Motivational Interviewing and Culture for Urban Native American Youth (MICUNAY)
Phase: NA
Conditions: Alcohol Use, Marijuana Use
Sponsor: RAND

 
Study Protocol and Statistical Analysis Plan 
Date: 05/09/2024 
National Clinical Trials #: NCT02290938 
Study Title: Motivational Interviewing and Culture for Urban Native American Youth 
(MICUNAY) 
 
 
 

 
SIGNATURE PAGE 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Principal Investigator 
         Name  
 
 
 
 
 
           (Date) 
 
 
 
 
Author 
        Name  
 
 
 
 
 
 
          (Date) 
 
 
 
 
 
 
 
Principal Investigator 
 
Title/Position 
 
Organization 
 
Location 
Elizabeth J. D’Amico 
Senior Behavioral Scientist 
RAND 
Santa Monica, California 
ClinicalTrials.gov identifier 
NCT 
Author 
 
Title/Position 
 
Organization 
 
Location 
Michael Woodward 
 
Research Operations Administrator 
 
RAND 
 
Santa Monica, CA 
Version 
Draft 0.1 
Elizabeth J. 
D'Amico
Digitally signed by 
Elizabeth J. D'Amico 
Date: 2024.05.09 
15:26:21 -07'00'
Michael J. 
Woodward
Digitally signed by Michael J. 
Woodward 
Date: 2024.05.09 15:27:17 -07'00'

 
Abbreviations 
 
AI/AN 
American Indian/Alaska Native 
CWG 
Community Wellness Gatherings 
AOD 
Alcohol and other drug 
MICUNAY 
Motivational Interviewing and Culture for 
Urban Native American Youth 
SPIWC 
Sacred Path Indigenous Wellness Center  
MI 
motivational interviewing 
RSE 
Resistance self-efficacy 
MEIM 
Multigroup Ethnic Identity Measure 
RCT 
Randomized Controlled Trial 
IRINAH 
Intervention Research to Improve Native 
American Health 
EBP 
Evidence-based Practice 
 
 
 
 
 
 
 
 

 
 
 
 
 
 
4 
 
 
 
Study Protocol 
 
Objectives 
 
The goal of the study was to compare six-month outcomes for urban AI/AN teens who only received a 
culturally appropriate community event to those who received this community event plus three AOD 
workshops that integrated the evidence-based practice of motivational interviewing (MI) with traditional 
AI/AN practices. 
 
Design 
This study’s primary purpose is prevention. It is a randomized, unmasked, 2-arm parallel intervention 
model. In Native American research, it is typical that both groups receive some degree of an 
intervention. In this study, participants either received a Community Wellness Gather (CWG) or a CWG 
plus MICUNAY. CWGs were culturally focused, and featured Native foods and entertainment (e.g., 
Native comedians, hoop dancing, lectures, storytellers, and talking circles). 
 
Methods 
From 2014 to 2017, we worked closely with our community partner, Sacred Path Indigenous Wellness 
Center (SPIWC), to recruit AI/AN adolescents from large cities in northern, central, and southern 
California. SPIWC is led by Dr. Carrie Johnson (Wahpeton Dakota) and is a non-profit organization that 
provides AOD and mental health services for AI/ANs, and consultation to help ensure that research and 
services are provided in a culturally appropriate manner. All procedures were approved by the institution’s 
review board and by the communities with whom we collaborated on the project. We also had a community 
Elder Advisory Board and a Teen Advisory Board, and we collaborated with AI/AN community 
organizations in every city to determine how to best engage the community in our project and recruit 
AI/AN families and adolescents. For example, each recruitment flyer used images relevant to the particular 
community (e.g., in one community, we used a picture of a known landmark that community members 
recognized in a park where culturally-related events were often held), and we worked closely with leaders 
in each community to provide events tailored to the needs of that particular community ( Jernigan, 
D’Amico, & Kaholokula, 2018). We held information meetings, attended Pow Wows and other community 
events, posted information on AI/AN email listservs and on Facebook, and hired AI/AN recruiters in each 
community to discuss the project with AI/AN families. Interested parents and adolescents could call our 1–
800 project number or provide contact information to one of our recruiters at these events and be called by 
our staff. Eligibility criteria required that adolescents be 14–18 years old (inclusive), and either verbally 
self-identify as AI/AN or be identified as AI/AN by a parent or community member. Eligible adolescents 
were then scheduled to complete a baseline survey at a time and place that was convenient to them. They 
were paid $25. At that time, teens were randomly assigned by block randomization to either Community 
Wellness Gathering (CWG) only or MICUNAY + CWG. Teens had a three-month period to complete all 
three MICUNAY workshops, which rotated weekly, and to complete one CWG, which occurred once per 
month. After completion of MICUNAY and/or the CWG, teens then completed a three and six month 
follow up interview, for which they were paid $50 and $75, respectively. We also reimbursed for 
transportation to the MICUNAY workshops, and adolescents were provided a $5 gift card or free movie 
pass at each workshop. 
 
