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Discuss why it is important to have a clear understanding of how clients come into the program, go through the program, and terminate from the program when doing a process evaluation study.  Explain how this process works in your field placement agency or the agency of your choice.  Also, discuss your own perspective of the process used in your agency.  Is the process working well or problematic and why?

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INTRODUCTION
Welcome to this module. This unit is packed full of great information for you. The readings offer you the opportunity
to learn about two of the four types of evaluation: process evaluation and efficiency evaluation. Please don’t
misinterpret the course structure. It isn’t that these two types are less important, they are grouped together in order
to help accommodate the full course content within the timeframe. You have activities using the other two types
simply because they are the most commonly used evaluations and are also a bit more straight forward to
understand. You need to know and be prepared to use these two types of evaluations equally well.
Process evaluation is simply as it states, it is a form of evaluation to examine processes used in agencies. Think
about how this might apply in your placement or place of work at this time. Think about how this might apply to your
education, course sequence, preparation for the next steps, and so on. Process, just like the other steps, must have
measures too. For example, one measure of process evaluation in your education is to determine if the course
sequence prepares you adequately to move from one course to the next successfully. Do you have the fundamental
knowledge to perform well at the next level course? Think about how this might apply in your practicum setting or
workplace from the client or client system perspective.
Efficiency evaluation is a bit more complex. Begin by thinking of your best definition of efficiency. What makes
anything work efficiently? It usually involves producing the best quality product at the least cost in the shortest
amount of time. However, these three points seldom align together. Which one is the best compromise within the
context of the agency? How much compromise is acceptable? What is viable while keeping the organization
functioning? Think also of the pieces of information that you need to have in order to complete an evaluation of this
type. Also, consider the possible different perspectives that may come from different stakeholders. In other words,
what might the client think? The CEO? The front line worker?
There is some excellent information in this module. Be sure to complete the full readings this week. Continue to work
ahead so that you are prepared for the coming key assignment in the course and the amount of time it will take to
complete it well. Ask your instructor now if you have any questions so that you are well prepared for the assignment.
LESSON COMPETENCIES
Competency 1: Demonstrate Ethical and Professional Behavior
•
•
A1.3 Use technology ethically and appropriately to facilitate practice outcomes
A1.4 Use technology ethically and appropriately to facilitate practice outcomes
COMPETENCY 2: ENGAGE DIVERSITY AND DIFFERENCE IN PRACTICE
•
A2.1 Apply and communicate an understanding of the importance of diversity and difference in shaping life
experiences in practice at the micro, mezzo, and macro levels
Competency 4: Engage in Practice-Informed Research and Research-Informed
Practice
•
•
•
A4.1 Appraise, evaluate, and propose various methods of program evaluation.
A4.2 Apply critical thinking to engage in analysis of quantitative and qualitative research methods and
research findings
A4.3 Evaluate how researcher values and biases impact research efforts
COMPETENCY 9: EVALUATE PRACTICE WITH INDIVIDUALS, FAMILIES, GROUPS,
ORGANIZATIONS, AND COMMUNITIES
•
•
•
A9.1 Use collaborative evaluation methods to measure the extent of change to individuals, families, groups,
organizations, and communities
A9.2 Distinguish, appraise and integrate multiple sources of knowledge, including research-based
knowledge and practice wisdom to achieve target outcomes
A9.3 Critically analyze, monitor, and evaluate intervention and program processes and outcomes.
READING, VIEWING, LISTENING
Please read, view or listen to the following:
READ:
•
•
Chapter 12
Chapter 14
VIEW
•
Chapters 12 and 14 PowerPoints
Chapter 12
Process Evaluations
A process
evaluation looks
at how programs
operate
How are activities
and administrative
systems organized
PURPOSES OF PROCESS EVALUATIONS
Improving
a
Program’s
Operations
Generating
Knowledge
for Our
Profession
Estimating
Cost
Efficiency
Steps in Process Evaluation
Step 1: Deciding What Questions to Ask
Step 2: Developing Data Collection Instruments
Step 3: Developing a Data Collection Monitoring System
Step 4: Scoring and Analyzing Data
Step 5: Developing a Feedback System
Step 6: Disseminating and Communicating Results
Chapter 14
Efficiency Evaluations
An efficiency evaluation is
concerned with determining
what it cost to achieve a
program’s outcomes
Cost Effectiveness versus Cost-Benefit
Cost effectiveness looks
at the costs of a program
in relation to its
outcomes
Cost benefit is a financial
approach that looks at
the costs of a program in
relation to the monetary
value of its outcomes.
