Lewis, &
Rimer, 1997). The subjective norms of the theory of reasoned action (an individual’s
attitude toward an action, expectations concerning the attributes of the action, and the
influence of people the individual respects) also provide predictive variables for adopting
adaptive health behaviors (Fishbein & Ajzen, 1975). Research into aspects of relational
communication between health care providers and patients offers thought-provoking data
to consider in maximizing the influence of CHWs for diabetes care and prevention. In one
study of interpersonal communication between doctors and patients, the physicians’
attributes of receptivity (openness), immediacy (warmth, familiarity), composure, formality
(professionalism), and similarity (in origin, ethnicity, culture, and economic challenges)
FIGURE 2 Social Support Theory as a Foundation for Community Health Advisor Model
Informational Instrumental Emotional Appraisal were significantly associated with patient
satisfaction with their care, but only similarity between patients and their providers was
significantly related to patient adoption of recommended health care behaviors (Burgoon et
al., 1987). Although this study involved physicians, the similarity of CHWs to their clients
may uniquely position them to communicate effectively with community members and
influence adoption of healthy behaviors. CHWs’ “insider,” or emic, understanding of their
community’s cultural strengths and values provides them with the background needed to
choose effective health communication approaches. Internalization is a communication
strategy that influences a person to adopt actions based on their consistency with their
existing personal and cultural values. Of the triad of communication strategies deemed
persuasive in promoting behaviors: 1) compliance-gaining, 2) identification (with admired
people), and 3) internalization, the latter is the most powerful (Arnold & Bowers, 1984).
This strategy is the means for identifying meaningful, culturally based images and messages
in health care programs, such as the stories and prayers written by Georgia Perez, a former
CHR, for the “S trong in Body and Spirit!” program by the Native American Diabetes Project
in New Mexico (Carter, Perez, & Gilliland, 1999) and adapted by various tribes using the
American Dia- Downloaded from hpp.sagepub.com at UNIV OF SOUTHERN CALIFORNIA on
September 20, 2012 Satterfield et al. / DIABETES PREVENTION AND CARE betes
Association’s “Awakening the Spirit!” Program for Native Americans (Perez, 1998). Other
examples of internalization are the culturally specific storytelling components within many
AI/AN diabetes programs (Acton et al., 1999; Gilliland et al., 1998; Hagey, 1984; Marlow,
Melkus, & Bosma, 1998; Mayer et al., 1998) and programs that support traditional
indigenous practices, including physical activity and food restoration and preparation (Cook
& Hurley, 1998; Duran & Duran, 1999; Leonard, Leonard, & Wilson, 1988; Olson, 1999;
Roubideaux, 1999). Finally, CHR functions may provide more time for one-to-one contact
during home visits and drives to health centers, particularly in rural communities. This
“drive time” can create the space for skilled CHRs to not only tell stories relevant to health
promotion and support but to listen to people’s own stories and explore with them the
meaning of their health and health challenges in the context of shared cultural values and
social relationships. Listening allows communicators to identify “what is close to people’s
hearts” (Labonte & Robertson, 1996, p. 441). The constructs of social support and social
influence, as well as certain interpersonal skills and traits, are reflected in the core roles,

7. competencies, and qualities of CHWs. The Community Health Advisor Study identified 7
core roles of CHAs, or CHWs, and 15 competencies (skills and qualities) for the position (see
Figure 3). This list should strike a familiar chord with all professionals who work in
communities because of their alliance with principles of community organization and
participatory action research, which involves a spirit of colearning (Minkler, 2000) and
invites the direct participation of people affected by problems (such as diabetes) in all
aspects of program planning and research design (Stringer, 1996). The key elements of
participatory action research, which include giving back, having respect and love for other
human beings, building trust, and having a sense of social justice (Smith, Wilms, & Johnson,
1997), are reflected in this list of skills and competencies. These values and skills are also
illustrated in a poem, “I Want to Help My People,” written by Lakota and Dakota CHRs from
the Aberdeen area (see Figure 4). “A poem is the shortest emotional distance between two
points,” said Robert Frost (Richardson, 1999, p. 521), and in sharing their poem, these CHRs
have transformed their personal experiences into a public form to 171 FIGURE 3
Community Health Advisor Core Roles, Skills, and Competencies SOURCE: Adapted from the
University of Arizona (1998). help others understand their work and commitment (Eisner,
1997). DISCUSSION Interventions that fail to address the root causes of the increasing
incidence of diabetes within an ecological context are unlikely to have sustained impact.
Moreover, “the direction of change for chronic disease prevention can only come from
within each community, by that community, and for that community” (Mayer et al., 1998, p.
143). To effectively address the growing threat of diabetes to AI/AN peoples, approaches
must anchor efforts within local social, cultural, and spiritual knowledge and control while
using the latest strides that public health and social science disciplines offer in terms of
assessment, planning, and evaluation. This hybrid approach has brought the experience and
wisdom of many people to bear on issues such as alcohol and drug prevention (Duran &
Duran, 1999) and, increasingly, diabetes prevention (Carter et al., 1999; Mayer et al., 1998;
Roubideaux, 1999). And, like Downloaded from hpp.sagepub.com at UNIV OF SOUTHERN
CALIFORNIA on September 20, 2012 172 HEALTH PROMOTION PRACTICE / April 2002
FIGURE 4 “I Want to Help My People”: A Poem by Lakota and Dakota Sioux Community
Health Representatives (CHRs) “I Want to Help my People” People” A Poem by Lakota &
Dakota Sioux Community Health Representatives “I am a representative of my community.”
“I am a representative for health.” “I believe in my Creator.” “I see it as a calling.” “This is
what I’m supposed to do.” “I want to help my people.” “My own life has to have balance or
nobody will believe me.” “I’m not better than anybody else.” “I ask for forgiveness.” “I have
to have a clean frame of mind.” “I pray to say the right things.” “I want to help my people.”
“It’s this idea of helping people.” “People trust me.” “They come to me in need.” “I’m there
for everyone.” “We’re the “in-between” people.” “I want to help my people.” “The eagle sees
everything that’s going on.” “Our ears are always open.” “Like bees, we’re busy, trying to
make things right.” “Sometimes we see things that make us sad.” “I can be fierce like a bear
…trying to protect.” “I want to help my people.” “We have feelings, too.” “I wish they knew
how much we care.” “I say, `We’re here for you but please meet us halfway’.” “Some people
thank us from the heart.” “Our elders — they understand.” “I want to help my people.”
“From the job came a concern for my people.” “I didn’t know my people were so sickly with