Over the course of the project, 334 adolescents provided consent to contact. Forty-one of these youth were 
not eligible, 9 declined participation, and 69 were not able to be contacted within the field period. Thus, 
215 adolescents screened in as eligible to be in the project (see Fig. 1). Of these adolescents, 30 did not 

 
 
 
 
 
 
5 
 
 
 
complete their baseline assessment within the field period or hand unreliable contact information. This 
yielded a final enrolled sample of 185 adolescents who completed a baseline survey. 
 
Measures 
Demographics—Initially, adolescents had to either verbally self-identify as AI/AN or be identified as AI/AN 
by a parent or community member to participate in the project (D’Amico et al., 2019). In a subsequent self-
report survey using categories established by NIH, participants checked “all that apply” for the following 
categories: AI/AN, Hispanic or Latino/Latina, Asian or Asian American, Native Hawaiian or Pacific 
Islander, black or African American, white or Caucasian, and other. Adolescents reported their age, gender, 
and level of education for each parent or guardian. 
 
AOD use—We assessed substance use with the well-established Monitoring the Future items (Miech, 
Johnston, O’Malley, Bachman, & Schulenberg, 2016). Adolescents reported past 3-month use for cigarettes, 
alcohol, and marijuana. For this study, we created a dichotomous indicator of whether adolescents reported 
any use of these substances. This is because AOD use rates are typically lower in younger adolescents, 
leading to highly skewed distributions in continuous variables (D’Amico et al., 2016). 
 
Consequences of alcohol and marijuana use—Adolescents reported on the consequences they had 
experienced in past three months. Consequences are based on DSM- IV criteria with 7 items for alcohol 
(e.g., missed school or work) and 5 for marijuana (e.g., had difficulty concentrating) (D’Amico et al., 2016). 
Both scales have been used extensively with adolescents and were reliable with teens in this study (α = 0.77 
for marijuana and α = 0.94 for alcohol). For this analysis we created dichotomous indicators of whether 
adolescents reported any consequences from alcohol or any consequences from marijuana. 
 
Intentions to use AOD—Three separate items assessed whether adolescents believed they would drink any 
alcohol, use any marijuana, or smoke a cigarette in the next six months (1=“definitely yes” to 4=“definitely 
no”) (Ellickson, McCaffrey, Ghosh-Dastidar, & Longshore, 2003). 
 
Resistance self-efficacy (RSE): ( D’Amico et al., 2012) for alcohol was defined as the average of four items 
rated from “I would definitely use” to “I would definitely not use” based on different situations (e.g., if my 
best friend were using; you were bored at party; your friend gives you a drink). RSE ranged from 1 to 4; 
higher scores indicated greater RSE (α = 0.94). 
 
Peer influence—Three separate items assessed how often adolescents spend time around teens who drink, 
use marijuana, or smoke cigarettes (1 = “never” to 4 = “often”) (D’Amico, Miles, Stern, & Meredith, 2008). 
 
Intentions to participate in traditional practices—Adolescents reported how likely they were to participate in 
>20 different traditional practices (e.g., going to Pow Wows, prayer, playing Native hand or stick games) in 
the next six months (1=“definitely yes” to 4=“definitely no”). Items were based upon extensive research 
conducted with AI/AN adolescents, parents, and community partners (α = 0.97) (Kaufman et al., 2014). 
 
Cultural pride and belonging—We assessed adolescents’ AI/AN cultural pride and sense of belonging with 
the Multigroup Ethnic Identity Measure (MEIM), which has twelve items (α = 0.94). Respondents are asked 
the degree to which they agree with statements such as, “I have a clear sense of my ethnic background and 
what it means to me” on a scale from 1 = “strongly disagree” to 5 = “strongly agree” (Phinney & Ong, 2007; 
Ponterotto, Gretchen, Utsey, Stracuzzi, & Saya, 2003). Given that our prior focus group work (Brown et al., 
2016) indicated that many adolescents were of mixed ethnicity, and our focus was on AI/AN identity, we 
modified these items to focus on AI/AN heritage (e.g., “I have clear sense of my AI/AN identity and what it 
means to me”). 