STEPS IN CONDUCTING A COST-BENEFIT EVALUATION (1)
Step 1: Deciding • Individual client’s
perspective
on an
• Funding ource’s
Accounting
perspective
Perspective
Step 2:
Specifying the
Cost-Benefit
Model
• Looking at costs
• Looking at benefits
STEPS IN CONDUCTING A COST-BENEFIT EVALUATION (2)
Step 3:
Determining
Costs
Direct
costs
Indirect
costs
STEPS IN CONDUCTING A COST-BENEFIT EVALUATION (3)
Step 4: Determining Benefit
Step 5: Adjusting for Present Value
Step 6: Completing the Cost-Benefit Analysis
Efficiency analyses put the
emphasis on economic aspects
of a program but do not take
into account benefits that
cannot be easily monetized
Nevertheless they are
important because funders will
often make their decisions
base on financial
considerations
THE WIIDOOKOWISHIN PROGRAM: RESULTS FROM A
QUALITATIVE PROCESS EVALUATION OF A CULTURALLY
TAILORED COMMERCIAL TOBACCO CESSATION PROGRAM
Linda M. Bosma, PhD, Joanne D’Silva, MPH, Amanda L. Jansen, MPP,
Nathan R. Sandman, BASc, and Rozanne L. Hink, BASW
Abstract: Commercial tobacco use rates remain disproportionately high
among American Indians (AIs). Tailored cessation programs such as the
Wiidookowishin (Help Me) program implemented at the Fond du Lac
Reservation in Minnesota have demonstrated that such programs can
be successful and achieve quit rates similar to mainstream programs.
This paper presents findings from a qualitative process evaluation of the
Wiidookowishin program and discusses elements that underlie its success
at recruiting and enrolling participants, including individualization,
flexibility, accessibility, ongoing outreach, and inclusion of traditional
tobacco teachings. Lessons learned can be applied to the development
of tailored programs to reduce tobacco-related disparities among AIs.
INTRODUCTION
The Wiidookowishin (Help Me) program is a commercial tobacco cessation program
developed by the Fond du Lac Band of Lake Superior Chippewa. Wiidookowishin is adapted from
the American Lung Association “Freedom from Smoking” curriculum and incorporates Ojibwe
culture, language, and traditional tobacco education into the curriculum. Previous evaluations have
demonstrated that the Wiidookowishin program achieves quit rates similar to those of mainstream
tobacco cessation programs (D’Silva, Schillo, Sandman, Leonard, & Boyle, 2011). Importantly, Fond
du Lac has been able to successfully recruit and enroll tribal members to take part in Wiidookowishin.
The tribe and its funder, ClearWay MinnesotaSM, partnered to evaluate what contributes to Fond
du Lac’s ability to connect tribal members to commercial tobacco cessation services. This paper
presents the results of a process evaluation that identified elements that contributed to successful
recruitment and enrollment of participants to the Wiidookowishin program.
18
CULTURALLY TAILORED TOBACCO CESSATION
19
BACKGROUND/LITERATURE REVIEW
Commercial tobacco use among American Indians (AIs) continues to be higher than among
other racial/ethnic groups despite the success of limited examples such as the Wiidookowishin
program. While smoking prevalence in the U.S. has declined to 18.0% (Centers for Disease Control
and Prevention, 2013), and the statewide smoking rate in Minnesota is 16.1% (Boyle et al., 2011),
a recent study indicates that 59% of AIs in Minnesota are commercial tobacco smokers (American
Indian Community Tobacco Projects, 2013). Minnesota’s AI nations are disproportionately
impacted by commercial tobacco: Five of the six leading causes of death among AIs—cancer,
coronary heart disease, stroke, diabetes, and lower respiratory disease (Great Lakes Inter-Tribal
Epidemiology Center, 2008)—are related to commercial tobacco use (U.S. Department of Health
& Human Services, 2004).
Research suggests that AI smokers have less success with quitting smoking when compared
to other racial/ethnic groups. Barriers to commercial tobacco cessation include a lack of information
about the harm of commercial tobacco (Hodge & Struthers, 2006) and low utilization of nicotine
replacement therapy and cessation medications (Burgess et al., 2007). Despite negative attitudes
about and distrust of cessation aids, expressed as a lack of trust in conventional medicine and
skepticism about side effects, evidence suggests that AI smokers might utilize pharmacotherapy if it
were made more accessible in the community (Burgess et al., 2007). Another barrier is that smoking
is perceived as normative in some communities. Because tribal nations are sovereign, state-level
smoke-free laws do not cover reservation communities. AIs, therefore, often live in settings where
smoking in public spaces is more common.