8. diabetes.” “People on dialysis talk to me — `If I had only known….’” “We’ve got to think
about our children and grandchildren.” “We need prevention here.” “I want to help my
people.” “We try again and again – then there’s a little change.” “She gets outside and starts
moving around.” “Just yesterday, he got off insulin and onto a pill.” “We did it! She switched
to diet pop!” “That’s rewarding…rewarding….rewarding…” “I want to help my people.” “We
should tell our youth, “No, diabetes doesn’t have to happen to you.” We know how to
prevent these long-term illnesses. Let’s commit again to our traditional ways of living, A life
of balance, of people walking together on the same path. Coming together in a good way. “I
want to help my people.” “I think of all the things I want for my community.” “I think of the
animals that fly, swim – that survive…” “I want our people to stand and be proud like the
eagle.” “I think of the patience of the turtle.” “I remember of the strength of the buffalo.” “I
want to help my people.” NOTE: Dedicated to Eugene Parker, a veteran CHR who put the
needs of his community before his own. Used with permission. other chronic disease
challenges, diabetes prevention and self-care is less dependent on “high-tech” medical
interventions than it is on “high-talk” interventions that include outreach, consistent follow-
up, preventive care, education of community and family members, and mobilization for
community-level action (Love et al., 1997). All health professionals and community healers,
leaders, and members are needed to arrest the mounting challenge of diabetes in AI/AN
communities. CHRs are uniquely qualified to carry out culturally relevant communication
and health promotion approaches necessary to address diabetes within an ecological
context because they are in a position to respect and honor local Downloaded from
hpp.sagepub.com at UNIV OF SOUTHERN CALIFORNIA on September 20, 2012 Satterfield et
al. / DIABETES PREVENTION AND CARE knowledge, speak their tribal language, build trust
for health care delivery systems, support people in making informed and adaptive health
choices consistent with their personal and cultural values, and help mobilize their
communities to promote participation in planning and delivery of interventions and
identification of additional resources. An academic appreciation for the theoretical
constructs grounding the CHW model may be helpful in building interventions based on
social support, social influence, self-efficacy, and health communications consistent with
cultural values. CHW approaches have recently received heightened attention from health
program planners, but this model is not new—it represents an ancient method of
communal care and health protection and, since 1968, a formal system of cultural mediation
and health promotion in AI/AN nations. One of the goals of the model, to strengthen existing
ties, is consistent with values integral to many AI/AN communities. Building on their ability
to draw from wisdom and experience in the history and culture of their peoples, as well as
to apply specialized knowledge in diabetes prevention and care supported by regular
training, CHRs can serve as “vital links” (Landen, 1992), “bridges,” and “culture brokers”
(Love et al., 1997, p. 510; McElroy & Jezewski, 2000, p. 193) between community residents
and health care delivery systems. Described by CHRs themselves as “the in-between” people
(see Figure 4, 3rd stanza), perhaps someday these “unsung heroes” (Yellow Bird, 1998) will
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(1994). The lay health advisor model in theory and practice: An example of an agency-based

10. program. Family and Community Health, 17, 70-79. Eng, E., Parker, E., & Harlan, C. (1997).
Lay health advisor intervention strategies: A continuum from natural helping to
paraprofessional helping. Health Education and Behavior, 24, 413-417. Eng, E., & Young, R.
(1992). Lay health advisors as community change agents. Family and Community Health,
15, 24-40. Downloaded from hpp.sagepub.com at UNIV OF SOUTHERN CALIFORNIA on
September 20, 2012 -RXUQDORI6XEVWDQFH$EXVH7UHDWPHQW[[[ [[[[ [[[²[[[ I. Zeledon,
et al. 2011). Fewer than 10% of OUD patients achieve long-term abstinence without
treatment, and buprenorphine is very effective in preventing relapse when patients adhere
to the treatment regimen (Tkacz, Severt, Cacciola, & Ruetsch, 2012). Information is needed
to further understand the facilitators and barriers to treatment of opioid use disorders
(OUD) among AI/ANs. 1.3. Integration of culturally centered substance use disorder
programs and traditional healing with Western treatments A crucial aspect of treatment
engagement is creating culturally congruent services. Western counseling services, for
example, can be unsuccessful for some Non-Western cultures, such as AI/ANs, if counselors
are not trained to understand the clients’ worldviews and philosophies (Trimble &
Thurman, 2002). It is therefore important to understand the differences between Western
medical models and traditional healing. Western science is secular and problem specific,
whereas AI/AN healing is focused on holistic wellness that is linked to identity, spirituality,
health, and wellness (McCormick, 2009; McCabe, 2008). Stewart (2008) proposes a Model
of Indigenous Mental Health & Healing to bridge western and traditional AI/AN healing
paradigms by valuing traditional healing as a legitimate component of broader services
available to the community, rather than considering it an alternative to mainstream
services. AI/AN traditional healing has been used to improve behavior, cognitions and
emotions (Yellowlees & Nafiz, 2010). An understudied area of the intersection of western
and traditional methods includes an analysis of the therapeutic effects of traditional healing;
however there have been studies emerging in this area. For example, Beckstead et al.
(2015) combined Dialectical Behavior Therapy (DBT) with traditional practices that met the
criteria for Mindfulness Based Practices (MBP), such as a sweat lodge ceremony, talking
circle and smudging for substance use treatment among AI/AN adolescents, resulting in
96% of participants reporting clinically significant change as either “recovered” or
“improved.” Additionally, results from a key stakeholder meeting convened by the National
Institute on Drug Abuse (NIDA) on MAT services for AI/AN communities highlighted the
importance of integrating MAT into AI/AN traditional healing (Venner et al., 2018). 1.1.
Unique vulnerabilities among California AI/AN California has the largest AI/AN population
in the US with over 720,000 AI/AN individuals (approximately 2% of the California
population), representing 109 Federally recognized Tribes and numerous non-Federally
recognized Tribes (Bureau of Indian Affairs, 2014; US Census, 2010). There are an
estimated 78 state Tribes petitioning for Federal recognition (California Courts, 2019).
Unlike other states, where most AI/ANs live on Tribal land owned by their own Tribe,
California AI/ANs are dispersed throughout rural and urban areas throughout the state–a
consequence of US government policies that relocated AI/ANs from reservations to urban
areas (Intertribal Friendship House & Lobo, 2002). Access to health care services can be
complicated for AI/AN populations because Indian Health Service (IHS) facilities in CA are

11. limited (Indian Health Service California Area Office, 2015). The diversity of Tribal and
urban Indian organizations providing resources for opioid use disorder treatment vary
regionally in CA. There are ten Urban Indian Health Programs (UIHP) which serve American
Indian and Alaska Native (AI/AN) people in select cities with a range of services including
community health, residential treatment and comprehensive primary health care services
(Urban Indian Health Institute, 2017). IHS, an agency within the US Department of Health
and Human Services, provides direct medical and public health services to federally
recognized American Indian and Alaska Native Tribes (Indian Health Service, 2015).
However, many of the IHS facilities in CA are limited to providing direct services, due to
budgetary factors, and must refer patients out for additional specialty care as is the case
with women’s wellness exams where a Pap smear is typically a direct service, but a
mammography is often referred out (Seals, Burhansstipanov, Satter, Chia, & Gatchell, 2006).
This leaves many California AI/ANs isolated from health services and culturally centered
resources. As a result, AI/ ANs are much less likely to receive needed services for
psychiatric and substance use disorders, despite the high prevalence of these conditions
among this population (Hilty et al., 2013). 1.4. Community-based needs assessment as a tool
to improve treatment of OUD among AI/AN communities A community needs assessment
can be useful to identify community member perspectives about the strengths, challenges
and available resources of the AI/AN community to address opioid use disorders (OUD). It
can provide critical information to identify unmet needs and generate evidence to support
systems change (Israel & Ilvento, 1995). Additionally, it can build leadership, group
cohesion, and a sense of local community involvement. Funding to conduct the needs
assessment was provided by the California Department of Health Care Services (DHCS)
Tribal Medication Assisted Treatment (MAT) Project. The Tribal MAT Project was designed
to meet the specific needs of California’s AI/AN urban and tribal communities. This project
includes a statewide needs assessment to increase access to and availability of MAT services
by identifying gaps in treatment, prevention, and recovery services. The needs assessment
is a core component of the project to inform CA Tribal MAT program expansion and reduce
opioid overdose related deaths in Indian Country. Tribal MAT is a subproject of CA DHCS’s
larger effort, the California MAT Expansion Project which was made possible by the
Substance Abuse and Mental Health Service Administration (SAMHSA) Opioid State
Targeted Response (STR) grant. Participatory action research (PAR) methods were used to
develop a needs assessment to develop an emergent process of collective knowledge
production and engage participants in iterative cycles of reflection and action, thereby
democratizing the research process (Cousins & Whitmore, 1998; Siegel, Attkisson, & Carson,
1978). By using PAR methods, key stakeholders were empowered by the research process
to contribute their expertise and influence the improvement of OUD treatment and other
systems change needs in the AI/AN community (Rhodes & Jason, 1991). This article
describes a community-based needs assessment of strengths and weakness among the
AI/AN community in CA to identify facilitators and barriers to treatment of OUD. The
purpose of this study was to assess the perspective of healthcare providers servicing AI/AN
1.2. Effectiveness of MAT in general populations Medication Assisted Treatment (MAT) is
the use of FDA-approved medications in combination with counseling and behavioral

