Fiedeldey Van Dijk et al.

Journal of Ethnicity in Substance Abuse ISSN: 1533-2640 (Print) 1533-2659 (Online) Journal homepage: http://www.tandfonline.com/loi/wesa20 Honoring Indigenous culture-as-intervention: Development and validity of the Native Wellness TM Assessment Carina Fiedeldey-Van Dijk, Margo Rowan, Colleen Dell, Chris Mushquash, Carol Hopkins, Barb Fornssler, Laura Hall, David Mykota, Marwa Farag & Bev Shea To cite this article: Carina Fiedeldey-Van Dijk, Margo Rowan, Colleen Dell, Chris Mushquash, Carol Hopkins, Barb Fornssler, Laura Hall, David Mykota, Marwa Farag & Bev Shea (2016): Honoring Indigenous culture-as-intervention: Development and validity of the Native Wellness Assessment TM , Journal of Ethnicity in Substance Abuse, DOI: 10.1080/15332640.2015.1119774 To link to this article: http://dx.doi.org/10.1080/15332640.2015.1119774 Published online: 15 Mar 2016. Submit your article to this journal View related articles View Crossmark data Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=wesa20 Download by: [Lakehead University] Date: 16 March 2016, At: 09:58 JOURNAL OF ETHNICITY IN SUBSTANCE ABUSE 2016, VOL. 00, NO. 00, 1–38 http://dx.doi.org/10.1080/15332640.2015.1119774 Honoring Indigenous culture-as-intervention: Development and validity of the Native Wellness AssessmentTM Carina Fiedeldey-Van Dijka, Margo Rowanb, Colleen Dellc, Chris Mushquashd, Carol Hopkinse, Barb Fornsslerf, Laura Hallg, David Mykotah, Marwa Faragi, and Bev Sheaj Downloaded by [Lakehead University] at 09:58 16 March 2016 a ePsy Consultancy, Toronto, Ontario, Canada; bRowan Research and Evaluation, Ottawa, Ontario, Canada; cDepartment of Sociology & School of Public Health/Canadian Centre on Substance Abuse, University of Saskatchewan, Saskatoon, Saskatchewan, Canada; dDepartment of Psychology and Northen Ontario School of Medicine, Lakehead University, Thunderbay, Ontario, Canada; eThunderbird (National Native Addictions) Partnership Foundation, Bothwell, Ontario, Canada; fDepartment of Sociology & School of Public Health, University of Saskatchewan, Saskatoon, Saskatchewan, Canada; g Centre for Humanities Research and Creativity, Laurentian University, Greater Sudbury, Ontario; h Department of Educational Psychology and Special Education, College of Education, University of Saskatchewan, Saskatoon, Saskatchewan, Canada; iSchool of Public Health, University of Saskatchewan, Saskatoon, Saskatchewan, Canada; jClinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada ABSTRACT KEYWORDS There is a need for Indigenous-centered research to appraise culture’s role in wellness. Researchers described the development and validity of the Native Wellness Assessment (NWATM). The NWA has culture-as-intervention at its apex. Wellness, culture, and cultural intervention practices (CIPs) are explored from an Indigenous perspective. Indigenous clients completed matching self-report and observer versions of the NWA at three time points during addictions treatment. Statistically and psychometrically, the NWA content and structure performed well, demonstrating that culture is an effective and fair intervention for Indigenous peoples with addictions. The NWA can inform Indigenous health and community-based programs and policy. Addiction; assessment; cultural intervention practices; culture; fairness; Indigenous peoples; intervention; Native wellness; NWA; reliability; treatment; validity Introduction Setting a study context Individuals with past or present addictions working to recover and heal in broad social determinants of life critically need social and educational support, outreach, and engagement efforts in overall wellness. This is especially relevant for Indigenous peoples where indicators of well-being are notoriously lower than those of other population groups. In Canada, First Nations, Métis, and Inuit comprise 4.3% of the Canadian population. On average, differences between Indigenous and non-Indigenous populations indicate that the former CONTACT Carina Fiedeldey-Van Dijk Aurora, Ontario, L4G 5TI, Canada. © 2016 Taylor & Francis [email protected] ePsy Consultancy, 144 Tamarac Trail, Downloaded by [Lakehead University] at 09:58 16 March 2016 2 C. FIEDELDEY-VAN DIJK ET AL. group is 12.9 years younger, grows at a faster rate by 14.9%, and has fewer children aged 14 and under living in a family with both parents by 26.4%. Canada’s colonial history and ongoing efforts at colonization has led to its Indigenous peoples having a higher risk than the general population of low income due to higher school dropout rates by 4.3%, higher household food insecurity by up to 20%, and more admissions to sentenced custody by 23.6%. Indigenous peoples have more diagnoses of chronic health conditions (e.g., obesity, diabetes) by 8% (Statistics Canada, 2011, 2015). A 2015 review of available Canadian data and reports likewise “revealed a disproportionate burden of substance use and harms” (Firestone, Tyndall, & Fischer, 2015, p.11). These statistics show the need to support wellness for Indigenous peoples through initiatives that reflect the community’s unique lived experiences and that highlight culturally appropriate modes of enhancing wellness, including the development and validation of wellness measurements. Framing the role of indigenous culture and cultural intervention practices Culture is a necessary part of prevention of and healing from traumatic events and addictions for Indigenous peoples (Chong, Fortier, & Morris, 2009; Mental Health Commission of Canada, 2009; Mussel, Cardiff, & White, 2004; Rowan et al., 2014; Royal Commission on Aboriginal Peoples, 1996). Native denotes the collectivistic cultures of all Aboriginals or Indigenous peoples. Indigenous culture is protective for well-being, particularly in light of the social and historical oppression and colonization experienced by Indigenous peoples (Kirmayer, Gone, & Moses, 2014; Snowshoe, Crooks, Tremblay, Craig, & Hinson, 2015). Indigenous people shield and maintain culture by resisting Euro-Canadian dominance (Berry, 1999). A body of social research (see Phinney, 1990) put forward a multidimensional conceptualization that identification with Indigenous culture is (a) closely linked to strength of self-concept (“who am I really”) and (b) implies a sense of distinguished, sought-after attachment (“where do I empathically belong”). How Indigenous people think of themselves and where they socially, ethnically, geographically, and historically place themselves provide a certain knowledge/perception and evaluation/affect that define and sustain culture (Berry, 1999) and form the guidelines whereby Indigenous culture is symbolized and expressed (Gans, 1979; Gone & Alcántara, 2007). The sweat lodge ceremony (Gossage et al., 2003; Schiff & Pelech, 2007) and traditional teachings (Edwards, 2003; Stone, Whitbeck, Chen, Johnson, & Olson, 2006) are two examples of cultural interventions that have long been practiced in Indigenous treatment programs. Such practices play an important role in a decolonization agenda (Gone, 2013; Gone & Calf Looking, 2015). In recognition of cultural suppression and forced assimilation of Indigenous peoples, cultural intervention practices serve a critical function to express Downloaded by [Lakehead University] at 09:58 16 March 2016 JOURNAL OF ETHNICITY IN SUBSTANCE ABUSE 3 collective identity and address imbalances in health and well-being within and among Indigenous peoples (Kirmayer et al., 2014). Combined cultural reclamation and cultural practices can be effective therapeutic interventions or treatments in substance abuse and toward wellness (Gone, 2011), which may be captured and tracked through measurement rooted in Indigenous culture. Diverse traditional practices that involve singular