 
 
 
 
 
 
6 
 
 
 
 
Spirituality/happiness—Spirituality and happiness were measured using a subset of ten items from the 12-
item Functional Assessment of Chronic Illness Therapy- Fatigue-Spiritual Questions instrument, or FACIT-
SP 12 (Peterman, Fitchet, Brady, Hernandez, & Cella, 2002). Adolescents reported agreement with 
statements such as “I find comfort in my faith or spiritual beliefs” and “I feel a sense of harmony within 
myself.” Two items that referred specifically to chronic illness were removed from the scale as they were not 
relevant for this study. Response options, which ranged from 1=“not at all” to 5=“very much,” were 
averaged (α = 0.83), with negative statements reversed such that higher scores indicated greater spirituality 
and happiness. 
 

 
 
 
 
 
 
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Statistical Analysis Plan (SAP) 
 
 
Introduction 
The goal of this study is to develop a community informed, culturally appropriate group intervention for 
Native American youth that integrates traditional healing approaches with motivational interviewing (MI). 
We will conduct a multilevel intervention and intervene at both the individual adolescent level with a 
group intervention and community level by utilizing Community Wellness Gatherings (CWG) that occur 
monthly in the community. We will compare three- and six-month outcomes for MICUNAY only 
adolescents and MICUNAY plus CWG adolescents. 
This statistical analysis plan will provide more detailed descriptions of the endpoints in the study and the 
corresponding analyses. 
Detailed study design 
We worked closely with communities and our Elder Advisory Board over the first year of the project to 
design the two interventions and determine how to best implement the RCT in these urban communities. 
Intervening at the community level, we offered monthly CWGs for all adolescents at each study site, with a 
focus on traditional practices and living a healthy life, which included making healthy choices around AOD 
use. Half of the youth were also randomized to attend three 2-h group workshops that addressed traditional 
practices, including beading, prayer, and Native cooking. Upon completion of the six-month follow up, 
every adolescent in the CWG only group was offered an opportunity to participate in the three MICUNAY 
workshops. 
 
Community wellness gatherings—Every youth that participated in the study was assigned to attend a CWG. 
These two-hour events were held monthly in each community, typically in the evening. Many communities 
often had these types of gatherings already scheduled. When this occurred, we would provide the food, and 
compensate the people who conducted the gathering (e.g., the Elder who conducted the beading workshop). 
When a gathering was not already scheduled, we worked with each community to have someone from the 
community conduct the CWG. Some examples of CWGs included beading workshops, hoop dancing, 
drumming and singing, and storytelling. Each CWG began with a prayer and discussion of the importance 
of making healthy choices. CWGs also focused on the importance of traditional practices and discussed 
ways that youth could connect with their culture. 
 
MICUNAY—We developed MICUNAY (Motivational Interviewing and Culture for Urban Native 
American Youth) to address the gap in culturally-appropriate evidence-based interventions targeting AOD 
use among urban AI/AN teens (Dickerson et al., 2015). Our team was one of the first groups funded as part 
of the IRINAH initiative, and we are the only research group to date to conduct culturally centered 
prevention intervention work with 
  
AI/AN adolescents in urban settings (Dickerson, Moore, et al., 2018). To help design MICUNAY, we 
conducted qualitative research with AI/AN adolescents, parents, providers, and Elders in two large urban 
cities in California (Dickerson et al., 2015). Findings highlighted that urban AI/AN adolescents struggle 
with cultural disconnection, mixed identity, and racial-ethnic discrimination. We also found that cultural 
identity and participation in traditional practices is protective for AI/AN youth (Brown et al., 2016; Brown 
et al., In press; Dickerson et al., 2015). In addition to utilizing traditional practices, our work (Dickerson et 
al., 2015; Dickerson, Moore, et al., 2018) and the work of others has emphasized the usefulness of MI with 
AI/ANs (Tomlin, Walker, Grover, Arquette, & Stewart, 2014; Venner et al., 2007). MI is one of the most 

 
 
 
 
 
 
8 
 
 
 
widely-used EBPs for AOD use in the U.S (SAMHSA National Registry of Evidence-based Programs and 
Practices (NREPP), 2014). Many studies have shown the acceptability (Feldstein Ewing, Wray, Mead, & 
Adams, 2012; Gilder et al., 2011; Venner et al., 2007) and efficacy of MI with non-white youth (D’Amico 
et al., 2018; Gil, Wagner, & Tubman, 2004; Gilder et al., 2011; Naar-King et al., 2010; Schmiege, 
Broaddus, Levin, & Bryan, 2009). 
 