Few other tobacco dependence treatment programs have been developed specifically for AIs
(Choi et al., 2006). Of those, the “It’s Your Life – It’s Our Future” smoking cessation project in
California demonstrated moderate success (5.7% quit rate in the intervention group vs. 3.1% quit rate
in the control group at 18-month follow up; Hodge, Larri, & Kipnis, 1999). Daley and colleagues
(2006) recently evaluated “The All Nations Breath of Life Program” (ANBL) to determine whether a
pan-tribal approach can be effective in promoting cessation to a wide array of tribal groups. ANBL
was developed using focus groups and a modified Suitability Assessment of Materials scoring process
to ensure cultural appropriateness of materials (Daley et al., 2009). A cessation and prevention
Web site also was adapted by conducting focus groups with urban AI/Alaska Native youth but has
not been evaluated for impact (Taualii, Bush, Brown, & Forguera, 2010).
Tailored programs provide an important and necessary opportunity to recognize the cultural
and traditional values and the unique relationship with sacred tobacco that exists for AI smokers
(Struthers & Hodge, 2004; Unger, Soto, & Thomas, 2008). For Ojibwe people, tobacco is seen as
the root and foundation of the culture. Historically, sacred tobacco for Ojibwe people was in the
20
VOLUME 21, NUMBER 1
form of Kinnickinnick or red willow, used for ceremonial activities and in medicinal and healing
rituals (Struthers & Hodge, 2004). Sacred tobacco may be burned in a pipe to carry offerings to
the Creator or given as a gift to an individual; however, in some instances, commercial tobacco is
used in place of traditional tobacco for ceremonial purposes (Forster, Rhodes, Poupart, Baker, &
Davey, 2007).
Because examples of culturally tailored programs for AIs are so limited, it is important to
learn as much as we can about programs like Wiidookowishin that have demonstrated success helping
commercial tobacco users quit smoking. Understanding the elements that contribute to successful
recruitment and enrollment may be as important as an examining the results, to inform program
administrators and funders as they design programs to reduce commercial tobacco use among AIs.
A previous outcome evaluation demonstrated that the program was successful at achieving a 21.8%
quit rate among participants 3 months after program completion (D’Silva et al., 2011). Therefore,
the purpose of this qualitative process evaluation was to examine the elements that contributed to
successful recruitment and enrollment in the program.
HISTORY OF THE WIIDOOKOWISHIN COMMERCIAL TOBACCO CESSATION
PROGRAM
The Fond du Lac Reservation is located in rural northeastern Minnesota. Fond du Lac has a
population of 4,174 (U.S. Census Bureau, 2013). Individuals are enrolled in federally recognized
tribes, with the majority of the members from the Fond du Lac Band of Lake Superior Chippewa,
one of the seven Ojibwe tribes located in Minnesota. ClearWay MinnesotaSM began funding
commercial tobacco cessation efforts at Fond du Lac in 2004. Sessions are held at the Min No
Aya Win tribal clinic located on the reservation, as well as at a satellite clinic, Center for American
Indian Resources (CAIR), in nearby Duluth, Minnesota.
As is the case for most Minnesota tribes, the majority of Fond du Lac’s enrolled members
live off the reservation, with many residing in the Twin Cities metropolitan area (Minneapolis and St.
Paul). An estimated 22,617 AIs, 37% of the entire AI population in the state, reside in this urban area
(U.S. Census Bureau, 2013). In 2007, Fond du Lac opened the Mashkiki Waakaaigan Pharmacy in
Minneapolis to dispense medications to tribal members living in the Twin Cities metropolitan area as
well as to members of all federally recognized AI tribes living there. Referrals to the pharmacy come
from local clinics and providers that serve the urban AI population. In 2008, the Wiidookowishin
program was expanded to make tobacco dependence treatment services available to the urban AI
population. Two pharmacists were trained as tobacco treatment specialists to provide individual
counseling using the Wiidookowishin curriculum onsite at the pharmacy.
CULTURALLY TAILORED TOBACCO CESSATION
21
Tailoring the Curriculum for Fond du Lac Members
Fond du Lac developed the culturally specific Wiidookowishin program in collaboration
with community members and cessation experts. From 2005-2007, modifications were made to
the American Lung Association Freedom from Smoking program by incorporating the unique
cultural and historical characteristics, and values and traditions, of the community. Adaptations to
the curriculum were made based on suggestions from the program coordinator, cessation specialists
with expertise specific to the Fond du Lac community, and key stakeholders in the community. To
make the program culturally appropriate, Ojibwe language and stories were incorporated into the
curriculum. Another vital adaptation was the inclusion of information on use of traditional tobacco.
The curriculum incorporates teachings on how to use tobacco as a sacred item in ceremonies and
in offering prayers to the Creator. These teachings are designed to help participants understand the
difference between sacred tobacco use and commercial tobacco abuse. The curriculum also was
adapted to incorporate proprietary Native knowledge and wisdom fundamental to AI culture and
lifeways on Fond du Lac.