or combined incorporation of “plant, animal and/or mineral medicines, spiritual therapies, manual techniques and exercises … to treat, diagnose or prevent illness” are defined by the World Health Organization (WHO, 2002, p. 1) as traditional medicines, which are regularly applied as culturally appropriate intervention strategies to promote healing and wellness (Bassett, Tsosie, & Nannauck, 2012). The latter authors reported that, according to the healers they interviewed, “culture is the primary vehicle for delivering healing” (p. 25). Culture-based, Indigenous means of treatment may include any or all of spirit, ceremonies, language, values and beliefs, stories and songs, land-based activities, food, relations, nature, and history, among others. To date, what little published information is available to measure and facilitate the effect of culture and cultural intervention practices on Indigenous peoples as the vehicle toward Native wellness relies on anecdotal evidence or is based on small samples and, while promising, rarely can be generalized (Rowan et al., 2014). In 2011, representatives of the National Native Addictions Partnership Foundation (NNAPF1), the Assembly of First Nations (AFN), and Health Canada First Nations and Inuit Health Branch (FNIHB) consulted with the National Native Alcohol and Drug Abuse Program (NNADAP) and the Youth Solvent Abuse Program (YSAP) to develop a comprehensive approach to mental health and addiction programming in Canada. The two programs underwent a comprehensive process of renewal culminating in a renewed program framework (Health Canada, 2011). Its strengths-based systems approach addresses substance misuse among First Nations by allotting attention to the social consequences to health and well-being. The representatives of the three entities concluded that “culture is vital for healing, although how culture is defined and practised varies across communities” (NNAPF et al., 2011, p. 9). They expressed a need to determine whether cultural commonalities can be identified for wellness purposes. They also called for Indigenouscentered research to measure and validate the role of culture and cultural renewal in wellness for First Nations communities, which are poorly understood in the Western-directed treatment system (Dell et al., 2011; Nagel, 1997). Subsequently, the Canadian Institutes of Health Research (CIHR) funded an alliance of NNAPF, AFN, the Centre for Addiction and Mental Health (CAMH), and the University of Saskatchewan to develop and validate a measure of the effectiveness of culture-as-intervention, specifically in Canadian 1 NNAPF was renamed to Thunderbird Partnership Foundation (TFP) in 2015. 4 C. FIEDELDEY-VAN DIJK ET AL. First Nation’s alcohol and drug treatment programs and in overall wellness. The study, Honoring Our Strengths: Culture as Intervention in Addiction Treatment ran from 2012 to 2015. Applying the concept of “two-eyed seeing” as a guiding principle, researchers were able, in the words of Elder Albert Marshall, “to see from one eye with the strengths of Indigenous ways of knowing, and to see from the other eye with the strengths of Western ways of knowing, and to use both of these eyes together” (Bartlett, Marshall, & Marshall, 2012, p. 335). Within this framework, project contributors prioritized Indigenous methods and ways of knowing alongside Western science (Hall et al., 2015). Downloaded by [Lakehead University] at 09:58 16 March 2016 Operationalizing Native wellness A holistic definition of wellness guided this project based on Indigenous culture conceptualized across the four directions in the Sacred Medicine Wheel and fundamental to all life, wherein all are considered sacred and equal (Dapice, 2006), guided the study. Native Wellness is a whole and healthy person expressed through a balance of spirit, heart, mind and body (McConnery & Dumont, 2010). Central to wellness is relations; that is, the belief in one’s connection to language, land, beings of creation, and ancestry, supported by a caring family and environment. This belief shapes the spiritual, emotional, mental, and physical well-being of individuals and communities (Wilson, 2003). Jim Dumont, a leading Indigenous researcher and the project’s guiding Elder, articulated these four quadrants of wellness, which function inseparably from a position of strength (Dumont & National Native Addictions Partnership Foundation [NNAPF], 2014): Spiritual The spiritual is the quality of being alive in a qualitative way; the reason to live, giving vitality, mobility, purpose and the desire to achieve the highest quality of living in the world. Spirit is central to the primary vision of life and worldview and thereby facilitates hope. Embedded in Indigenous culture, spiritual strength can contend with challenges concerning loss of religion, avoidance of ceremonies, hopelessness, and despair. Emotional The emotional is rooted in family, community and within creation as extended family; the foundation of belonging and relationships. The heart is nurtured by one’s belonging through interdependent relationships with others and by living in relation to creation, including beings in creation. Set in culture, emotional strength can oppose loss of identity, (posttraumatic) stress, anxiety, depression, and suicide when wellness is severely imbalanced. Mental The mental is the conscious and intelligent drive to know and activate one’s being and becoming; having a reason for being, which gives meaning to life. JOURNAL OF ETHNICITY IN SUBSTANCE ABUSE 5 Downloaded by [Lakehead University] at 09:58 16 March 2016 The mind operates in both a rational and intuitive capacity. Rooted in Indigenous culture, mental strength can reduce hampered communication, ceased contact with elders, and devalued or lost experiential learning. Mental strength can resist the loss of ability to speak/understand Native language and even brain damage as a result of substance abuse. Physical The physical is a way of behaving and doing that actualizes the intention and desire of the spirit in the world, coupled with the knowledge that the spirit has something to do in the world, which generates a sense of purpose, conscious of being part of something that is much greater than people are as individuals. The body is the most outer part of being and is composed of the most immediate behavioral aspects of our being. Engrained in culture, physical strength can overcome body weakness and damage (i.e., a target for [chronic] illness) and susceptibility to craving (e.g., overeating), misuse (unhealthy habits, inactivity), and abuse (addictions). Dumont and NNAPF (2014) emphasized client strength and empowerment in the quadrants according to a worldview that people are resourceful and resilient in the face of adversity, which encourages reflection to enlarge capacities for healing and well-being (Guo & Tsui, 2010). Outside of Indigenous culture, lists of possible challenges to wellness (borrowed from Dapice, 2006) are commonly referenced in the literature depicting those with addictions as trapped in complex connections involving drug use, crime, violence, emotional instability, financial hardship, low education, deviance, social processes associated with the crack market, and other factors compounding risk (De La Rosa, Lambert, & Gropper, 1990). These lists also narrow the focus to individuals as victims, who are simultaneously responsible for surmounting their addiction individually. As deficiencies the identification and conquering of these challenges point to evidence. Yet, this approach fails to acknowledge consequence in its omission of the intergenerational effects of colonization through the residential schools, sixties scoop, structural inequities across the social