12. therapies to treat substance use disorders. MAT is an evidence-based approach that is used
primarily to treat opioid use disorder with prescribed medications, including
buprenorphine, methadone, and naltrexone to normalize body functions without negative
effects, block euphoric effects of opioids, and relieve physiological cravings. The objective of
MAT, coupled with social, medical and psychological services, is to treat patients to improve
their health and wellness. MAT is clinically effective in reducing mortality in patients with
opioid use disorder (OUD) and reducing the need for inpatient detoxification services
(Korthuis et al., 2017). Studies have demonstrated the feasibility of MAT in rural areas
(O’Malley et al., 2008). However, in a recent survey of SUD treatment programs serving
AI/AN clients, only 28% used MAT (Rieckmann, Moore, Croy, Aarons, & Novins, 2017).
Barriers to MAT implementation among clinicians included perceived suitability of MAT to
their treatment approach and lack of staff expertise and training (Rieckmann et al., 2017).
In addition to the low uptake of MAT in AI/AN-serving clinics, there are currently no MAT
outcome studies among these populations in the peer-reviewed literature. -
RXUQDORI6XEVWDQFH$EXVH7UHDWPHQW[[[ [[[[ [[[²[[[ I. Zeledon, et al. Table 1
California tribal and urban opioid needs assessment domain questions. Description of
substance use in community 1. What types of substances are most commonly seen in your
community’s Native American population with substance use disorder? 2. Please name the
three most common substances seen in your community. Risk factors 1. What are some
risks or stressful events that may contribute to substance use disorder in the Native
American community? 2. What are some co-occurring mental health conditions in your area
which frequently complicate substance use disorder treatment? (For example, use of drugs
or alcohol and mental illness (depression, PTSD, anxiety, etc.)) Medication Assisted
Treatment (MAT) programs and other available support service systems 1. What
prevention services for substance use disorder services are available in your community? 2.
What substance use disorder treatment and services are available in your community? 3.
Have you heard of Medication Assisted Treatment, otherwise known as MAT? a. If no,
explain what it is and ask if they would like to have MAT offered in their organization. b.
Probe: What are some perceived barriers of MAT use that patients have shared? c. Probe:
What are some perceived barriers of MAT implementation in your organization? 4. What
additional substance use disorder services are needed for Native Americans in your
community? a. Probe: Are there any opioid use disorder treatment needs in your
community? Integrating cultural way of life 1. Does the Native American community seek
services from traditional healers? 2. What types of cultural and traditional services are
currently used by the Native American population in your community to address substance
use disorder? Barriers to accessing services 1. What kinds of barriers do Native Americans
in your community face when trying to access substance use disorder treatment services?
Factors that facilitate effective treatment 1. Speaking generally to the Native American
patients you see and are served by your organization, can you describe what you see as
protective and preventive factors from substance use disorder? a. Probe: How about opioids
specifically? populations with key informant interviews (KII) about the most common
substances used in their community, availability of MAT and other OUD services, and
traditional healing services. health professionals) within each organization identified.

13. Demographic information was collected from participants, including their organization,
their role within said organization, gender identity, racial identity, and geographic location.
2. Materials and methods 2.3. Data collection 2.1. Research design Qualitative KIIs were
conducted among AI/AN SUD specialists and service providers to gain a deeper
understanding of the opioid use treatment and prevention needs within each program’s
service area. Interviews were conducted either in person or over the phone. All interviews
were audio-recorded and transcribed for analysis. All key informants signed consent forms
before the interviews. Ethical research principles were followed throughout the study, and
all protocols, scripts, materials, and procedures were reviewed and approved by the
University of Southern California Institutional Review Board. All participants received a $30
gift card incentive for participating in the approximately one-hour long interview. Our
needs assessment team was comprised of members from two academic organizations and
four community-based organizations. The CA academic organizations included two
American Indian researchers and other researchers who have worked with the AI/AN
community. All the community-based organizations represented by research team
members are AI/AN-serving organizations based in urban or Tribal areas of CA. The team
met weekly from June to December 2018 to develop research tools, review national and
statewide data regarding the opioid epidemic in California, and coordinate data collection
activities. The needs assessment team consisted of several American Indian (AI) and Non-AI
health experts. Acknowledging the complex, diverse histories and epistemologies of AI/AN
people and how those histories inform health outcomes was central to informing the design
and implementation of research. Data were collected from June to December 2018 using a
participatory action research (PAR) design. Key informants (N = 21) included healthcare
professionals from sixteen agencies which included Urban Indian Health Programs, Tribal
clinics and community-based organizations throughout California. 2.4. Measures The KII
was pilot tested with seven key informants in urban and rural/Tribal areas. It was revised
based on the feedback received from post-interview debriefing sessions and a finalized KII
script was created and submitted for IRB approval (see Table 1: California tribal and urban
opioid needs assessment domain questions). 2.2. Participants 2.5. Data analysis Key
informants were selected if they served in: Each KII was audio recorded and transcribed. An
initial coding structure was developed by our needs assessment team based on the KII
questions and domains of interest. The coding structure was defined a priori and refined
through an iterative process whereby several members of the research team read and
coded multiple transcripts to identify adaptations and revisions necessary to capture the
prominent themes. The 6 primary codes were: (Beckstead et al., 2015) Barriers Accessing
Services; (Brave Heart et al., 2016) Risk Factors; (Bureau of Indian Affairs, 2014) Protective
Factors; (Bussey, 2011) Community Substance 1) Indian health programs or community-
based organizations that provide health services to AI/AN populations; and 2) Programs
that are currently utilizing MAT services at some level (i.e. prevention, treatment,
educational programming). Snowball sampling was used to recruit participants based on
organizational roles (e.g., administrators, medical providers, behavioral -
RXUQDORI6XEVWDQFH$EXVH7UHDWPHQW[[[ [[[[ [[[²[[[ I. Zeledon, et al. reported
alcohol, 62% marijuana and 43% reported opioids. Table 2 Demographic information of key