After these adaptations were made, the revised curriculum was pretested with community
members; as a result, several additional changes were made. The original curriculum of eight
group sessions was revised to four, in recognition of participants’ concerns about the level of
time commitment and staff concerns about retention. In addition, an individual counseling model
was developed apart from the group counseling format for those who expressed privacy concerns
related to the group setting (D’Silva et al., 2011). Each session in the current curriculum––for both
individual and group counseling––is 1 hour long and covers the following topics, with the culturally
specific information described above incorporated throughout each session:
• Session 1: Thinking about a Healthier Life: Quitting Smoking – Information on building
motivation, making the decision to quit, and the costs of smoking.
• Session 2: Starting the Journey – Information about coping with urges and making a plan
to quit.
• Session 3: Quit Day: A New Beginning & New Skills for a Healthier Life – Information
about social support and weight management.
• Session 4: Staying on the Road to a Healthier Life – Information about exercise, assertive
communication, and relapse prevention.
Services are individualized to each person, so some participants complete the sessions
weekly, and some allow more time between sessions.
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VOLUME 21, NUMBER 1
Program Implementation
Program participants are recruited through a variety of systems and outreach approaches.
On the reservation, a significant amount of referrals are made by internal tribal clinic staff and
providers who have all been trained in tobacco dependence clinical guidelines (Fiore et al., 2008).
Other clients come directly from established relationships and referral systems with outside social
service organizations, clinics, businesses, and networks. In addition, an on-reservation tobacco
health educator actively recruits through community health fairs, powwows, elders’ meetings, and
any festival or event where the community gathers. The majority of participants in the pharmacy
program come from provider referrals from local clinics that serve AIs in the metropolitan area.
A tobacco health educator is employed at the Min No Aya Win and CAIR sites to conduct
outreach and recruitment and to provide the Wiidookowishin program. The tobacco health educator
works with each participant to develop a program individualized to his/her preferences and timeline,
allowing for sessions to be conducted in groups or individually to maximize comfort level. Some
participants contact the tobacco health educator between sessions for additional support. To provide
additional opportunities for people to obtain cessation services, pharmacists at both the reservation
and urban sites are also trained to provide cessation counseling. The tobacco health educator and
pharmacists receive training from the Mayo Clinic Nicotine Dependence Center, which is accredited
by the Council on Tobacco Treatment Training Programs. While outreach is a main component of
the tobacco health educator position at the reservation locations, the metro pharmacy does not have
an outreach staffing component.
Procedures are in place to encourage the use of both counseling and pharmacotherapy.
At both the reservation clinic and the metro pharmacy, nicotine replacement therapy (NRT) and
cessation medications are offered free of charge to eliminate financial barriers. After a medical
staff member discusses commercial tobacco use with the client, a referral is given to the tobacco
health educator. The client must first enroll in the Wiidookowishin program in order to receive
cessation medication. After the client completes the first counseling session, the tobacco health
educator provides a pharmacy slip to the client that verifies enrollment in the program and allows
the fulfillment of the prescription. A pharmacy slip from the tobacco health educator is required
at every medication refill to ensure continued compliance with the counseling protocol. Small
incentives, such as water bottles or craft supplies, are provided throughout the program and all
clients are offered a $25 gift card after the completion of all four sessions.
CULTURALLY TAILORED TOBACCO CESSATION
23
Participation Numbers
The Wiidookowishin Program has been successful at enrolling its members in commercial
tobacco cessation programming. Since inception in 2004, the program enrolled 1,191 people at
the Min No Aya Win and CAIR locations and another 142 at the metro pharmacy site. The average
participant enrollment per year, averaged across 8.5 years, is just over 140 in the non-metro sites,
or approximately 3.3% of the total population. Using data from the recent Tribal Tobacco Use
Project (AI Community Tobacco Projects, 2013), which found that 59% of Minnesota’s AIs smoke
commercial tobacco, Fond du Lac has potentially enrolled 5.6% of smokers per year in cessation
services.
METHODS
It is important for those seeking to partner with AI communities to approach that work with
respect and understanding for nations’ sovereignty, unique history, and self-determination. While
this approach is essential in any evaluation work, it is especially so in tribal communities. Tribes
have often had negative experiences with outsiders who come into their communities and gather
data and information with little consideration of the communities’ needs or perspective. This is often
called the “helicopter approach” (Gray, Gillis, Hill, Abe, & Martin, 2008). In recognition of this
history, the evaluation plan and methods were reviewed and approved by key program staff at Fond
du Lac, and their input was incorporated to reflect tribal expertise. Evaluation instruments then were
reviewed and approved by the Fond du Lac and Indian Health Service Institutional Review Boards.