determinants of health, and a lack of access to culture as a way to explain addictions. Indigenous social service agencies, such as friendship centers, view an individual’s addiction as a symptom of deeper problems rooted in racism, powerlessness, and cultural breakdown. This notion sets the tone for the framework whereby a Native wellness assessment was developed and validated in this study. The inextricable link among the four directional quadrants in advancing wellness is consistent in the literature (Dingwall & Cairney, 2010; Thomas, Cairney, Gunthorpe, Paradies, & Sayers, 2010). It is important to work and grow culturally in each quadrant relational to the others for balance and wholeness. Wellness is simultaneously contingent on all four of the spiritual, emotional, mental, or physical quadrants. Western science emphasizes the pursuit of consecutive evidence on which to base theory, models, and 6 C. FIEDELDEY-VAN DIJK ET AL. Downloaded by [Lakehead University] at 09:58 16 March 2016 measures. Evidence is derived from a collection of ideas and observations, some of which have been tested and demonstrated to be valid and reliable across specific populations of people. In the Indigenous worldview, evidence is informed by knowledge that emphasizes the integration of physical and spiritual realities in healing and wellness. It is done such that the manifestation of spirit in physical reality is accepted as proof when the understanding of such manifestation or expression can be tied to cultural teachings and community knowledge passed on from generation to generation. With this tie, change for the better can occur. This implies that Indigenous well-being can be measured, followed, and developed, for example, by way of a Native wellness assessment. The need for a Native Wellness Assessment There is a scarcity of appropriate, scientifically validated, and holistic wellness assessments that have Indigenous culture at their foundation and that measure and can control for the contribution of culture, as expressed through cultural intervention practices (CIPs). Rowan et al. (2014) conducted an extensive scoping review of CIPs to treat addictions among Indigenous peoples in residential programs as tied to wellness in residential programs. They found that less than 0.5% of studies used surveys and that these had been developed in house (56%), were Western based (44%), and/or focused on alcohol and drug use. Only two instruments—the American Indian Cultural Involvement Index (Boyd-Ball, Dishion, Myers, & Light, 2011) and the Cherokee Self-Reliance Questionnaire (Lowe, Liang, Riggs, & Henson, 2012)—were oriented to Indigenous culture. These measures accommodate traditional/cultural healing components by adding them to addiction treatment (including talking circles, family involvement, and incorporation of CIPs) and identify the components at least in part as the cause for a successful outcome of lower substance/solvent/alcohol abuse. By comparison, this study focuses on wellness with culture at its apex, shifting from method to foundation. The project team set out to embed identification with culture and entrench how culture is practiced in wellness; improvements in wellness during the course of recovery from addictions are needed to sustain healing and liberate those who are thinking of deficiencies only. The review highlighted that there is an overreliance on Western-based assessments to evaluate Native wellness as tied to addictions. Pace et al. (2006) cautioned against using assessments centered on the dominant culture, as interpretation is outside the context of the profound social, historical, and political understanding and experience of Indigenous peoples. A progressive alternative is to develop new Indigenous-specific measures directed and governed by Indigenous peoples and informed by Western-based science. Such a Downloaded by [Lakehead University] at 09:58 16 March 2016 JOURNAL OF ETHNICITY IN SUBSTANCE ABUSE 7 process would better ensure cultural relevance and align with the global movement toward a strengths-based resiliency perspective on alcohol and drug addiction among Indigenous peoples (Dell, Hopkins, & Dell, 2004; Graham & Stamler, 2010; Mohatt, Fok, Burket, Henry, & Allen, 2011). Other studies, including Indigenous-directed research, deconstructed wellness and focused on developing and validating scales related to isolated aspects of wellness, such as physical or emotional health (Chong et al., 2009; Mohatt et al., 2011; Thomas et al., 2010). While there is value in measuring separate aspects of wellness, in isolation they can misrepresent wellness in its entirety. A holistic perspective allows researchers to examine the critical interconnectedness and interdependence of wellness. The review also revealed that assessments were often disconnected from an Indigenous worldview, focussing on risk factors, disease processes, and socioeconomic problems (Bartlett, 2005) rather than strengths (Snowshoe et al., 2015). Culture-as-intervention was not embedded in these instruments, yielding measures incongruent with Indigenous conceptualizations and diminished strength. Differing conceptualizations and worldviews can be addressed using approaches such as two-eyed seeing (Hall et al., 2015) yet cannot replace culture as strength at the apex of an Indigenous assessment. Culture is inescapable and beneficial (Dyck & Kearns, 1995; Lynam & Young, 2000). For example, Canada benefits notably by more than 600,000 youth who will have entered the labor market by 2026 (Calliou, 2012). The culturally grounded LE,NONET project at the University of Victoria, which helps growing numbers of Indigenous students adapt to campus life, honor their values, and improve their success, reported increases of 100% in term-to-term continuation and 20% in graduation rates and reduction of 67% in withdrawal rates from 2005 to 2009 (Mason, 2010). Postsecondary education attainment is associated with improvement in social determinants (Wells, 2010). Approximately 53 million Canadian dollars were loaned to more than 800 Indigenous start-up businesses in Alberta by one local developer over the last 28 years (Calliou, 2012). The Royal Bank of Canada (RBC) and others reported on Indigenous success stories for businesses, communities, and individuals. For example, Indigenous peoples are increasingly forming partnerships with the corporate sector; are actively involved in on-reserve mortgage housing and real estate, water issues, oil sands, telecommunication, and entertainment and service industries; enroll in various education projects and programs; partake in the North American Indigenous Games; have special advisory and senior managerial input to RBC decision making; established access to opportunities giving law students legal and business skills needed; and are formally recognized in diversity initiatives (Goulet & Swanson, 2013; Kishk Anaquot Health Research, 2007; Royal Bank of Canada [RBC], 2015). Publicly recognized stories and other anecdotal reports demonstrate how sustainable prosperity for Indigenous peoples is Downloaded by [Lakehead University] at 09:58 16 March 2016 8 C. FIEDELDEY-VAN DIJK ET AL. approached through economic development strongly intertwined with community and social development, employment, training and education, and cross-cultural trust. These widespread progressions help demonstrate that strengths lie in culture for Indigenous peoples- the importance of Indigenous culture cannot be overstated. Building on Indigenous success stories, in this project researchers cooperated cross-culturally by implementing cultural ways of knowing inherent to the cultural target group—Indigenous peoples. In the introductory discussion, researchers specified the context within