Half of the teens in the study were randomized to three 2-h MICUNAY workshops in addition to the CWG 
to test the added benefit of the workshops. One hour of the workshop focused on AOD use and making 
healthy choices using MI, and 1 h focused on a traditional Native American practice. MICUNAY workshop 
content was developed with extensive input from the community (Dickerson et al., 2015), and the AOD 
information was taken, in part, from previous MI intervention development and evaluation work with 
adolescents (D’Amico et al., 2015; D’Amico, Hunter, Miles, Ewing, & Osilla, 2013; D’Amico et al., 2018). 
One of the unique elements of the MICUNAY workshops was to ensure that the MI component and 
traditional practice component connected to ensure cohesiveness, deliverability and cultural relevance 
(Dickerson et al., 2015). For each traditional component, we provided guidelines for the facilitators on the 
overarching topic, but encouraged them to discuss the traditional practice in a way that fit best for their 
community. Based on our focus groups (Brown et al., 2016), and given that these urban AI/AN adolescents 
came from over 60 tribes (Brown et al., In press), the focus of the cultural component of the workshop was 
on “pan-Indian” identity (being AI/AN in general) while empowering youth to learn about their own tribal-
specific roots (Dickerson et al., 2015). Workshops were tailored to each participant’s experience and 
cultural background so that all felt welcome (Jernigan, D’Amico, Duran, & Buchwald, 2018). 
 
The cultural component of every session began with a discussion of the Medicine Wheel. As there are many 
versions of the Medicine Wheel, facilitators were encouraged to discuss the Medicine Wheel in ways that 
were most locally appropriate. Each workshop addressed a different aspect of the Medicine Wheel (Fig. 2). 
Every workshop was interactive and delivered using MI strategies, such as open-ended questions and 
reflections throughout both the cultural and MI portions of the session. Session 1 addressed “Making 
Healthy Choices for My Brain,” and started with a beading workshop for 1 h, after which youth could 
continue beading during the discussion of how AOD use can affect the brain. This interactive discussion 
encouraged teens to think about how AOD use may affect their brain and behavior, how and whether the 
brain recovers from AOD use, and how thinking about this information could affect their own personal use 
of substances. Session 2 addressed “Making Healthy Choices for my Body” which focused first on 
discussing the pros and cons of AOD use, how AOD use can affect one’s life, and alternative life paths to 
AOD use. The facilitator also used willingness and confidence rulers to discuss with teens where they were 
at in terms of potentially changing their AOD use, and how confident they were in making a change if they 
were ready. The second part of Session 2 addressed healthy food choices, focusing on Native American 
foods and traditions. 
 
Facilitators were instructed to discuss topics that were locally appropriate and interesting to youth. Some 
example topics were discussions of hunting and fishing, watching portions of the documentary, Good Meat, 
origins of the bow and arrow, and utilizing local tools and ingredients to make recipes, such as Three Sister 
Stew (https://en.wikibooks.org/wiki/ Cookbook:Three_Sisters_Stew). Teens then had an opportunity to 
taste different foods, such as buffalo stew, grilled salmon, acorn squash, and Three Sister Stew. Session 3 
addressed “Making Healthy Choices for My Spirit,” which first focused on different risky situations that 
may occur because of AOD use, as well as ways to make healthy life choices to avoid these risks. Teens 
were encouraged to discuss the pros and cons of substance use with two specific examples: impaired driving 
and having sex without a condom. Discussion revolved around how to make a healthy choice in these 
situations by planning ahead. Based on the strategies discussed, the facilitator then used the willingness and 
confidence rulers to help teens evaluate whether they felt that they could use these strategies to make a 

 
 
 
 
 
 
9 
 
 
 
change if they were ready.  
 
The second part of Session 3 addressed spiritual life and ways of praying. Facilitators could use a YouTube 
video called, “Picking sage and great advice from an Elder” to generate discussion or discuss local 
traditions for praying. 
 