14. informants (n = 21). N = 21 % Gender Male Female 12 9 57 43 Race American
Indian/Alaska Native Other 14 7 67 33 Occupation Pharmacy or behavioral health director
Substance use counselor Therapist Primary care physician Case manager Coordinator
Psychologist Intern Youth specialist Psychiatric social worker 5 4 2 2 2 2 1 1 1 1 23 19 10
10 10 10 5 5 5 5 Organization type Indian health centers California tribal TANF partnership
Child & family services Residential treatment program County services Indian education
center 12 3 2 2 1 1 57 15 10 10 5 5 County Oakland Los Angeles Covelo Sonoma Lake Tulare
Bishop Sacramento 5 4 3 3 2 2 1 1 24 20 14 14 10 10 5 5 3.1. Barriers to accessing services
The first code identified themes related to the kinds of barriers that members of the AI/AN
community might encounter when trying to obtain treatment services in their local area.
External (to the individual) barriers identified included limited availability of
transportation, lack of insurance coverage, unstable living conditions, privacy, being
waitlisted for services and limited sober living opportunities. Regarding Transportation, in
some areas of California, treatment centers are far away (i.e. 10–30 miles one-way
distance), making it difficult to obtain treatment services and aftercare services and to
adhere to treatment regimens. Accessibility and cost for transportation can be burdensome
to continued treatment. Lack of Insurance Coverage was also identified as a barrier in that
many clients may not have insurance coverage or documentation of their insurance
coverage. Unstable Living Conditions were barriers to service access because many clients
do not have a stable home or are experiencing homelessness, which makes attendance and
adherence to treatment difficult. Additionally, participants identified the lack of Sober
Living Conditions for people transitioning from residential treatment back into the
community as a barrier to accessing the full spectrum of services necessary to promote
recovery. Finally, residential treatment centers are unavailable or difficult to access in many
urban areas and Tribal communities. Many of the residential treatment centers are not
readily accessible, have limited availability for new clients, and/or have a short duration of
stay which results in long waitlists. For example, one participant noted how lack of living
conditions, transportation and appropriate documentation interfered with clients’ ability to
access services: I think that it’s difficult to access the services that are currently being
provided due to like eligibility. Like if Native Americans are coming off the reservation here.
Like in order to get services they’ll need to get a California ID. And if, you know, when you’re
out in your addiction, you lose all your documents. So it can take a while to get those
documents, to get California ID. Sometimes we lose them in the process or they become
frustrated with the intake process because it can be pretty lengthy. And residential
treatment nowadays is like 30 days. So I mean it’ll take longer than that to get everything
that they need. Just to be able to access support and resources. The location of services is
pretty sparse. I mean we got Los Angeles, Long Beach, Orange County but that’s a great
difference between agencies and if people are on the bus, which they more than likely are, it
can be pretty difficult to access. And then there’s a huge wait… Huge wait waitlist for
services. So you know we lose people that way. [LCSW] Use Description; (California Courts,
2019) SUD and OUD Services Available; and (CDC, n.d.) Services System Needs. There were
5 coders who participated in coding transcripts, with each transcript coded by at least two
different coders. Coding discrepancies were resolved in research team consensus meetings.

15. Data analysis involved coding each of the 21 transcripts using the developed coding
structure as applied in NVivo qualitative coding software. Coding reports were produced by
code, themes were identified and counted, and quotations illustrating themes were pulled
into separate reports. Inclusion criteria for key themes included either high frequency (i.e.
reported by 3 or more key informants) or high significance (i.e. low frequency, but deemed
impactful by the research team). Key themes were discussed and determined in weekly
team meetings, facilitating an iterative process to ensure that themes were discussed in
depth and understood in context. The key themes are listed in Table 3. Internal (within
individual) barriers to accessing services included stigma and lack of readiness. Participants
discussed that the shame associated with being identified by others in the community
prevented their clients from reaching out to services. Participants noted Privacy concerns
because they could be easily identified by acquaintances while seeking mental health
services in a small community. These privacy concerns reflect the stigma surrounding
mental health services in tribal communities and how stigma might prevent access to
services. As a participant described, an internal challenge some clients confront is
overcoming the stigma about mental health issues and treatment. 3. Results Data were
collected from 21 participants representing 16 organizations in 8 different counties
throughout California (Oakland, Los Angeles, Covelo, Sonoma, Lake, Tulare, Bishop and
Sacramento). Approximately 43% of participants were female and 57% male with varying
occupations that included pharmacy /behavioral health director (n = 5, 24%), SUD
counselor (n = 4, 19%), primary care physician (n = 2, 10%), therapist (n = 2, 10%), case
manager (n = 2, 10%), among other occupations (see Table 2: Demographic information of
key informants). Most key informants identified as AI/AN (67%). When key informants
were asked to name the top three substances impacting their communities, all mentioned
methamphetamine, 95% Well …you know, the old stigma. You know, we’re a small
community, it kind of loops back around to the peer pressure thing… if you’re going to
[Organization Omitted] you must have some kind of problem. Again, like I mentioned …the
people, the most barrier is themselves, you know…the old saying…‘You need to get out of
your own way sometimes’. [Intern] -RXUQDORI6XEVWDQFH$EXVH7UHDWPHQW[[[ [[[[
[[[²[[[ I. Zeledon, et al. What I’ve dealt with is that a lot of Native Americans don’t want to
admit that they used opiates, you know, until later on because it’s considered, I believe,
from what they told me, it’s considered shame, shameful to use that. [Psychiatric Social
Worker] traumatic experiences that pose mental health issues and as a result, predispose
clients to substance use: “I also think that it’s a risk factor because someone from my
generation, you know, my mother was treated or grew up a certain way because her
grandmother and her parents were maybe placed in boarding schools or they saw different
events happened to American Indians, in terms of loss of language, and land, and
spirituality, etcetera. So I think that it’s just the transmission of trauma onto another person
and a person and another person until you figure out how to kind of manage your own
emotions and your own situations so that you can not traumatize other people. So yes, I
think people use substances to deal with the emotion and just chaos and learned behavior. I
feel like I’m just talking all over the place.” [Psychologist] Well, the clinic has a very robust
behavioral health department with, you know, psychiatrists, LCSWs, MSCCs, and, you know,

