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This is the Results Article for CTN-0044-A-2.
Longstanding disparities in substance use disorders and treatment access exist among American Indians/Alaska Natives (AI/AN). Computerized, web-delivered interventions have the potential to increase access to quality treatment and improve patient outcomes. National Drug Abuse Treatment Clinical Trials Network (CTN) protocol CTN-0044 established the efficacy in lowering drop-out rates and increasing abstinence of an interactive, web-based version of the Community Reinforcement Approach (CRA) intervention plus incentives, the Therapeutic Education System (TES). However, TES has not been tested among AI/AN populations. This mixed method acceptability study was conducted at two urban outpatient substance abuse treatment programs affiliated with the Clinical Trials Network; one in the Northern Plains region, the other on the Pacific Northwest. The sample consisted of 40 urban AI/AN, and results found TES acceptable across seven indices (range 7.8-9.4 on 0-10 scales with 10 indicating highest acceptability). Clients gave the highest ratings of acceptability to TES modules that included HIV/STI information, as well as managing triggers that can lead to risky sexual or drug using behavior. Modules receiving lower ratings tended to be those completed earlier; lower rating may reflect features of TES functionality, such as getting comfortable with the interface and answering questions to demonstrate learning to be able to move from one module to the next. Initial, lower acceptable rates, and the relatively low use of the internet of the population at baseline, may indicate that web-based interventions need more comprehensive introduction in this population.
Conclusions: Overall, findings suggest that core TES content is acceptable among a diverse population of AI/AN clients in outpatient substance use treatment. Qualitative interviews suggest adaptation of the TES content specific to AI/AN culture could improve adoption. Additional efforts to adapt TES and conduct a larger effectiveness study are warranted.
Related protocols: CTN-0044-A-2
With high rates of substance abuse and barriers to treatment, American Indian/Alaska Native (AI/AN) clients could benefit from culturally sensitive web-based treatments. This study, CTN-0044-A-2, will examine culture and ethnicity in AI/AN clients enrolled in outpatient substance abuse treatment and how culture is related to the acceptability of the Therapeutic Education System (TES), a web-based version of the Community Reinforcement Approach. AI/AN clients from two programs (Northern Plains and Pacific Northwest) completed assessments at baseline and 1 week after the 8-week intervention phase. Participants completed the Scale of Ethnic Experience and questions from the ASI-Native American Version. Participants were also asked to complete 32 skills-based TES modules on acceptability and relevance. Sixty-eight clients were approached to participate in twice weekly TES and assessments; 4 agreed (58.8%). The sample was about half female, mean age 36. Over 80% participated in AI/AN cultural activities, including AI/AN religious ceremonies, dance activities, and church meetings. About half were familiar with their native language, and 73% had lived on a reservation. Analyses will include exploratory chi-square (categorical) and t-tests (continuous) to determine if cultural involvement variables are related to TES acceptability. This study will explore how culture and ethnicity relate to the acceptability of a web-based intervention.
Long standing disparities in substance use and treatment access exist among American Indian/Alaska Native (AI/AN) communities. A web-delivered intervention could address some of the access barriers and improve service delivery. The purpose of this CTN platform study was to assess the acceptability of the Therapeutic Education System (TES), a web-based version of the Community Reinforcement Approach, among AI/AN men and women enrolled in outpatient substance abuse treatment. Acceptability was measured by (a) proportion of participants who agreed to participate; (b) treatment retention; and (c) participant feedback collected after each TES module across seven acceptability indicators. Sixty-eight clients were approached for the study and 40 enrolled (58.8%). Participants completed an average of 19.5 modules. Results indicate high acceptability across seven indicators: interesting (M=8.3), useful (M=8.5); introduction of new material (M=8.3), easy to understand (M=7.4); satisfaction (M=8.5); relevance (M=8.4), and overall likability (M=8.2). Efficacious interventions often require context or population-specific adaptation to maintain effectiveness during implementation. Overall, these findings suggest that core TES content is acceptable among a diverse AI/AN client population who agreed to participate. Initial, lower acceptance rates may indicate that web-based interventions need more comprehensive introduction. Acceptability may improve for several modules with greater visibility and integration of AI/AN-specific culture.
Related protocols: CTN-0044-A-2