Figure 1. Flowchart of screening and inclusion process 
 
 
Primary analysis  
We first tested whether teens in the MICUNAY + CWG and CWG only groups differed at baseline with 
Fisher's exact tests for categorical characteristics and t-tests for continuous characteristics. We used 
intention-to-treat analyses to assess all intervention effects. Intervention efficacy was estimated with a series 

 
 
 
 
 
 
10 
 
 
 
of longitudinal linear and logistic regression models. The models included an indicator for being randomized 
to the intervention group and the following covariates: baseline value of the outcome and demographics (age, 
gender, and race/ethnicity [self-identification as Hispanic, multi-racial, or other vs. AI/AN]). Because 
follow-up surveys were administered over a somewhat wide timespan from the intended 3-month and 6-
month time points (the interquartile range was 80–158 days for administration of the 3-month survey and 
170–243 days for the 6-month survey), models additionally adjust for the number of days between the end of 
the treatment period and the follow-up survey date, as well as which follow-up survey the response is from. 
Because each adolescent contributed two records (3- and 6-month follow up) to this analysis, standard errors 
were adjusted for clustering on individuals with SAS Proc SURVEYREG and SURVEYLOGISTIC. Among 
the intervention group only, a similar set of regressions was fit to estimate the effect of each intervention 
session.  
 
Missing data 
All analyses of responses to follow-up surveys were based on imputed data. SAS Proc MI was used to 
generate 40 imputed datasets for all variables used in the analysis at all time points, including for completely 
missing follow-up surveys. Imputed values were truncated to their original minima and maxima. SAS Proc 
MIANALYZE was used post-analysis to compile results across the 40 imputed datasets.  
 
Descriptive statistics  
Means at follow-up were calculated as the mean of the means from each of the 40 imputed data sets. 
Standard deviations were calculated using standard rules for multiple imputation (Rubin, 2004), which 
estimates the overall variance as the average within-imputation variance plus the product of the between-
imputation variance and 1 + (1/m) where m = the number of imputations (40).  
 
Loss to follow-up  
Although we imputed data for those lost to follow-up, we also assessed the degree to which those lost to 
follow-up were different from those for whom we had complete data. Differential loss to follow-up was 
assessed by comparing adolescents who responded to either the 3- or 6-month follow-up survey to 
adolescents who did not respond to either survey on a variety of baseline characteristics. Statistical 
significance was assessed with t-tests for continuous characteristics or Fisher's exact tests for binary 
characteristics. t-Tests and Fisher's exact tests were similarly used to compare means and percentages 
reported for the control (CWG only) group versus the intervention (MICUNAY + CWG) group at baseline. 
 
Baseline differences and attrition 
There were 115 adolescents in the MICUNAY + CWG group and 70 adolescents in the CWG-only group. 
As noted, to be part of the project, all teens had to either verbally self-identify as AI/AN or be identified as 
AI/AN by a parent or community member. Adolescents also self- reported race/ethnicity on baseline 
surveys, marking “all that apply.” Based on this self- report, 81% of the overall sample identified as AI/AN 
(35 youth did not mark AI/AN on the survey), 45% as Hispanic/Latino, and 17% White/Caucasian. Female 
participants made up 51% of the sample; 14- and 15-year-olds comprised 49% of the sample. In the 3 
months prior to baseline, 15% of participants reported tobacco use, 23% reported drinking alcohol, 28% 
used marijuana, and 13% had 5 or more drinks in a row. Sixteen percent of the sample reported 
experiencing consequences from drinking alcohol in the past 3 months, and 15% reported experiencing 
consequences from marijuana use.  
 
The only statistically significant difference between the two intervention groups at baseline was in terms of 
gender, where females made up 69% of the CWG only group and 41% of the MICUNAY + CWG group (p 
< 0.001). The MICUNAY + CWG group reported marginally more alcohol resistance self-efficacy (average 
score of 3.43) than the CWG group (average 3.18, p = 0.06), and also had a marginally higher score for the 

 
 
 
 
 
 
11 
 
 
 
spirituality and happiness scale (3.71 vs. 3.51, p = 0.08). 
 