Evaluation Design
Qualitative interviews were identified as the best method to provide rich, deep data and to
allow respondents the greatest opportunity to share their impressions of the program. The process
evaluation design included key informant interviews with Wiidookowishin program participants
(n = 20) to assess motivation for participating in the program and how they became of aware of
its availability, and with stakeholders from clinic and community settings likely to refer people to
services (n = 13) to learn more about their impressions and understanding of the program. The design
also included staff interviews with the tobacco health educators and lead health educator, as well
as document analysis of quarterly program reports to ensure the evaluator understood the program
context and implementation. Key informant interviews were semi-structured to enable follow-up
questions to ensure understanding of responses. Interviews were conducted by the lead evaluator.
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VOLUME 21, NUMBER 1
Sample
During the evaluation period (August 2011 to January 2012), the Fond du Lac program
enrolled 74 participants, with 20 (27%) completing all four sessions of the program, 6 (8%)
completing three sessions, 28 (37%) completing two sessions, and the remainder at least one session.
The evaluator and program staff determined that 20 participants, or roughly one quarter of
people enrolling in the program during the study period, would provide broad representation of
participants. The evaluator sampled individuals who participated in the Wiidookowishin program by
selecting every fourth name on the full list of program participants in order of program enrollment
date. When a participant declined (n = 1) or was unreachable (n = 4), the next name on the list was
selected. The sample included participants from all three locations where services are provided—
Min No Aya Win clinic (n = 15), CAIR (n = 3), and the metro pharmacy (n = 2). Participants were
interviewed at various stages in their cessation process, so some had completed the program and some
were attending sessions at the time they were interviewed, but all had attended at least one session.
The evaluator worked in partnership with Min No Aya Win’s lead health educator to identify
a representative sample of stakeholder respondents who had awareness of and some familiarity
with the cessation program. Stakeholders included representatives from the medical and dental
clinic staff; the Women, Infants, and Children (WIC) program; the chemical dependency treatment
center; and community centers.
Prior to starting the interviews, the evaluator described the evaluation to participants,
including the voluntary nature of the interview. Interviewees signed a consent form and were
given a copy of it to keep, and also received a $25 gift card to a local merchant as an incentive for
participation. Interviews were conducted at the clinic settings where cessation services are provided
to increase comfort level and convenience, unless a respondent indicated a preference for another
location, which was accommodated as requested. Fond du Lac staff provided space for interviews
in a clinic conference room located distant from the tobacco health educator’s office, to protect
respondents’ confidentiality.
Cessation program participants were interviewed about how they learned of the program; what
motivated them to participate; their general impressions of the program content and implementation
(including the tobacco health educator who provided the programming); and their views on the
value of traditional tobacco inclusion in the curriculum, availability of NRT and medications, and
having programming conducted by Fond du Lac.
Stakeholder interviews addressed familiarity and interactions with the program, awareness of
Fond du Lac’s adaptation of the program, inclusion of traditional tobacco, and general impressions.
CULTURALLY TAILORED TOBACCO CESSATION
25
Staff interviews were conducted to ensure the evaluator understood the program and how it
was implemented, and to stay informed of any developments in implementation. The staff interviews
ensured that the evaluator had sufficient context and understanding to interpret the participant and
stakeholder interviews.
Analysis
Both participant and stakeholder interviews were recorded and transcribed. Transcripts were
imported into Atlas.ti qualitative software to facilitate organizing and coding. The lead evaluator
coded and analyzed the key informant interviews for common and emergent themes; a second
qualitative analyst then conducted a secondary review of the coding. Member checks of findings
were conducted with Fond du Lac staff for accuracy and clarification.
Table 1
Elements that Contributed to Successful Enrollment and Participation
in the Wiidookowishin Commercial Tobacco Cessation Program
1.
Credibility through tribal oversight and administration
2.
Systemic commitment to helping members quit
3.
Individualized services
4.
Tobacco health educator accessibility and flexibility
5.
Outreach and community awareness
6.
Traditional tobacco education
7.
Curriculum tailored to Fon du Lac
8.
Tobacco health educator who is AI and from the community
9.
Pharmacists engaged in providing cessation services
10.
Nicotine replacement therapy and medications; required participation in cessation counseling
FINDINGS AND DISCUSSION
Several elements contributed to the Wiidookowishin program’s success at recruiting and
enrolling participants.
