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Multilevel Prevention on Southern California Reservations
Multilevel intervention including community-wide and individual-level prevention strategies to reduce underage drinking.
This intervention to reduce underage drinking is composed of community level efforts to raise awareness among convenience store clerks using Rewards and Reminders (R&R) and the community using outreach presentations and activities, as well as individual-level interactions with Tribal youth using brief motivational interviewing (MI) or psycho-education. R&R uses “decoys” who appear to be underage to reduce successful alcohol purchases without identification (see R&R webpage). In the described implementation, American Indian outreach staff made 298 presentations or disseminated information to youths, community members, Tribal leaders, and medical staff. Culturally adapted MI was compared with psycho-educational sessions delivered individually or in small groups in single 1.5-hour sessions. The overall efficacy of this multilevel intervention was tested using a quasi-experimental design in a reservation-based community.
Outcomes
Modest beneficial effects demonstrated in three types of outcome data.
There were three types of outcome data: R&R clerk compliance data; self-report alcohol consumption data from youth randomized to MI or psycho-education; and overall intervention effects measured with state-level self-report alcohol consumption data from the California Healthy Kids Survey (CHKS). The R&R component found that after the baseline (33%) and first round of post-intervention (38%) visits, no stores (0%) failed to request identification during an alcohol sale. The comparison of MI and psycho-education found no difference across conditions but decreased alcohol consumption and behavioral problems among youth who were already drinking at baseline, and a slight increase in consumption and no change in behavioral problems among youth who were not already drinking at baseline. The analysis of CHKS state survey data found decreases in lifetime and 30-day frequency of drinking (26.5% decrease in mean drinking days vs 14.3% and 16.7% in comparison groups) and heavy drinking (31.4% decline in frequency compared to a slight increase in the two comparison groups) among AI/AN youth in communities exposed to the intervention.
Costs
Medium start-up costs followed by slightly lower ongoing costs primarily for supporting staff.
Medium-level start-up costs include hiring and thoroughly training staff in MI, training decoys, and creating educational and outreach materials. Ongoing costs include repeated visits to convenience stores, outreach activities (including presentations and informational activities), space and personnel for MI or psycho-education sessions, travel, incentives, and rewards for R&R clerks.
Cultural Engagment
Interventions modified from non-Native programs with community and Tribal input.
The community awareness activity materials were culturally adapted to include local imagery and laws. The individual-level interventions employed a culturally tailored MI manual. Tribal leadership prioritized the project, a Tribal Advisory Group was formed, and Tribal Councils approved proclamations for R&R.
Participants
Adolescent, Young Adult; Native; Female, Male
Setting
Community Wide, Clinical/Healthcare, Reservation
Delivery
Individual, Small Group, Large Group, Multi-level
Convenience store clerks and reservation-residing youth.
R&R participants comprised 51 clerks (27 women, 24 men) working at outlets selling alcohol near or on reservations, with a mean estimated age of 31 years. The Native status of the clerks was not noted. MI and psycho-education participants included 60 AI/AN adolescents (24 boys, 36 girls) between 13 and 20 years of age. Seven waves of CHKS data for students in 9th and 11th grade were analyzed comparing three groups: AI/AN students from schools surrounding the intervention reservations (n = 617), non-AI/AN students from the same schools (n = 33,469), and AI/AN students from schools further removed from the intervention reservations (n = 976).
Staffing Needs
Community Member
Community members served as decoys and conducted community presentations. AI/AN staff delivered the MI intervention.
R&R decoys were community members trained by advanced degree professionals. The staff member who provided the MI intervention was an AI/AN researcher from the reservation clinic, trained in motivational interviewing.
Research Design
Quasi experimental design
Developmental stage of research
The mid-stage categorization reflects beneficial effects of R&R and in the overall sample exposed to MI and psycho-education, while recognizing the limitations of small sample size, lack of comparison groups, and possible bias in sample selection.
The pilot studies demonstrated largely positive results. However, there were no control groups and no difference between the two intervention groups (MI and psycho-education). Comparisons were made between baseline and 6-month follow-up only, and participants were divided into drinkers and non-drinkers. Indirect data from CHKS provide intriguing support for overall intervention efficacy. Future research would benefit from longer implementation and follow-up.
Potential
This multilevel intervention may be transferable to other reservation-based communities.
With strong community support and engagement, this multilevel intervention could be adapted and delivered to other Native communities. The R&R intervention was shown to be effective. A longer term of implementation of R&R could result in enhanced restriction of alcohol sales to youth at little additional cost.
References
Moore RS, Roberts J, McGaffigan R, et al. Implementing a reward and reminder underage drinking prevention program in convenience stores near Southern California American Indian reservations. Am J Drug Alcohol Abuse. 2012;38(5):456-460. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3445436. https://doi.org/10.3109/00952990.2012.696758.
Gilder DA, Geisler JR, Luna JA, et al. A pilot randomized trial of Motivational Interviewing compared to Psycho-Education for reducing and preventing underage drinking in American Indian adolescents. J Subst Abuse Treat. 2017;82:74-81. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5683100. https://doi.org/10.1016/j.jsat.2017.09.004.
Moore RS, Gilder DA, Grube JW, et al. Prevention of underage drinking on California Indian reservations using individual- and community-level approaches. Am J Public Health. 2018;108(8):1035-1041. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6050833. https://doi.org/10.2105/ajph.2018.304447.
Ehlers CL, Geisler JR, Luna JA, et al. Community awareness of outreach efforts to reduce underage drinking on California Indian reservations. Am Indian Alsk Native Ment Health Res. 2020;27(1):21-41.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7197713. https://doi.org/10.5820/aian.2701.2020.21.
Lee JP, Moore RS, Roberts J, et al. Off-premise alcohol outlets on and around Tribal land: Risks for rural California Indian youth. J Ethn Subst Abuse. 2015;14(1):59-78. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4344917. https://doi.org/10.1080/15332640.2014.958643.
Gilder DA, Luna JA, Calac D, Moore RS, Monti PM, Ehlers CL. Acceptability of the use of motivational interviewing to reduce underage drinking in a Native American community. Subst Use Misuse. 2011;46(6):836-842. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3075848. https://doi.org/10.3109/10826084.2010.541963.
Venner KL, Feldstein SW, Tafoya N. Native American Motivational Interviewing: Weaving Native American and Western Practices. A Manual for Counselors in Native American Communities. Unpublished treatment manual. Albuquerque, NM: Center on Alcohol, Substance Use, and Addictions. 2006. https://casaa.unm.edu/assets/html/namitxt.html.
Related Intervention Webpage
National Institute on Alcohol Abuse and Alcoholism. Reward and Reminder (R&R). October 2024.
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