which the measure needs to be developed and validated and reviewed the theoretical underpinning behind the wellness dimensions. The scoping review and trends described above underscore the need for closing the gap in measurement of culture-based approaches. Native wellness was defined in alignment with enablement of communities and individuals to “actualize their potential spiritually, emotionally, physically and intellectually,” which Kishk Anaquot Health Research (2007, p. 5) provided as success criteria. The project goal was to develop a valid assessment to measure culturally embedded wellness among Indigenous peoples whereby the NWA contributes to Indigenous success. In the remainder of the article, researchers focus on the empirical piloting of the NWA and describe its development, its psychometric reliability and validation, and its intended function and utility, adhering to the fundamental importance of culture-as-intervention in wellness. Method Participants During piloting in Year 2 of the study, 55 treatment centers in the NNADAP/ YSAP system across Canada were operational and were targeted as practical and relevant data collection locations and invited to participate in the research. These treatment centers which primarily serve members of First nations, Métis, and Inuit populations, are located across Canada and predominantly in Ontario and the four western provinces that house the largest Indigenous populations (Statistics Canada, 2011). Funded service availability at these treatment centers was about 865 beds and another 200 beds sourced elsewhere per annum, with 80% average occupancy rate as reported to Health Canada, offered to in- and out-patients in continuous and/or block formats, with accommodation of physical disabilities (93%), pregnant women (82%), court referral or correctional clients (85%), clients on methadone/ Suboxone (25%), and clients on other psychoactive medications (64%). Access to a psychologist was available for 45% of the centers via direct service and 33% via clinical supervision. On average, treatment centers were run by 6.38 full-time staff members, 71% of whom were certified addiction counsellors. Program length in days Downloaded by [Lakehead University] at 09:58 16 March 2016 JOURNAL OF ETHNICITY IN SUBSTANCE ABUSE 9 ranged between 7 and 180 days and offered concurrent disorder capability (67%), residential schools (51%), on-the-land programs (44%), genderbased programs (49%), family treatment (24%), child counseling (33%), and couples counseling (38%). Together the centers equally admitted male and female clients, of whom about two thirds completed the program. Participating clients ranged widely with respect to gender (male, female, other), age in years, Indigenous ethnicity, work, and cultural experience: 1. Clients ranged from 13 (youth) to 63 (adult) years with an average age of 30 years and 9 months. 2. Males (47.3%) and females (53.7%) were fairly equally distributed in both gender-specific and coed programs offered at treatment centers. 3. The average treatment program length was 8.63 weeks, ranging from 4 to 16 weeks. 4. Participating clients returned for treatment an average of 2.11 times, ranging from the current treatment being the first time (for 51.4% of clients) up to 11 times (second to fifth time for 44.6% of clients). 5. Clients reported widely varying proficiency in their Native language; a rudimentary measure of adeptness put Native language competence at about 44.11% of strength compared to other languages (predominantly English). 6. Male clients reported a higher dominance in their Native language over another comparative language (e.g., English) than did female clients. Data collection Twelve treatment centers (21.82%) self-selected participation in the project by accepting the invitation. This response was workable; treatment center staff members are taxed on their time demand and clients are given priority. These participating centers placed wellness at the forefront of addiction treatment from a Native cultural perspective; almost all centers offered access to an Elder (98%) and cultural practitioner (75%). Self-selection naturally ensured that participating treatment centers subscribed to the philosophy of the project and were engaged in assessment development by and for Indigenous peoples. Data were collected over a period of 6 months in Year 3 of the study. Projections of a 50% participation rate from participating treatment centers based on the above annual intake numbers enabled rudimentary projection based on cluster sampling. Clusters represented different regions, Indigenous cultures, and client groups with respect to gender and age. The NWA validation sample comprised m ¼ 177 volunteer clients from 12 treatment centers and a 26% average response rate based on original projection of the maximum possible sample size. Plausible reasons for the realized response rate were as follows: one treatment center had to close for building repair during the data collection period; it was impossible to align the 6-months data collection period perfectly with the treatment cycle of every treatment center; occupancy Downloaded by [Lakehead University] at 09:58 16 March 2016 10 C. FIEDELDEY-VAN DIJK ET AL. rates were rarely 100%—some clients arrived days after the planned intake date and dropouts were common; out-patients living off-site were less accessible than clients in residence in the data collection period; and administration enabling repeat assessments required additional time commitment. The response rate was smaller than projected yet reflected circumstances realistically. Regardless, the piloted sample composition was diverse and met statistical sample requirements for exploring NWA validation. A composite sample character equipped to handle parametric statistics based on a minimum size of 100 respondents with approximation of a normal distribution curve lends credibility to research findings as it enables appraisal of test fairness and minimizes bias from known causes when it accurately represents the target population; in this case, Indigenous peoples (American Educational Research Association [AERA], American Psychological Association [APA], & National Council on Measurement in Education [NCME], 1999; Schield, 1994). During the data collection period, the NWA was completed at different stages of client treatment, allowing for repeat assessments of the same clients. This intentional design enabled researchers to test the NWA’s effectiveness in reporting changes in wellness over time. Data collection allowed for 0–3 survey completions based on self-report forms and observer forms as completed by the client and/or a staff member, for a maximum of six possible iterations per client. Most clients self-completed the NWA multiple times and/or were assessed by staff members. This repeated effort resulted in an iteration-dependent sample of size n ¼ 471 completed surveys (Table 1). Only 10 of the 177 participating clients in the independent sample did not self-complete at least once; a staff member completed on their behalf. Measure The NWA was developed to provide feedback on a person’s state of wellness from the perspective of Indigenous culture. The NWA may be completed at specific points in time: on entry (P1), midway (P2), and at exit of treatment (P3). The NWA consists of a self-report form (S version) and a parallel observer form (O version)—the first of its kind specific to Indigenous peoples. When mental, physical, language and/or educational background constraints prevent an individual from self-completing the survey, the parallel O version can be completed by a staff member of the treatment center or someone close to the client, such as a relative or a friend. Provision is