1. Credibility Through Tribal Oversight and Administration
The Wiidookowishin program is administered by Fond du Lac Human Services. Tribal
members have confidence in services provided at Min No Aya Win and trust the providers and staff
affiliated with it. As stakeholders noted, “This is their clinic.” Tribal members believe they will
receive competent and confidential services from Min No Aya Win. Many participants expressed
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VOLUME 21, NUMBER 1
confidence that a program would not be operated by Fond du Lac unless it was high quality. This
trust emanates from both confidence in Fond du Lac Human Services and the fact that services
provided there are for the Fond du Lac community.
One participant said she would be unlikely to participate in a cessation program if it were
offered by an agency not operated by Fond du Lac. Participants distrust mainstream services and
frequently have had negative experiences with such agencies. Historical traumas, such as forced
removal of ancestors to boarding schools, assimilation, and prohibitions on exercising tribal sacred
beliefs, contribute to many tribal members’ lack of trust in non-reservation providers. Stakeholders
agreed, and often were more candid about specific experiences that would inhibit a tribal member
from seeking services outside of Fond du Lac. As one participant said, “That would be like off
brand…like that would not be comfortable.”
2. Systemic Commitment to Helping Members Quit
All providers are committed to screening for cessation. Treatment providers, doctors,
pharmacists, dentists, the WIC program staff, public health staff, and community center directors
value cessation and refer people to the program. Screening is a regular part of many providers’
interactions with their patients. This systemic commitment means that Fond du Lac community
members are continually encountering opportunities to be connected to cessation services. Cessation
is seen as part of everyone’s work, not just something done by the tobacco health educator.
Stakeholders both within and beyond health services believe cessation is important, and
are aware that AI smoking rates are high and that AIs experience disproportionate harm related to
commercial tobacco use. Other clinic staff members relate smoking harm to their own programs—
whether it is recognizing the value of support to stop smoking while undergoing substance abuse
treatment, improving health outcomes for other medical conditions, reducing exposure to secondhand smoke for other household members, or reducing the economic costs of commercial tobacco.
The commitment to cessation continued during a gap in services when a longtime tobacco
health educator resigned, leaving the position vacant for several months while a replacement was
sought. Despite the popularity of the tobacco health educator who resigned, stakeholders both
within the health care systems and in the community were confident that a high level of services
would be continued with a new individual. Indeed, while there was an interruption in the level of
services during the transition, when the position was filled the new tobacco health educator quickly
restored services to their prior levels—indicating that commitment is for the program itself, and is
not dependent on an individual person in the position.
CULTURALLY TAILORED TOBACCO CESSATION
27
Within Min No Aya Win, support from the lead health educator (who oversees the cessation
program) has been crucial. While the tobacco health educator position was vacant, the lead health
educator kept stakeholders informed of the hiring process, coordinated with the funding agency to
ensure continued support, coordinated with pharmacists to ensure that NRT remained available to
participants who sought cessation services, and sometimes provided cessation services in addition
to his other job. Having a long-established member of the staff deeply invested in the success of
the program and committed to its continued viability has been essential to sustaining the program
through staffing transitions.
3. Individualized Services
Participants value that cessation services are individualized and tailored to their schedule
and comfort level. Many participants desire the privacy of an individual session rather than a group
session, and the tobacco health educator accommodates those requests. The small scale of the
program is an asset for many participants. When asked if they would seek services from a mainstream
provider, many participants suspected programs outside the reservation would be too big and too
bureaucratic. More than one said they felt they would just be a number, not a person, at a nonFond du Lac program. The tobacco health educator’s ability to adapt services to each individual’s
preferences and schedule make the program more accessible for many. As one stakeholder said,
part of the goal is to “reduce any barriers” to obtaining cessation services.
4. Tobacco Health Educator Accessibility and Flexibility
Adequate training, expertise, and skill are necessary for staff who provide cessation services.
Beyond that, flexibility and accessibility are important to Fond du Lac participants. They find it
helpful to know that they can contact the tobacco health educator (or the pharmacist) between
scheduled sessions. Knowing they can call with questions or for extra advice or encouragement is
valued. Participants feel the tobacco health educator is their advocate and cares about them quitting.
An approachable personality—characteristics such as being easy to talk to, comfortable, nonjudgmental, friendly, and having a sense of humor—were all reported as important to participants.
5. Outreach and Community Awareness
The tobacco health educator conducts ongoing outreach throughout the community. While
many participants come into contact with the program through a referral from a service provider
such as their doctor, or via another program in which they participate, participants are also recruited
from throughout the community. The tobacco health educator conducts outreach at organizations,
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VOLUME 21, NUMBER 1
agencies, and events throughout the Fond du Lac community every week. Outreach efforts seek
not only to recruit participants, but to increase awareness of the program within the community.