16. social workers, community outreach aides. So our, our clinic is very complete in services
offered but getting people to walk up that flight of stairs from the main lobby to the
behavioral health department is a huge challenge because everybody can see you walking
up the stairs and… “Boy, you must have a problem if you have to go upstairs.” [Director]
MAT was particularly stigmatized as it was often not viewed by clients or the community as
a form of sobriety. Destigmatizing MAT involved reframing MAT as a treatment for
addiction analogous to a biological disease. As a participant explained, recognizing MAT as a
legitimate part of medical treatment for addiction in the community helped clients accept
MAT services. Participants also spoke about the disconnection experienced by clients due to
cultural loss having a cumulative effect that places individuals at significant risk for
substance abuse and other problems. Disconnection from community or any event that
interferes with the individual’s sense of belonging to their community, such as poverty,
mental illness or lack of employment predisposed clients to substance use. Well, medication
assisted treatment has, has gone from being something that was stigmatized to something
now that has been recognized as, as part of, of good medicine, not somebody that’s got a
weak character and is a drug addict that needs help… it’s a medical problem or it’s a medical
opportunity and that it should be treated and not stigmatized. So that’s been a big challenge,
to get people to change their thinking about, you know, the, the people, you know. You used
to say the same thing about diabetics, you know, the type two diabetics, it’s a, it’s their own
fault that they’re dying of their diabetes, but you still treat them…it’s the, moving the stigma
out… [Physician] “I think the fact that some Natives have grown up in the city but they don’t
know about their traditional cultural practices. Some of them know they’re Native they
don’t even know their Tribe. I’ve met people who were adopted and found out they were
Native. So my point is if you have a loss, you know, of connection to your tribe or your
culture, that’s definitely a risk.” [Psychologist] “I would say anything that disconnects
people from, you know, from the community whatever all of those different things that I
listed. Whether it’s your loss of work, poverty, mental health condition, you know. When
people are having some kind of health challenges not just mental health where they get
disconnected from their community. That contributes to people trying to figure out how to
feel ok and substance abuse is often the way that people can turn to.” [Substance Abuse
Counselor] Lack of Readiness was also identified by participants as an internal barrier. The
process to recovery was described as an individualized experience. For some, seeking OUD
services is compulsory, not initiated by the client. Others seek assistance as needed to deal
with the negative consequences of their substance use and cycle between recovery and
relapse as described by the following participants: Additionally, mental health
comorbidities such as PTSD, anxiety, and depression were identified as placing individuals
at significant risk for developing a SUD, including OUD. Respondents believed that
underlying most SUD and OUD disorders is untreated depression, anxiety, trauma, and
other mental health issues that must be addressed to facilitate recovery. “Yeah, I think the
barriers are one of transportation or, you know, people just aren’t ready for what, you
know, a whole host of reasons. I don’t know why but none of us [inaudible] just that people
to tend to come in when they’re hitting the bottom rather than, you know, when they’re
comfortably floating around the middle and don’t think that there’s a problem yet.”

17. [Physician] Yeah, so, you know, dual diagnosis, I think across the line, at least were part of
most of our chronic drug use, and by definition our dual diagnosis with depression, anxiety,
and PTSD because of early trauma, that early childhood trauma and other things that go on.
We also have a substantial amount of mental illness that’s not taken care of in our society,
and specifically in the Native, in the Native part of our community, specifically addressing
serious mental health issues, including schizophrenia and other mixed diagnoses that
include PTSD mixed in with schizoaffective and other disorders. [Physician] Since recovery
is an individualized process with differing trajectories for each client, participants proposed
multiple entry points into OUD service system as necessary to increase clients’ likelihood of
recovery. “You know, because not everybody will acquiesce to services and recovery is a
multistep process and we don’t expect everybody to recover on the first try, and so there
has to be multiple opportunities for people to access these services. And a lot of people
wind up in lots of different programs for different periods of time.” [Director] Polysubstance
Use was also identified as a risk factor, with respondents noting that initiating one
substance exposed clients to other types of substance use. Specifically, for OUD, losing
access to prescription opioids resulted in transitioning to other more readily accessible
substances, such as heroin or methamphetamine. Participants described clients’
progression into polysubstance use as follows: 3.2. Risk factors The second code identified
themes related to risk factors leading to substance use disorders (SUD), particularly opioid
use disorders (OUD) in their local AI/AN community. One theme identified by KIs was the
impact of historical and intergenerational trauma on the well-being of communities and
family units. For example, participants spoke about I would think that most people who are
using one substance tend to use something else. I think it’s rare that we have people that are
only drinking alcohol or only smoking pot, I think it’s more usual that people may have
smoked a little bit and then gone on and tried -
RXUQDORI6XEVWDQFH$EXVH7UHDWPHQW[[[ [[[[ [[[²[[[ I. Zeledon, et al. other things and
eventually come to their drug of choice, which might be methamphetamines or opiates or
alcohol. But along the way they, they, our patients tend to be exposed to and use other
things, too. So I don’t know, I’m, I’m guessing somewhere between 10- and 20%
polysubstance abuse, but most people claim, you know, “My go-to is alcohol,” or Norco, or
meth, or whatever. [Intern] community members. So that’s definitely a strength, you know,
the culture itself. [Substance Abuse Counselor] I think connection is the key to decreasing
any mental health or substance abuse issue for people in general. So when people are
connected to their community whether, whether that be their family, friends, you know
even at this clinic, I feel like this is home for people a lot of times. They come here to connect
back into the community. And it definitely gives people a place to feel like they belong and
are able to start that journey of healing. So absolutely. [Therapist] Actually quite often. They
almost pretty much go hand in hand here. You know, whatever the reason is they start out
on painkillers or stuff and then they slowly adapt to street drugs because of, of loss of
prescriptions and everything. And, I mean, seriously, they just kind of go, you know, alcohol
and the methamphetamine and the heroin and the opiate abuse, it’s more than not here I
would say. [Physician] Patient-Provider Communication was identified as an important
facilitator of effective treatment. Building trust and connection included creating safe spaces

18. for clients, providing or referring to culturallycentered services, and honoring of cultural
traditions by physicians and providers. Participants attributed the disconnect between
clients and non-Native providers to a lack of understanding of the AI/AN way of life, limited
culturally-centered treatment resources or a lack of understanding of the specific life
experiences that impact AI/AN communities. The Normalization of SUD, particularly OUD,
was identified as contributing to community norms that promoted the chronic and
pervasive exposure to substances in many AI/AN communities. Finally, Economic Stress
was noted as a key contributor to risk for SUD, including poverty, lack of employment and
financial issues. There’s poverty, there is… In our community I feel like there is a lot …But in
the community, for example if somebody ends up in the criminal justice system they’re
mandated to do certain kinds of treatment and that may not necessarily work for them…So
the risks and the stressful events can be homelessness, inability to provide for oneself,
whether that’s food, shelter. Difficulty may be finding employment, difficulty connecting–
That’s what I was trying to say with that other example there’s a difficulty of connecting into
the larger system of support and community because people don’t maybe have the cultural
understanding of our community here at the clinic and… Especially with the poverty that
can get very kind of, what I would say snowball, so if somebody has one life event like a
major health issue like cancer or they get in a car accident or they for some reason lose their
longtime job, it can spiral and it can spiral someone because they don’t have that financial
space or ability to rebuild. And so that can that can be really… It can be really stressful and
it’s part of the risks for people. [Substance Abuse Counselor] There’s a, a big disconnect with
Native people and non-Native providers. And there’s, there’s a trust issue that many
traditionally trained providers don’t know how to overcome. And so the effectiveness
because of a lack of trust is diminished in many instances between non-Native providers
and Native patients. [Physician] I think there are resources that are based in our clinic and
traditional things …It can be a benefit to have a really strong cultural base for treatment
opportunities for patients. We also have staff that are Native that address specific Native-
centric issues that I think are important, and I think the use of Red Road and other
programs that have a different interpretation of Twelve Steps and how to integrate that into
a Native’s lifestyle are imperative. [Substance Use Counselor] Solutions to increasing the
effectiveness of patient-provider communication included having providers educated on
cultural sensitivity, being exposed to AI/AN culture and traditional treatments, and helping
providers get comfortable referring their clients to culturally-centered treatments. One
participant shared the following strategy for increasing cultural sensitivity in their
providers: 3.3. Protective factors The third code identified protective factors that facilitate
resilience against SUD and OUD and promote recovery and overall wellness in AI/ AN
communities. Cultural Cohesion was identified as the extent to which family units and
community members participate in cultural activities. For example, beading and drumming
in a drug-free environment allows positive cultural engagement. However, cultural
activities are more available on Tribal lands than in urban areas. Family dynamics was
described as immediate and extended family supporting, caring for, and nurturing one
another. Both family units and community events were reported as an opportunity to feel
connected and have a sense of belonging that is crucial to heal from SUD. And then our