made for verbatim comments at the end of the form. The NWA takes about 15 minutes to complete. Flesch reading ease of the NWA statements for the S and O versions are 75.3 and 65.7 (easily understood by a 12-year-old and easily understood by a 14-year-old, respectively), and Flesch-Kincaid grade levels 5.6 and 7.3, respectively (Flesch, n.d.). The NWA consists of statements and cultural JOURNAL OF ETHNICITY IN SUBSTANCE ABUSE 11 Downloaded by [Lakehead University] at 09:58 16 March 2016 intervention practices (CIPs). Together they expand the existing knowledge base of wellness; apart they serve as controls and encouragement for each other. Statements The NWA contains 66 randomly ordered, concurrence-oriented cultural statements, such as “My Native culture fuels my desire to live a good life,” “I go to Elders to learn about our Native ways,” and “The client practices traditional forms of sharing.” Respondents rate statements using a Likert-type scale ranging from disagree (0) to strongly agree (4). Respondents are allowed to opt for a don’t know option as a built-in validity indicator; during NWA development and item refinement, researchers worked to limit reasons for choosing this option. Other built-in validity indicators with interpretational guidelines in the NWA report are response inconsistency and social desirability. Cultural intervention practices NWA respondents are asked about their education or experience with a list of common CIPs. Indigenous peoples from diverse treatment centers, nations, and tribes identified the CIPs during NWA development by honoring the cultural evidence base held within their tradition. A CIP can be described as observable expressions of culture through language, speech, food and medicines, rituals, rites, customs, teachings, and traditions, whereby cultural values, beliefs, sentiment, relations, existence, and wisdom may be demonstrated and regeneration occurs in forms of healing, restoration, and renewal toward wellness. The listed cultural interventions are not exhaustive; those included in the NWA (Table 3) were practiced 15%–95% of the time before assessment at P1–P3. The NWA design can also accommodate completion following treatment to examine long-term outcomes in wellness or in contexts not associated with treatment. There is no technical limit to how often the NWA can be administered to an individual, although practically a minimum interval of three weeks is recommended to allow for a treatment effect (if one exists) and to maintain good test reliability. This suggested time interval maximizes the range and average length of most treatment programs, minimizes carryover effects Table 1. Breakdown of pilot data sample. Assessments were completed at different points in treatment: P1¼ on entry; P2¼ midway; P3¼ at exit. S (Self) O (Observer) Subtotal P1–P3 P1 (Entry) P2 (Midpoint) P3 (Exit) Subtotal S/O 91 55 146 102 64 166 88 71 159 281 190 471 Note. m ¼ 177 clients completed: n ¼ 471 surveys, either self or via observers, across three different points in treatment. S ¼ self-report form; O ¼ observer form. 12 C. FIEDELDEY-VAN DIJK ET AL. Table 2. NWA structure formation: Distribution of the 66 statements in the NWA across the quadrants of wellness and their subthemes. Wellness quadrants and subthemes (66 statements) Downloaded by [Lakehead University] at 09:58 16 March 2016 Physical (body), creates purpose (18) Way of being (6) Way of doing (9) Wholeness (3) Mental (mind), creates meaning (17) Intuition (6) Rational (4) Understanding (7) Spiritual (spirit), creates hope (16) Belief (7) Identity (6) Values (3) Emotional (heart), creates belonging (15) Attitude (4) Community (4) Family (4) Relationship (3) from a previous completion (U.S. Department of Education, n.d.), and accommodates a context in which measured change as a result of treatment is desired in short order while allowing clients time to improve their wellness. For individuals, the Addictions Management Information System (AMIS) enables automated scoring and direct reporting online. AMIS is a national data management system available to a network of 55 NNADAP/YSAP addiction treatment programs in Canada, generally used for screening, assessment, referral, and case management. Having the NWA in this national database ensures centralized data collection for ongoing validation and reporting. A paper version of the NWA versions is also available; responses can be captured post facto for scoring and reporting. Plans are under way to provide greater Indigenous community-based access to the NWA and standardize the NWA according to growing national Indigenous norm groups in 2016/17. Table 3. NWA cultural intervention practices (CIPs): NWA’s 39 CIP groups according to frequency of practice among clients in the pilot study. Group 1 (≥70% practiced) Group 2 (50%–69% practiced) Group 3 (<50% practiced) • • • • Smudging Prayer Sweat lodge ceremony Talking/sharing circle • • • • Fishing/hunting Spiritual teachings Water as healing Use of sacred medicines • • • • • • • • • • • Nature walks Meaning of prayer Use of drum/pipe/shaker Sacred medicines Use of natural foods Ceremony preparation Cultural songs • • • • • • • • Community cultural activities Fire as healing Storytelling Culture-based art Pipe ceremony Sacred places Use of Native language Creation story • • • • • • • • • Cultural dances/pow wow • • Receiving help from traditional Healer/Elder • Gardening, harvesting • Giveaway ceremony Shaker/hand drum making Naming ceremony Water bath Blanketing/welcoming ceremony Cultural events/marches Dream interpretation Land-based/cultural camp Ghost/memorial feast Hide making/tanning Fasting Horse program Other taught/participated in/experienced Other (name): ________________ JOURNAL OF ETHNICITY IN SUBSTANCE ABUSE 13 Downloaded by [Lakehead University] at 09:58 16 March 2016 Validation model Cronbach (1988) and Messick (1988) argued for the importance of values, which form a basis for assigning meaning and resulting in action, to be infused in classical validation of psychometric assessments. In this study, value derives from Indigenous culture. The terms value and valid share the same Latin root, which means to be strong and is in support of a strengths-based approach. Validity is mainly concerned with evidential verification of the meaning and implications of a measured construct, such as wellness. Validity is unitarily focused on justifying the construct being measured (i.e., construct validation), accomplished through integration of complementary forms of evidence (Messick, 1988). Researchers viewed validation from a unified framework as suggested by Gregory (1992) and Messick (1995) and jointly endorsed by the AERA, APA, and NCME (1999). In the 1980s this pragmatic framework was expanded from the classical validation model described by Cronbach and Meehl (1955). The unified model denotes validation as an integrated evaluative process of gathering evidence (following the classical validation model) about an assessment underpinned by theory, to argue for and support the adequacy and appropriateness of interpretation and applications based on assessment findings; i.e., to consider their consequences also (Cronbach, 1982, 1988; Messick, 1989; Strauss & Smith, 2009). The validation framework guided researchers to employ an integrated evaluative judgment of six aspects as much as possible through NWA development, beta testing, and piloting. These six aspects conjointly function as general validity criteria or standards for all educational and psychological measurement: 1. Content relevance and representation: soundness in construction of the NWA attributes and their dimensionality (i.e., quadrants, subthemes, descriptors) in terms of relevance to and representation of the Native wellness domain. Does the NWA content appear to be measuring wellness and can it do so consistently? 