Stakeholders noted that ongoing outreach is essential; as one said, “It’s not a one-time effort, it has
to be done over and over.” Awareness in the community helps increase confidence and credibility
in the program.
6. Traditional Tobacco Education
Tobacco has a complex history for AIs. AIs have used traditional tobacco in ceremonies
and daily life for centuries, a use that has been corrupted by commercial tobacco. Many AIs are
disconnected from traditional tobacco due to decades of cultural suppression within mainstream
society in the U.S. Some are unfamiliar with traditional tobacco customs. This situation creates
special challenges for programs that seek to help Native people discontinue commercial use. Thus,
it is important to incorporate traditional tobacco teachings into the Wiidookowishin curriculum.
Many stakeholders feel especially strongly about this issue, and believe an important function
of cessation programming is to seek to restore traditional tobacco customs among Fond du Lac
members, as these customs are part of their history and culture. Although a number of participants
do not observe traditional use and do not feel it is useful to them personally, in general participants
feel that having information on traditional tobacco is important in programming, and should be
available for any who need it.
This finding demonstrates the complexity of traditional tobacco use among tribal members,
and is another indication that the flexibility of the program to adjust to individual needs is valuable.
Regardless of the amount of emphasis on traditional tobacco in the curriculum, it is important that
the information is available and that the tobacco health educator delivering services understand
traditional use.
7. Curriculum Tailored to Fond du Lac
Stakeholders were often aware of the history of the Wiidookowishin curriculum and of the
fact that Fond du Lac members had helped to adapt the curriculum to include Ojibwe language and
stories as well as traditional tobacco teachings. This knowledge enhances the program’s credibility
among stakeholders and makes them feel more confident about referring people. Stakeholders feel
this tailored approach is an important element that improves the program. (Participants were not
likely to know that the curriculum was adapted from a mainstream program, so this issue was not
explored with participants.)
CULTURALLY TAILORED TOBACCO CESSATION
29
8. Tobacco Health Educator who is AI and from the Community
It matters to many participants and stakeholders that the current and past tobacco health
educators are AI and are from the Fond du Lac community. Many participants and stakeholders know
both the current and previous tobacco health educators and, while many believed the position could
be filled by an outsider, as several people who work at Min No Aya Win are non-Native, all agree it
would take an outsider much longer to gain trust, if s/he could do so at all. Previously, the program
did have two non-Natives in this role; the lead health educator shared that they were unfamiliar
with traditional tobacco and with the community’s history and culture, which created an additional
barrier to gaining trust. Participants feel that a tobacco health educator from the community knows
and understands their concerns and is more likely to be nonjudgmental, thereby increasing trust.
It should be noted that many of the pharmacists are not Native, but have successfully gained
the trust of community members because of their longevity within the community. However, some
pharmacists interviewed said they often felt that their services might be more effective if provided
by a Fond du Lac member. They also felt ill-equipped to provide information on traditional tobacco.
9. NRT and Medications; Required Participation in Cessation Counseling
The Wiidookowishin program offers a variety of aids to help participants who are trying to
stop smoking: Nicotine gum, patches, Chantix, Wellbutrin, and other cessation aids are available at
no cost. Participants are required to enroll in cessation counseling as a condition of receiving those
aids. Participants feel these aids are very important, since they often try several until they find one
that works for them. Being able to obtain them at no cost eliminates any barriers participants might
face due to insurance limits or inability to pay, and removes any stigma that might be associated with
limited resources. Pharmacists are familiar with research that shows that cessation medications are
more effective if combined with counseling (Fiore et al., 2008). The type of cessation aid provided is
based on a variety of considerations. In some cases, doctors or pharmacists make recommendations
for some participants based on medical history or condition; in others, the tobacco health educator
works with participants to help them select a cessation aid that fits their preferences and needs.
10. Pharmacists Engaged in Providing Cessation Services
Pharmacists provide cessation counseling at all three locations, and receive training so they
can carry out cessation services and implement the curriculum. While Min No Aya Win and CAIR are
served by a full-time tobacco health educator, there is no designated position to provide counseling
or outreach at the metro pharmacy, so the pharmacists fit participants in around their normal duties.
They have a high level of commitment to cessation, and cessation counseling fits well with other
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advice they provide (e.g., nutrition, diet, exercise, diabetes prevention). The pharmacists are often
a point of entry to cessation, because counseling is a requirement to get NRT and other cessationrelated medication prescriptions filled, so their buy-in is important. Having pharmacists trained to
provide cessation counseling expands the options available to participants and helps provide support
for those with complicated medical histories.