19. clinicians who are providing services have some sort of background, a lineage, with being
Native American but didn’t necessarily grow up with that. A lot of our case managers
definitely have grown up in that environment going to sweats and ceremonies and really
being involved in their culture. So we really kind of have a mixture. But one thing that we,
we focus on is, even if someone comes in and they’re non-Native American, really trying our
best to help educate and getting them exposed to, all of what our culture has to bring so
they’d be comfortable with talking about it and referring [to culturally centered services] if
needed. And being culturally sensitive, that’s important, we never want to, offend our
clients or anything like that, so educating our providers as much as possible. [Therapist]
Well, I think that the fact that we have so, so many different cultural activities, I think that’s
a huge strength of our community and it’s a huge resource for our community. I think our
ceremony is important, you know, and I think one, one challenge that I see is not having a
lot of, you know, different activities or outreach or resources like on a reservation. So I think
that’s limited but I think, you know, locally here in the urban setting, you know, our
powwows, you know, smudging, prayer, sweats, talking circles, those are definitely a little
more accessible, especially with some of the different, you know, Native programs around
and, and connecting with Pain Management Contracts, which are agreements between
patients, physicians and behavioral health practitioners to monitor the prescribing of pain
medications, were also identified as important tools in preventing OUD for clients with
chronic pain. Contracts decrease diversion of opioids and allow clients to manage their pain
with decreased risks for OUD. Contracts were reported as most effective if -
RXUQDORI6XEVWDQFH$EXVH7UHDWPHQW[[[ [[[[ [[[²[[[ I. Zeledon, et al. coupled with
Active Case Management, which involves having an integrated team of primary care
physicians and mental health professionals coordinate the client’s care. Active case
management was reported to increase pain management contract adherence and facilitate
management of relapse by ensuring patients were being treated at the right dosages and
without abrupt changes to care. Participants reported the benefits of pain management
contracts in reducing OUD and the utility of active case management in contract adherence
and management of relapse as follows: Table 3 Summary of key informant needs
assessment themes. Barriers to accessing services External barriers ● Transportation ●
Lack of insurance coverage ● Waitlisted for services ● Unstable living conditions ● Privacy
● Lack of sober living conditions ● Lacking multiple entry points Internal barriers So I, I
think it’s [Pain management contracts] useful, I think it engages the patient with behavioral
health. There’s usually some underlying issues that we [behavioral health] can be of help
with. You know, it, it helps us track their use, whether it’s being diverted or abused. I’d say
the most challenging piece of that contract is to get them to follow through. You know, they
agree to three sessions with behavioral health and it’s not uncommon for them to attend
one or two, but to get them to attend three can be a bit challenging. [Director] Risk factors
Protective factors Well, we do a lot of warm handoffs when folks are seeing [omitted], who
are our addiction therapists, and there’s a mental health issue going on. We’ll, they’ll pull me
in and I’ll meet the individual, and vice versa if I’m working with somebody with a
substance use issue, I’ll do a warm handoff, get them acquainted, making appropriate
referrals. We’re working on becoming a little more integrated over on the primary care side.

20. [Psychologist, PhD] SUD and OUD services available ● ● ● ● ● ● ● Service system needs
● ● ● ● Community substance use description Pain management contracts are successful
if there’s a close relationship with the physician prescribing medication and the behavioral
health provider. Patients can often see pain management contracts as punitive and this can
interfere with their effectiveness. Managing patients closely with Behavioral health and
primary care physicians will help prevent abrupt changes in their medications or
discontinuity in medications if contracts are breached.” [Substance Use Counselor] ● ● ●
● ● ● ● ● ● ● ● ● ● ● …we have a robust program right now for specifically
addressing opioid dependence and, use and abuse, and also with chronic pain. That’s, we
have a, a multidisciplinary program that involves a clinical pharmacist, behavioral health,
medical personnel, as well as a medical social worker. Our team in the clinic includes the
provider as well as the medical assistant and the case manager or nurse that have identified
who our substance use patients are and doing protective work in terms of making sure that
treatment is being offered and followed, as well as treatment through referrals to
behavioral health and addressing substance use as a medical problem, or polysubstance
abuse, dual diagnosis as a, a medical problem that includes referrals to behavioral health.
Unfortunately, there’s not enough support in terms of monies and availability for specific
psychiatric help, which is problematic for mental illness, which includes things like ADHD
for, ADD for kids, as well as polysubstance abuse and other mental illness problems.
[Physician, MD] Lack of readiness Stigma Polysubstance use Mental health comorbidities
Historical and intergenerational trauma Disconnection Economic stressors Normalization
(of drug usage) Cultural cohesion Family dynamics Patient-provider communication
(cultural sensitivity) Active case management/integrated care Pain management contracts
Management of relapse Increased use overall Easy access to substances Age of substance
use initiation is younger Medication Assisted Treatment (MAT) programs Wellbriety
Traditional healing Cultural activities AI/AN inpatient/residential treatment facilities
AI/AN sober living facilities Life skills and re-entry aftercare programs Transportation to
services As for the youth, it’s kind of almost become societal, it’s kind of been that, the thing
to do. I know specifically with the opioid use and pill use, having children in high school, it is
pretty prevalent and, you know, that, it’s kind of like before in the past it would be like the
marijuana use, now I would say that pill use is almost kind of on the same level. You know,
that’s almost like the gateway now. [Case Manager] From my experience as a substance use
counselor you see an onset as a young adult and Then it kind of turns into this battle that
they struggle with for like 10 to 20 years. I mean it’s been extremely hard for the opiates
population to get off of the drugs and stay off the drugs and achieve long term sobriety. And
even if they do they tend to switch addictions. So they’ll go from like opiates to heroin. And
once they get off… I’m sorry Opiates to meth. And then Sometimes they’ll just be struggling
with alcohol after that so it’s a long road for them. [Therapist] 3.4. Community substance
use characteristics A common community characteristic described by participants was the
easy access and availability of substances within the community. This easy access to
substances included substances such as heroin, methamphetamine, and opioids. The fourth
code captured information about the prevalence and trends in SUD and OUD in urban and
tribal communities throughout California. Participants noted Increased Use Overall