Among the 185 adolescents who were included in the study, we were able to reach 76% for follow-up 
surveys at 3 months, and 82% at 6 months. Adolescents who completed at least one of the two follow-up 
surveys (89% of the 185) differed from those who did not on several baseline characteristics. On 
demographics, they were more likely to be female (54% vs. 29%, p = 0.04), younger (p = 0.01), and have 
mothers who were more likely to have a high school degree (84% vs. 40%, p < 0.001). For substance use 
outcomes, those who completed follow up were less likely to report tobacco use (12% vs. 43%, p = 0.001) 
or heavy drinking (11% vs. 29%, p = 0.04) at baseline. Those who completed a follow-up survey also had 
lower intentions to smoke marijuana (scale mean 1.67 vs. 2.29, p = 0.01), were with other teens smoking 
cigarettes less often (1.53 vs 2.14, p = 0.05), and scored lower on the spirituality/happiness scale (3.58 vs. 
4.08, p = 0.004) at baseline. There was not a significant difference in follow-up rates between the 
intervention groups at 3 months (75.7% for MICUNAY +CWG vs. 75.7% for CWG only, p = 1.00 per 
Fisher’s exact test) or 6 months (82.6% MICUNAY +CWG vs. 80.0% CWG only, p = 0.70). 
 
Outcomes 
For outcomes, we found that the estimated added benefit of MICUNAY + CWG compared to CWG-only 
was small on the 16 outcomes we measured, with most effect sizes estimated to be <0.1 in magnitude, and 
confidence intervals including both positive and negative values. The largest estimated effect size was 
−0.18 for consequences from using marijuana in the past 3 months, corresponding to an odds ratio of 0.72; 
however, the 95% confidence interval includes strong odds ratios in both directions (0.35–1.48, p = 0.37). 
  
Rates of use for the overall sample remained fairly stable over time, with 23% of the sample reporting 
alcohol use in the past 3 months at baseline, and 30% of the sample reporting use at 6 months. Similarly, for 
marijuana, 28% of the sample reported use in the past three months at baseline, and 29% reported use in the 
past three months at the six month follow up. Intentions to drink and use marijuana were also stable for the 
overall sample over the course of the study, as was the time that teens spent with peers who used alcohol, 
tobacco, and marijuana. Of note, tobacco use for the overall sample appeared to increase over time, as did 
the number of teens reporting consequences from drinking or marijuana. Among those who were 
randomized to the MICUNAY + CWG group, 21 (18%) attended no workshops, 17 (15%) attended one 
workshop, 11 (10%) attended two workshops, and 66 (57%) attended all three MICUNAY workshops. The 
effect of each additional session of MICUNAY attended in this group was small, with an estimated effect 
size of about 0.15 or less in magnitude for each outcome. Three outcomes had moderately sized 
associations and marginal p- values: intentions to drink alcohol, alcohol resistance self- efficacy, and 
intentions to participate in cultural activities. For example, for each MICUNAY session attended, the 
average alcohol resistance self-efficacy response was estimated to be 0.19 higher, with an effect size of 0.17 
and a p-value of 0.04. However, the confidence interval for this effect is large, and after adjusting for 
performing tests on all 16 outcomes, the Bonferroni-adjusted p-value was 0.64. Although the Bonferroni 
adjustment is likely conservative, we conclude that there is not strong evidence in favor of a treatment 
effect for MICUNAY + CWG on these outcomes. 
 
 

 
 
 
 
 
 
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Primary outcomes 
a) Alcohol Use -- this is a Standard Question Used in Monitoring the Future. [Time Frame: change from 
baseline to 6 months] 
 