2. Response processes and regularity: empirical verification and strength of the substance contained in the NWA through an appropriate sampling of statements and CIPs as they relate theoretically and structurally to wellness. Is the theoretical foundation—culture—underlying wellness sound as profiled by NWA scores? 3. Score structure: rational consistency in NWA quadrant and subtheme scoring and results presentation with what is postulated about the wellness construct domain. Do the interrelationships of the NWA attributes— quadrants, subthemes, descriptors—correlate with each other and with overall wellness? 4. Generalizability and fairness: provision of representative coverage of wellness through the NWA among Indigenous peoples with present addictions Downloaded by [Lakehead University] at 09:58 16 March 2016 14 C. FIEDELDEY-VAN DIJK ET AL. and in recovery of addictions, with potential for wider identified applications. Does the NWA generalize across different groups, settings, and contexts? 5. Relation to other variables: appraisal of the degree to which the low, high, and interactive NWA attribute scores are mirrored by external indicators of wellness, whether assessed or nonassessed yet implicit. Does the NWA have convergent, discriminant, and predictive qualities? 6. Intended and unintended consequences: enablement and accrual of positive implications as a result of NWA use as well as evidence that adverse consequences and test bias are minimal. Does the NWA have merit despite potential risks if scores are invalid or inappropriately interpreted? In answering these six criteria, researchers provided essential empirical validation evidence including content and construct validity under the classical model as detailed in the next sections and a dimensionally sound scientific basis for accurately interpreting NWA scores and considering their implications. These extensive criteria are backed by strong scientific argument for addressing all of them in test development and validation. Cizek, Rosenberg, and Koons (2008) conducted a review of the BUROS Sixteenth Mental Measurements Yearbook sourcing validity evaluations for 283 published measures (many of which were longstanding), focusing on conformity to traditional versus modern validity theory and sources of validity evidence typically reported. They found that evidence sourced specifically by construct, concurrent and content validity (i.e., aspects 3, 4, 5, and 1) featured roughly half the time; with consequences and evidence sourced as related to response processes (i.e., aspects 6 and 2) appeared close to 1% and 2% of all cases. Sources from the classical model of validation were routinely favored above others, likely because more test authors followed that model in years past, and many test authors may have been up against practical constraints such as higher cost and time associated with getting long-term cooperation from people and organizations and reliance on others for gathering data sourced from multiple samples. Furthermore, it is difficult to synthesize empirical evidence with theoretical rationales founded in values and meaning (Cizek, Bowen, & Church, 2010). Following on the first plausible reason, Cizek et al. (2010) replicated this study. They used two data sources: 1,007 more recently published articles in eight esteemed applied measurement and testing journals and 326 articles published at the last two annual meetings from the AERA, APA, and NCME at the time. In 1999, these associations jointly published 264 distinct standards for validation based on the unified framework. The authors arrived at the same conclusion as their colleagues. Since Messick’s (1989) influential chapter on the topic, evidence based on assessment consequences was tacitly ignored or largely underreported for 25 Downloaded by [Lakehead University] at 09:58 16 March 2016 JOURNAL OF ETHNICITY IN SUBSTANCE ABUSE 15 years. Researchers have long advocated for addressing validation in a unified manner, placing the responsibility in both academic and applied settings. The persistent disparity in validation practices can be addressed by detailing evidence and considering consequence in all test development and validation steps and continuing scrutiny of intended and unintended implications of testing in longer-term planning and publication of ongoing validation research. This call for action also requires innovative approaches to the number and types of sources used for validation, especially when health and social consequences are at stake (Hubley & Zumbo, 1996; Messick, 1989). Project researchers used the standards nonprescriptively in response to the evolving field since the classical validation model was described by Cronbach and Meehl (1955). It is hoped that this article will encourage more researchers to use and integrate complementary forms of evidence to construct validation in efforts to break current trends in validation practices. The AERA, APA, and NCME (1999) cautioned that evaluation of the acceptability of an assessment and its application “does not rest on the literal satisfaction of every standard … and acceptability cannot be determined by using a checklist” (p. 4). Application of fragmented, unitary approaches to scientific development and validation of psychometric assessments that are unified in the context of consequences is helpful (Fairchild, 2013). The next sections provide opportunity for traditional psychometric appraisal, expanded by judgments about practical relevance and utility of the NWA for user cost benefit. Evidence and consequence of measured wellness underpinned by cultural values are offered within rational organization of NWA development and validation. Results Statistical validation of the NWA piloted data comprised a range of standard descriptive, inferential, and multivariate analyses assuming an asymptotic (i.e., closely) normal distribution, using SAS software. Chi-square contingency associations were computed to display the demographic character of the sample. These were followed by Student t tests for variables with two categories (e. g., male and female) and general linear modeling (ANOVA) with Sheffé’s post hoc analysis for variables with multiple categories to explore potential test bias while accommodating unequal sample sizes. Significance of p < .05 was used as guideline for interpreting differences in comparative scores. Responses to statements were treated at the interval scale level of measurement to allow adding, subtracting, and weighing in scoring. The six iterations were analyzed separately. Select findings at overall, quadrant, and subtheme levels are discussed here. (Detailed results are available upon request.) Possible implications of every step in NWA development were scrutinized by a diverse project team member base and by the communities involved. Downloaded by [Lakehead University] at 09:58 16 March 2016 16 C. FIEDELDEY-VAN DIJK ET AL. Figure 1. Research project outline: Three-year outline specifying the project timeline and role of main collaborator groups. Content relevance and representation in NWA development The project team included project and territory Elders, Indigenous knowledge keepers and users, experts in the field of addictions and/or Indigenous culture-based treatment across Canada, and contractors (Figure 1), ensuring a rich and relevant knowledge base in both academic and applied settings. Research principles were established at the first large group meeting in Year 1, ensuring endorsement of self-determination practices throughout the project. Ownership, control, access, and possession remained with Indigenous peoples