21. throughout AI/AN communities in California, with the most common substances described
in Table 3: Most Common Substances Reported by Key Informants. In youth, participants
reported that the Age of Substance Use Initiation is Younger than in previous years and
there is a high prevalence of use among youth peers. The implications of earlier onset were
reported as a longer trajectory of recovery with a higher risk for polysubstance use.
Unfortunately, they’re too accessible. We have one, two, three stores alone here in this small
community that sell various kinds of alcohol and, and a bar. Unfortunately, the street drugs
such as meth and heroin are just way too easy to access. [Substance Use Counselor] -
RXUQDORI6XEVWDQFH$EXVH7UHDWPHQW[[[ [[[[ [[[²[[[ I. Zeledon, et al. So from what
I’ve heard it’s pretty accessible. I know I’ve worked with a lot of different clients who’ve,
who said a lot of very consistent things with, “You know, if, if I need something I know
where to get it.” And so that’s kind of where sometimes the conversation will shift, and so
very rarely does, has anyone said, “Well, this is where I’ve gotten it,” or “This is where I can,”
it’s usually kind of grazed over with something simple as, “You know, I know if I go down
this street I could get what I need,” “I know if I go to this certain person, you know, I know I
can get what I need.” So to my knowledge it, it seems pretty accessible to the individuals
who, who need whatever the substance is. [Therapist] Traditional Healing and Cultural
Activities were often offered either onsite or through referrals in the organizations. While it
was reported as an important resource of a culturally-centered program, challenges still
exist regarding how to best integrate traditional healing with behavioral health and primary
care. The other thing that’s not supported and we don’t know how to do it well would be to
support our Native healers to our Native communities that do healing apart from drug
abuse. I think healing in general would be a means of appropriately supporting the many
Native healers that we have and would go a long way. And there’s no established, really
good way of doing that right now that I know of, but figuring out how we could integrate,
you know, the traditional and spiritual treatment for patients in with our behavioral health
and medical health would be awesome. [Physician, MD] I would, any, anybody can get
anything they want. Probably with the exception of the opioids because of the way that
they’re being monitored, but they could probably get those outside the community
anywhere they want as well. [Psychologist] 3.6. SUD and OUD service system needs 3.5. SUD
and OUD services available The sixth code described participants’ perceptions about what
services were needed most in AI/AN communities in California. Participants spoke of the
need for AI/AN Inpatient or Residential Treatment Facilities, noting that few of these
resources existed within their communities, particularly in rural areas. The allotted length
of stay in these services was also often not considered sufficient to help transition the client
back into the community. A major challenge for clients was not having a sober living
environment after leaving an inpatient or residential treatment facility. Participants noted
the importance of AI/AN sober living facilities to extend remission and recovery beyond
initial acute treatment. Life and Re-entry Skills Programs were also identified as being a
critical service for promoting enhanced recovery. These services can assist clients in being
engaged and having a skillset to be able to provide their basic needs, like housing and food.
The fifth code identified current SUD and OUD treatment services available and perceptions
about the access to and quality of such services. Medication Assisted Treatment (MAT)

22. programs were reported as an available resource at clinics or through referrals. Suggestions
to improve the effectiveness of MAT services included providing additional support using
residential treatment or aftercare simultaneously. Case management, aftercare, education.
You know implementing and using a MAT program, but also getting them the proper
treatment. I mean there are some clients… We are an outpatient facility, but there are some
clients that most benefit, they don’t know either …and they need that extra push to go into
residential. So having that available as well. [Director] I think you know [Organization
Omitted] is a program that is good for helping people get mental health treatment. But I
think one of the challenges is that sometimes people will be there for 90 days and then they
might go back to the reservation and or and then they go back into the same environment or
they’re there for 90 days and they think oh I’m going to live in L.A. and I’m going to go to
school. But what people don’t realize is that if you’re not from Los Angeles and you don’t
have a good job it’s very difficult to live here and just start going to school or going to work.
It’s very expensive I guess is the problem. So I think that treatment’s good but I think there
needs to be more transitional services. [Substance Use Counselor] The second service
identified by participants as being currently utilized is a Wellbriety. Wellbriety programs
are culturally adapted Twelve Steps of Alcoholics Anonymous (A.A.) programs that utilize
teachings of the Medicine Wheel to incorporate Native American cultural elements to assist
in sustaining sobriety to recover from the effects of drugs and alcohol (Coyhis & Simonelli,
2008; White Bison). Traditional Healing and Cultural Activities were reported as available
services that provided clients with a way to reconnect with their culture. Reconnecting
clients to their culture and community was a major component to successful treatment.
Many KIs recommended having more funding to provide community events such as
traditional arts and dance in addition to partnering with other organizations that provide
cultural services. Many Cultural Services were identified as important in transmitting life
lessons and values that contribute to connecting to the AI/ AN culture. One example of a
cultural activity provided was teepee building: Like in substance abuse, arrest, and
addiction is only one part, you know. People have to learn like life skill and engage in like
new healthier activities, so the cultural activities are really important. As the substance use
providers, we have to be able to provide them with the resources to get established, so like
housing and food, gifts Cards. Of course, whenever you’re having these meetings, to have
food. [Substance Use Counselor] Well the teepee… With the North American Tribes it
actually was home, inside that teepee. There was life, there was birth, there was love…Also,
the other part of the teepee is there are actually 18 poles. When I build the teepee, I tell
these guys that one pole cannot hold up the whole teepee. So when we start intermingling
all the poles together it becomes strength. It becomes strong. We have to depend on each
other when the poles are leaning against each other and tied off, that teepee will withstand
probably 60 mile winds. Its strength is togetherness. Cohesiveness. And that’s where the
family is. That part of teaching is what I teach. So it does relay that. And that was told by my
father and his father told him and his father told him. So the responsibility comes to me to
provide for my family. To Provide shelter, food. [Director] Finally, participants highlighted
the need for Transportation to Services, given the remote locations of many tribal areas and
the dispersion of available services, many far from areas where AI/AN people actually live.

23. 4. Discussion Our KIIs identified major themes relevant to evaluating the current state of
SUD and OUD treatment in California AI/AN communities. Themes were organized by an a
priori coding structure based on the structured interview that captured information across
six primary -RXUQDORI6XEVWDQFH$EXVH7UHDWPHQW[[[ [[[[ [[[²[[[ I. Zeledon, et al.
substantive areas: (Beckstead et al., 2015) Barriers to Accessing Services; (Brave Heart et
al., 2016) Risk Factors; (Bureau of Indian Affairs, 2014) Protective Factors; (Bussey, 2011)
Community Substance Use Descriptions; (California Courts, 2019) SUD and OUD Services
Available; and (CDC, n.d.) Service System Needs. Several “meta” themes were pervasive and
cross-cutting across coding categories; therefore, we integrated this information to
conceptualize critical areas for further study related to improving SUD and OUD services to
AI/AN communities. Our discussion is organized around these perceived domains related to
promoting effective culturally-relevant SUD and OUD services to these communities.
provider communication and active incorporation of case management through effective
integration of multi-disciplinary providers in the management of clients’ treatment plans.
They noted that a team approach where clinicians, case managers, patients, and other
relevant providers communicate and collaborate is critical to the success of treatment.
Another key gap in services is the need for transitional care when clients return from acute
care back to their communities. Participants noted the lack of sober living and community
integration services and attributed the high rates of relapse in AI/AN communities to the
lack of these services. There is evidence to support the critical need for community-based
services to sustain sobriety as detox and acute treatment are just the first in many steps
towards recovery and healing (Hazel & Mohatt, 2001). Especially in AI/AN communities
where SUDs are highly prevalent and community norms sometimes may allow for the
normalization and encouragement of substance use, it is vital that clients in recovery have
access to other sober individuals and community supports that help sustain their recovery.
Related to the importance of a system of care approach, KIs noted that effective SUD and
OUD treatment programs would directly address the multitude of barriers to accessing
services in AI/AN communities. Among those mentioned were distance to travel, insurance,
transient living conditions, and privacy concerns. In addition, KIs identified the role of
stigma about treatment and a general lack of preparation or readiness of some AI/AN
community members to receive services. Thus, findings from this initial study suggest that
what might work best in these communities is a coordinated system of services that
promotes a wrap-around approach encompassing the various needs along the spectrum of
recovery from acute treatment to sober living conditions within the local community, with
open and transparent communication between the patient and various providers. In
addition, effective treatment would directly address known barriers to treatment success
such as stigma and readiness to change, as well as practical impediments such as distance,
insurance, and privacy. Responses from KIs reinforce the idea that system developers need
to take a bird’s eye view to the holistic system of care needed by AI/AN individuals in
recovery rather than work in silos that remain disconnected and fragmented and set both
individuals and the system up for failure. KIs reported the lack of residential substance
abuse treatment centers for AI/AN populations. Specifically, such treatment programs can
provide a positive spiritual experience, empowerment, increase selfesteem, reconnect to