b) Marijuana Use--this is a Standard Question Used in Monitoring the Future. [Time Frame: change from 
baseline to 6 months]  
Secondary outcomes 
a) Consequences of Alcohol Use - [Time Frame: change from baseline to 6 months] 
b) Consequences of Marijuana Use - [Time Frame: change from baseline to 6 months] 
c) Intentions to Use - Alcohol [Time Frame: change from baseline to 6 months] 
d) Intentions to Use - Cigarettes [Time Frame: change from baseline to 6 months] 
e) Intentions to Use - Marijuana [Time Frame: change from baseline to 6 months] 
f) Alcohol Resistance Self-efficacy [Time Frame: change from baseline to 6 months] 
g) Peer Influence - Alcohol [Time Frame: change from baseline to 6 months] 
h) Peer Influence - Marijuana [Time Frame: change from baseline to 6 months] 
i) Peer Influence - Cigarettes [Time Frame: change from baseline to 6 months] 
j) Intentions to Participate in Traditional Practices [Time Frame: change from baseline to 6 months] 
k) Cultural Identification [Time Frame: change from baseline to 6 months] 
l) Spirituality/Happiness [Time Frame: change from baseline to 6 months] 
Risk factors 
Unique risk factors may predispose urban AIs/ANs to initiate AOD use during adolescence. For example, 
experiences of acculturative stress directly and indirectly associated with historical trauma experienced by 
AIs/ANs throughout U.S. history have been shown to result in poor mental health outcomes. Among urban 
AI/AN youth, acculturative stress may also play a role in AOD use as identity issues among urban AI/AN 
adolescents have been postulated to contribute to lower self-worth, which is associated with the genesis and 
maintenance of AOD problems. In addition, a variety of psychosocial and environmental risk factors, such 
as witnessing domestic violence, physical/sexual/emotional abuse, issues associated with stigma, and 
family histories of mental health and substance abuse may increase AOD use among urban AI/AN youth. 
Thus, these stressors may increase the potential for AOD use due to issues associated with cultural identity, 
decreased spiritual base, and lack of community cohesion. Providing an AOD program that incorporates 
traditional healing activities, promotes community involvement, and encourages healthy notions of AI/AN 
identity may increase wellbeing and other healthy behaviors by addressing sources of stress linked to 
cultural identity, stigma, and community connections. However, few evidenced-based programs have been 
successfully developed and implemented among urban AI/AN youth that integrate such important cultural 
elements. 
Surveys and scales 
All youth will complete surveys at baseline, 3- and 6-months that will focus on behaviors of AI/AN 

 
 
 
 
 
 
13 
 
 
 
participants as they relate to AOD use. 
 
Scale names 
For the secondary measures, “Intentions to Participate in Traditional Practices” and “Cultural 
Identification,” we used the Multigroup Ethnic Identity Measure (MEIM), which has twelve items (α = 
0.94). Respondents are asked the degree to which they agree with statements such as, “I have a clear sense 
of my ethnic background and what it means to me” on a scale from 1 = “strongly disagree” to 5 = “strongly 
agree”. Given that our prior focus group work indicated that many adolescents were of mixed ethnicity, and 
our focus was on AI/AN identity, we modified these items to focus on AI/AN heritage (e.g., “I have clear 
sense of my AI/AN identity and what it means to me”). 
 
For the secondary measure, “Spirituality/Happiness,” we used a subset of ten items from the 12-item 
Functional Assessment of Chronic Illness Therapy-Fatigue-Spiritual Questions instrument, or FACIT-SP 
12. Adolescents reported agreement with statements such as “I find comfort in my faith or spiritual beliefs” 
and “I feel a sense of harmony within myself.” Two items that referred specifically to chronic illness were 
removed from the scale as they were not relevant for this study. Response options, which ranged from 
1=“not at all” to 5=“very much,” were averaged (α = 0.83), with negative statements reversed such that 
higher scores indicated greater spirituality and happiness. 
Safety outcomes 
Adverse event reporting policy 
The current study involves Elders, providers, parents, and AI/AN youth aged 14-18 as participants. It is 
unlikely that focus group participation, completing questionnaires or participation in CWG or MICUNAY 
will cause participants to experience an ―adverse event‖; however, trained staff will be conducting the 
focus groups, surveys, and MICUNAY, and overseeing the CWGs to ensure that participants are stable 
enough to participate in this study and to address any potential crises. Co-Investigators Dickerson and 
Brown will be present at every focus group to lead these groups and oversee the process. We will also have 
at least one of our staff attend each CWG to ensure that things run smoothly and to handle any issues should 
they arise. All MICUNAY facilitators on the project will have received extensive training on the 
community, MI, the MICUNAY protocol, and how to handle adverse events, should they arise. In addition, 
D‘Amico and Dickerson will conduct weekly supervision throughout the duration of MICUNAY 
implementation to address any issues. Furthermore, all digital recordings will be reviewed and coded each 
week by research assistants for adherence to MI and fidelity so recordings that are high in non-adherence to 
MI or are low in fidelity to the protocol will be flagged immediately and brought to the attention of 
D‘Amico and Dickerson. Finally, D‘Amico and Dickerson will be available during the intervention 
implementation times so that if a crisis arises, the facilitator can call them immediately. As clinicians, 
D‘Amico and Dickerson have extensive experience conducting and supervising interventions. Should any 
adverse events occur during the study, we will use standard IRB and NIH procedures for reporting these 
events. 
 
No adverse events occurred during the course of the clinical trial.