through rigorous sequential timelines (Crooks, Snowshoe, Chiodo, & Brunette-Debassige, 2013; Streiner & Norman, 2008). Researchers followed rigorous assessment development practices by incorporating justified progression in statement generation and refinement, with continuous input from treatment center staff and clients along the way. Construct scoping The primary source of information for initial statement development was generated through environmental scan focus groups with 12 NNADAP/YSAP treatment centers across Canada. The two-day focus groups took place over 4 months in Years 1 and 2 and involved treatment center staff, community participants, and Elders. The project Elder led these sessions, beginning with the Creation Story as a platform to facilitate in-depth conversation about the meaning of wellness and about cultural interventions toward wellness. The JOURNAL OF ETHNICITY IN SUBSTANCE ABUSE 17 Downloaded by [Lakehead University] at 09:58 16 March 2016 conversations were founded on Indigenous values of giving before asking. This ensured the interactions were mutually beneficial at all times while adhering to Indigenous community standards grounded in traditional knowledge advocated by Gone (2012). A wealth of stories and topics was offered by community-based researchers and community members from each participating treatment center. Numerous CIPs used in treatment centers across Canada were gathered along with their meaning of origin to help grasp culture-as-intervention. No data were captured on the rituals or the process for conducting cultural interventions in recognition that cultural practices come from a spiritual foundation. CIPs were linked to their story of origin or cultural society to qualify as Indigenous. Participants had an opportunity to verify the data captured during focus groups. Domain identification A smaller, core Indigenous knowledge group (IKG) of researchers sorted this information first in emergent, inductive fashion, followed by a deductive approach grounded in the project definition of wellness. The IKG worked with another group of project researchers who independently coded the focus-group information using NVivo qualitative data analysis software (Miles & Huberman, 1994) to inform the themes that emerged from the IKG work and establish construct validity in NWA development from the perspective of two-eyed seeing. Each small work group represented researchers with either subject-matter expertise or direct project involvement, or both. Statement generation Researchers further established and grounded domain identification through the quadrants of wellness and the combined efforts from focus-group results. The construct was comprehensively represented through initial statement generating following a model of inclusiveness; all emergent ideas were considered equal at this point. Researchers presented a set of culturally rooted descriptions at a large gathering in Year 2. The IKG grouped the descriptions that formed the statement pool of 256 self-report statements, with matching or paired observer statements, into 47 descriptor labels containing 1–12 statements each. Organization into the different levels ensured measurable dimensionality within the construct domain of wellness. Structure formation The statement pool and descriptor labels provided a solid base for developing a structure formation in NWA development (Table 2), yielding 13 subthemes among the quadrants. Attending to assessment length while allowing for a sufficient number of items to assess the construct, the statement pool was synthesised into 66 statements of low content redundancy. Statements were worded in the same direction; their effect on the response set weighed against the keystone that culture implies strength in wellness. Each item was used Downloaded by [Lakehead University] at 09:58 16 March 2016 18 C. FIEDELDEY-VAN DIJK ET AL. once only in scoring, which comprises (a) a summative process and (b) conversion to an interpretable percentage score as an extension of the scaled raw values that vary in range depending on the number of statements in each. Percentages set the baseline at 100, which is familiar to most and whereby scores can be directly compared within and across reports. A list of CIPs was developed alongside the NWA statements. CIPs that are both commonly practiced and specific to nation and gender were described during the focus groups in Year 1. Researchers considered the CIPs from the perspectives of teaching, participation, and experience in Year 2 to reach consensus on the list. Nomenclature was standardized with input from treatment center directors, staff, and clients as outlined previously. NWA statements and CIPs, as two different systems of inquiry, keep each other in check and as a consequence bring forward and make visible their underlying values and assumptions in the NWA structure formation (Moss, 1998). Rational expert judgment Collaborator team gatherings relied on cultural, practical, psychometric, and statistical expertise to further refine these 66 statements and address content validity through five progressive opportunities. These included, among other practices 1. Fine tuning of psychometric properties of statements and their response format, incorporating qualitative and quantitative item analysis based on expert feedback and testing; 2. Initial beta testing and quantitative scrutiny of the responses and verbatim comments from a sample of 36 clients at different participating treatment centers as the target population; 3. Simplification of statement wording to address ease of readability; and 4. Relevance of and client identification with statement content. The process of assessment development and validation is also described in the NWA user’s manual available from NNAPF2. A list of 52 CIPs was piloted; participants were asked to check all cultural interventions they practiced recently. The list was then further reduced to 39 CIPs and grouped according to frequency (Table 3). Care was taken to moderate the effect of seasonal CIPs in alignment with treatment cycles across the three groups. The question format was refined from the dichotomous check/no-check response to a rating scale of clients’ strength of connection to each, ranging from weak (1) to strong (3), including a did not practice response option in closer alignment with the successful response format used for the statements upon piloting. This permitted greater insight into the effect of CIPs in wellness. 2 Related, the NWA is supported by a free step-by-step client activity guide and facilitator’s handbook for service providers and their clients (http://www.addictionresearchchair.ca/ca.creating_knowledge/national/honouring-ourstrengths-culture-as-intervention/gowing-wellness-connectin-with-culture/). Downloaded by [Lakehead University] at 09:58 16 March 2016 JOURNAL OF ETHNICITY IN SUBSTANCE ABUSE 19 Empirical testing The NWA was piloted in Year 3. During piloting, participating clients were assessed with the NWA only. The statistical examination of statements and CIPs at six different iterations ([S, O] x [P1, P2, P3]) helped researchers establish cross-referenced validation evidence for the NWA during a 2-day discussion of a comprehensive technical report of statistical tables (Fiedeldey-Van Dijk, 2015). Items were analyzed to establish their psychometric properties, unimodality, and response distribution; internal consistency, and correlation to total; structural and content validity; and power to discriminate between different demographic groups. Scored items were analyzed at the levels of quadrants, subthemes, and descriptors to determine their interpretational feasibility and comparability (i.e., convergent validity) between self- and