Limitations
This evaluation examined participants who were currently enrolled in and/or participating
in the Wiidookowishin program. Thus, a limitation of this evaluation is that we did not have the
opportunity to interview individuals who had chosen not to participate in cessation services. There
may be reasons some people decline to receive services that could further inform program outreach
and implementation, or barriers that we were unable to identify by limiting our sample to participants.
Program enrollment data were obtained from reports to the funder by Fond du Lac staff.
While participants at the Min No Aya Win and CAIR clinics are primarily Fond du Lac members,
the metro pharmacy serves all AIs in the metro area and is not exclusive to Fond du Lac members;
data on tribal membership was not available, but it is reasonable to assume that many of the urban
participants are not Fond du Lac members. Projected estimates of smokers were based on statewide
data, because data specific to Fond du Lac are not available. Despite these limits, enrolling 1,191
participants in 8.5 years is a laudable level of participation.
We also were unable to compare Fond du Lac’s experience with other tribal settings. A
future evaluation might consider examining a setting where enrollment had been less successful, to
determine areas where efforts were similar or different. While the experience of the Wiidookowishin
program seems to hold valuable lessons for others attempting to design and provide cessation
services for AIs, this evaluation is specific to Fond du Lac’s experience.
Recommendations
Many of the elements that our evaluation identified as important to Wiidookowishin’s success
in connecting people to services might be applicable to program planning in other communities,
including non-AI communities. However, they are of special importance in AI settings where issues
around historical trauma and sovereignty are especially salient. Tribal ownership and control, cultural
tailoring of the curriculum, and restoration of traditional tobacco are integral to work in AI settings.
Recommendations for program providers: The Wiidookowishin program indicates that at least
ten elements are important to successful implementation of cessation programming in tribal settings.
Tribal control and administration are important—tribal members need to feel confidence and trust
CULTURALLY TAILORED TOBACCO CESSATION
31
in the agency providing services. The systemic commitment to commercial tobacco cessation––
specifically, integration of referrals from various providers––underlies the Wiidookowishin
program’s success. Programs that start without a strong level of commitment to cessation may not
be as successful. The program should have the flexibility to be individualized to participant needs.
Tobacco health educators should be flexible, willing to adjust schedules, and available between
regular sessions to support and encourage participants. Ongoing outreach needs to be included to
increase awareness among both potential participants and providers who may make referrals. The
program needs to reflect the community by incorporating traditional tobacco teachings, adapting
the curriculum to reflect the community to build trust and credibility, and hiring tribal community
members. The program should provide a variety of medications and therapies for participants and
remove cost as a barrier. Pharmacists should be engaged in providing services—their expertise
makes them credible providers, and cessation fits with other advice they provide.
Recommendations for funding agencies: As the Wiidookowishin program has developed
over the years, a close collaboration between the program funder (ClearWay MinnesotaSM) and
Fond du Lac Human Services has been important to the program’s success. The funder has been
flexible and has allowed Fond du Lac time to plan, revise the curriculum, and refine the cessation
program. Further, Fond du Lac was given the opportunity to brand its own services in ways that
were culturally appropriate and important to the community. When staffing transitions occurred,
the funder allowed adjustment on grant timelines and deadlines that gave necessary assurance that
the program would continue. Some funding agencies, especially government-based funders, might
not have been able to be this flexible, but for new programs in tribal settings, this flexibility can be
essential to successful program development, planning, and implementation.
Recommendations for future research: The disproportionate impact of commercial tobacco
points to the need for more information on commercial tobacco cessation for AIs. Little research
exists on culturally tailored programs, or the effectiveness of these programs compared to the
mainstream programming that is most prevalent. This evaluation was limited by available resources,
but still went beyond what program staff could have undertaken without outside funding for this
purpose. Future evaluations should examine barriers to learn more about those who do not enroll
in programs or those who begin a program but do not complete it.
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CONCLUSION
It is essential that effective programs continue to address the impact of commercial tobacco
use in AI communities. The Wiidookowishin program has demonstrated that a tailored program
can be successful at helping tribal members stop smoking, and this evaluation identified several
elements that contributed to success of the program. These findings may be valuable for program
developers and funders to consider when attempting to implement a commercial tobacco cessation
program in a tribal setting.
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AUTHOR INFORMATION
Dr. Bosma is with Bosma Consulting. She is the corresponding author and can be reached at
1616 Clemson Drive, Suite B, Eagan, MN, 55122; (651) 330-2488; or linda@bosmaconsulting.com.
Ms. D’Silva and Ms. Jansen are with ClearWaySM Minnesota.
Mr. Sandman and Ms. Hink are with the Fond du Lac Band of Lake Superior Chippewa.
Copyright of American Indian & Alaska Native Mental Health Research: The Journal of the
National Center is the property of University of Colorado Denver and its content may not be
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