24. traditional values, and allow forgiveness (Edwards, 2003). Additionally, outpatient
aftercare is needed to provide support groups, family counseling, and employment
opportunities. It would be particularly beneficial for the clients if the transitional care was
near the residential treatment centers to enhance their recovery services and alleviate the
potential of returning to the same environment that initially started their substance use
behavior. If more soberliving homes for clients were available it could reduce the high rates
of recidivism (Jason & Ferrari, 2010). 4.1. Cultural factors that facilitate effective treatment
The KIs highlighted the importance of culturally-centered activities and treatments to
prevent and/or treat SUD, particularly OUD. They recommended that traditional healers
become an integral part of the MAT program to provide culturally based sources of healing
and develop the spiritual, mental, and physical strengths of the individual. The
incorporation of traditional and cultural activities into health services resonates with the
AI/AN worldviews, as suggested by others (Gone, 2004; Rieckmann et al., 2016). Indeed,
previous literature suggests that participation in cultural activities and ceremonies such as
sweat lodges, drumming, singing, beading and regalia making can provide relief from
distress and strengthen individual and community support systems to heal (Dickerson,
Robichaud, Teruya, Nagaran, & Hser, 2012; Moghaddam & Momper, 2011). In particular, the
KIs described the Wellbriety concept, which means to be sober and well from a holistic
perspective congruent with AI/AN cultural belief system. Wellbriety also acknowledges the
unique history of AI/AN and is offered in some Tribal and Urban Indian Health clinics in CA.
It has been used with clients who accept both western medicine and traditional healing
treatments to develop coping skills, reconnect with their AI/AN identity, and engage in their
community and with family members. Cultural activities create safe spaces for clients to re-
engage with family and their community, which builds trust and improves connection with
others. This may be particularly important to address historical trauma in the treatment
process. KIs described the very real contemporary impact of historical traumas such as
genocide, separation from tribal homelands, boarding schools, and attempts at cultural
annihilation. There is longstanding evidence of the connection between trauma exposure
and the development of SUD with AI/AN communities having an aggregate exposure to
historical trauma (Lucero & Bussey, 2015). Separate from the intergenerational effects of
historical trauma, there is evidence that AI/AN peoples are also disproportionately affected
by direct trauma exposure and adverse life events (Kenney & Singh, 2016). Consistent with
this evidence, KIs described a common pattern among clients who have experienced trauma
including child abuse, domestic violence, and family dysfunction. There is a clear link
between clients’ reports of experiencing trauma, untreated post-traumatic stress disorder
(PTSD), and self-medicating with drugs and alcohol (Bussey, 2011; Gone, 2013). Ultimately,
results from the KIs suggest that effective SUD and OUD services will incorporate a
culturally responsive approach to working with AI/AN populations, one that incorporates
cultural values and tribal worldviews. 4.3. Treating mental health issues alongside
substance abuse KIs mentioned rates of SUD and OUD and their comorbidity with anxiety,
depression, PTSD and other mental health diagnosis among AI/ AN populations. These
issues disproportionately burden the AI/AN community with high levels of morbidity and
mortality related to SUD and co-occurring disorders. Studies have shown AI/ANs with SUD

25. were also at high risk for comorbid psychiatric disorders (Gilder, Wall, & Ehlers, 2004;
O’connell et al., 2006). In addition to a higher prevalence of SUD, AI/ANs also have a higher
prevalence of anxiety and other mood disorders, compared with Non-Hispanic Whites
((Brave Heart et al., 2016). As we consider the implications of these results and our
qualitative findings, adequate treatment is important to address the overall well-being and
health of AI/AN populations. 4.2. Addressing individual and systemic barriers to effective
treatment The KIs reported an overall increase in SUD and OUD in their local communities,
especially among younger age youth. KIs noted that treatment is essential to curb the high
rates of SUD and OUD, and that current services are lacking in many areas. While MAT
services are available in some areas that are accessible by AI/AN, many AI/ANs are unable
to access comparable services. In addition, KIs spoke to the importance of a system of care
approach in which there is good patient -RXUQDORI6XEVWDQFH$EXVH7UHDWPHQW[[[
[[[[ [[[²[[[ I. Zeledon, et al. 4.4. Recognizing and capitalizing on community and cultural
strengths multiple factors affecting AI/AN individuals and communities regarding the
impacts of opioid use. As part of the USC California Tribal and Urban Opioid Needs
Assessment, additional data collection is currently underway including statewide focus
groups targeting AI/AN youth and adults in both urban and rural/Tribal communities. The
data from these focus groups will be used to better understand the community-level
experience and impact of the opioid crisis in Tribal and urban AI/AN Communities.
Integrated with the findings presented in this study, subsequent research will develop a
comprehensive picture of the AI/AN community and service system needs to develop
effective, culturally centered OUD treatment and statewide system change. The cultural
strengths of AI/AN communities are generally believed to be essential to assisting an
individual in quitting their addiction, maintaining recovery, and preventing relapse. These
strengths include strong family values, respect for elders, community connectedness, and
maintaining a traditional way of life. Cultural activities are essential in providing the
opportunities for a sense of belonging and cultural identity to be built. Cultural
connectedness, which involves engagement in traditional activities, identification with
AI/AN culture, and spirituality, is a protective factor against alcohol dependence, of
substance use, violence, delinquency, and suicidality (Hill, 2006; Yu & Stiffman, 2007). High
levels of cultural connectedness have been associated with resilience (Henson, Sabo,
Trujillo, & Teufel-Shone, 2017; Pu et al., 2013; Mmari, Blum, & Teufel-Shone, 2010; Pharris,
Resnick, & Blum, 1997). Cultural activities also reinforce the AI/AN beliefs and way of life.
An existing AIAN framework, The Relational Worldview, outlines the indigenous people
values of extended family, meaning of land and spiritual elements (Goodluck, 2002). These
elements combine in traditional AIAN medicine wheel teaching in which well-being means
having balance and harmony (Roundtree & Smith, 2016). Oral and ceremonial traditions
have embedded within them lessons for character strength building, resiliency, reciprocity,
and connections to the community (Isaacson, Bott-knutson, Fishbeck, Varnum, &
Brandenburger, 2018). References Beckstead, D. J., Lambert, M. J., DuBose, A. P., & Linehan,
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Arizona Press. 4.5. Limitations Limitations to this study include that participants may not be
representative of all OUD/SUD service providers. For example, even though traditional
healers were reported as a strength and integral for the delivery of culturally-centered
services, our survey of KIs does not include traditional healers or those facilitating cultural
activities. However, recommendations were made by KIs for traditional healers to be
permanent paid employees by the Indian Health clinics. Th…