observer reports and divergent validity over time in the context of expected changes as a result of treatment. The progressive process of assessment development and validation based on piloted data enabled researchers to refine the NWA where needed and concluded the project with an edition of NWA including S and O versions that are fit for use in NNADAP/YSAP treatment centers and beyond. NWA content relevance and representation demonstrated in reliability Comparisons of self-report and observer versions The sample of 471 completed NWA surveys from 177 participating clients across the three treatment points enabled calculation of Pearson productmoment correlation coefficients between the S and O versions (Table 4). Correlations between the NWA-S and NWA-O at P1–P3 treatment points were statistically significant (p < .001) and moderate, indicating response accuracy and convergent validity between versions while allowing for discussion of different perspectives that may incite further learning (Mersman & Donaldson, 2000). Internal consistency Using Cronbach’s coefficient alpha, researchers found internal consistency to be generally high, regardless of the varying number of statements in each subtheme (Table 5), averaging at 77.8, 78.6, and 81.1 for the S-version subthemes across P1–P3, and correspondingly at 84.8, 85.2 and 84.2 for the O-version subthemes. Subthemes with either a lower (<.70) or higher (>.90) coefficient led researchers to identify and revise statements in pursuit of a consistent Table 4. NWA self- and observer correlation over time: Pearson product-moment correlation coefficients between the self (S) and observer (O) versions of the NWA. Six iterations Correlation between S and O versions Entry (P1) Midpoint (P2) Exit (P3) 0.61 0.51 0.61 Note. S ¼ self-report form; O ¼ observer form. Assessments were completed at different points in treatment: P1 ¼ on entry; P2 ¼ midway; P3 ¼ at exit. 20 C. FIEDELDEY-VAN DIJK ET AL. Downloaded by [Lakehead University] at 09:58 16 March 2016 Table 5. Internal consistency of the NWA: Cronbach’s coefficient alpha for quadrants and subthemes in the NWA. Quadrant subthemes S_P1 S_P2 S_P3 O_P1 O_P2 O_P3 Spiritual Belief Identity Values Emotional Attitude Community Family Relationship Mental Intuition Rational Understanding Physical Way of being Way of doing Wholeness 0.92 0.87 0.84 0.61 0.91 0.84 0.71 0.71 0.65 0.95 0.83 0.80 0.89 0.92 0.78 0.91 0.68 0.91 0.87 0.82 0.63 0.92 0.84 0.82 0.70 0.67 0.95 0.87 0.84 0.87 0.93 0.83 0.89 0.57 0.93 0.88 0.88 0.59 0.93 0.86 0.81 0.75 0.75 0.93 0.84 0.81 0.89 0.92 0.82 0.89 0.77 0.96 0.93 0.86 0.75 0.95 0.87 0.89 0.83 0.75 0.97 0.95 0.90 0.92 0.96 0.87 0.95 0.56 0.96 0.94 0.89 0.80 0.95 0.88 0.83 0.88 0.78 0.95 0.88 0.85 0.86 0.96 0.86 0.93 0.69 0.93 0.90 0.89 0.62 0.94 0.91 0.84 0.87 0.85 0.93 0.88 0.86 0.79 0.94 0.82 0.91 0.81 Note. S ¼ self-report form; O ¼ observer form. Assessments were completed at different points in treatment: P1 ¼ on entry; P2 ¼ midway; P3 ¼ at exit. correlation with the total across statements (Gliem & Gliem, 2003; Tavakol & Dennick, 2011), thereby addressing those with comparatively weaker correlation and those with statistical and conceptual indications that signaled redundancy between statements. Intercorrelation matrices Pearson’s product-moment correlation coefficients were computed among the quadrants, subthemes, and statements for all six iterations. Given space restrictions, two of the matrices S_P1 and O_P3 at the quadrant level are presented in Table 6, representing one of S and O each at the beginning Table 6. Partial Correlation Matrix of NWA Quadrants Examples of Pearson product-moment correlation coefficients (r) between the two NWA versions taken at different points across the quadrants of wellness Pearson’s r S_P1 S_P1 S_P1 S_P1 % % % % Spiritual Emotional Mental Physical Pearson’s r O_P3 O_P3 O_P3 O_P3 % % % % Spiritual Emotional Mental Physical % Spiritual % Emotional % Mental % Physical S_P1 S_P1 S_P1 S_P1 1.0000 0.8622 0.8997 0.8999 1.0000 0.8432 0.8613 1.0000 0.9186 1.0000 % Spiritual % Emotional % Mental % Physical O_P3 O_P3 O_P3 O_P3 1.0000 0.9626 1.0000 0.9661 0.9645 1.0000 0.9544 0.9428 0.9501 1.0000 JOURNAL OF ETHNICITY IN SUBSTANCE ABUSE 21 Downloaded by [Lakehead University] at 09:58 16 March 2016 and end points of treatment respectively, chosen based on respectable sample sizes. (All six matrices can be provided upon request.) Overall, very high coefficients were found at the quadrant level. This suggests that the wellness quadrants are inseparable. By contrast, intercorrelations at subtheme level were found to lie on average at approximately r ¼ 0.50 with considerable variation. Researchers used correlation coefficients <.30 or >.70 as a guide in pinpointing specific statements in identified subthemes, which required further refinement in wording. Statistics of corresponding statements in S and O versions served as a helpful additional steer for item refinement. Approximately one third of the statements underwent refinement, reinforcing the scope and soundness of the NWA structure at quadrant, subtheme, and descriptor levels and improving item reliability. NWA response processes and regularities shown in wellness profiling and treatment effect Reported states of wellness Descriptive scores across the six iterations for overall wellness and the CIPs are outlined in Table 7. Clients scored themselves more consistently around the reported average of low 80%; observer scores lay at mid-60% on average. The average difference of 18.92% across the quadrants at P1–P3 is consistent with 360-degree comparisons based on formative response scales in general (Howard, 1980; Tornow, 1993). Average wellness score differences between S and O versions contain diagnostic utility: Comparatively high average client scores may signal strong needs to identify with Indigenous culture despite what observers may evidence. For CIPs, mean scores were found to be low 50% for clients and low 60% for observers across P1–P3, rendering a Table 7. NWA descriptive statistics of wellness and the cultural interventions practices: Overall wellness and CIP scores as reported by clients and observers during treatment. Overall wellness S_P1 % Wellness S_P2 % Wellness S_P3 % Wellness O_P1 % Wellness O_P2 % Wellness O_P3 % Wellness Overall CIPs S_P1 % CIPs S_P2 % CIPs S_P3 % CIPs O_P1 % CIPs O_P2 % CIPs O_P3 % CIPs n Mean SD Std error Skewness Kurtosis 91 102 88 55 64 71 76.80 82.21 84.17 50.94 64.64 70.99 18.41 17.09 16.26 24.62 21.55 22.51 1.93 1.69 1.73 3.32 2.69 2.67 0.91 1.32 1.33 0.34 0.42 0.80 0.72 1.86 1.97 0.96 0.67 0.38 91 102 88 55 64 71 49.75 54.92 52.41 60.72 61.46 64.84 24.47 23.85 20.73 20.36 19.14 14.03 2.57 2.36 2.21 2.74 2.39 1.66 0.05 0.16 0.09 0.49 0.32 0.30 0.97 0.81 0.55 0.68 0.57 0.09 Note. S ¼ self-report form; O ¼ observer form; n¼number of surveys. Assessments were completed at different points in treatment: P1 ¼ on entry; P2 ¼ midway; P3 ¼ at exit. Std error ¼ standard error of the mean (sampling error); SD ¼ standard deviation; CIPs ¼ cultural intervention practices. 22 C. FIEDELDEY-VAN DIJK ET AL. Downloaded by [Lakehead University] at 09:58 16 March 2016 Table 8. NWA wellness at quadrant level: Quadrant scores of wellness as reported by clients and observers during treatment. Cultural quadrants n Mean SD S_P1 % Spiritual S_P1 % Emotional S_P1 % Mental S_P1 % Physical S_P2 % Spiritual S_P2 % Emotional S_P2 % Mental S_P2 % Physical S_P3 % Spiritual S_P3 % Emotional S_P3 % Mental S_P3 % Physical O_P1 % Spiritual O_P1 % Emotional O_P1 % Mental O_P1 % Physical O_P2 % Spiritual O_P2 % Emotional O_P2 % Mental O_P2 % Physical O_P3 % Spiritual O_P3 % Emotional O_P3 % Mental O_P3 % Physical 91 91 91 91 102 102 102 102 88 88 88 88 55 55 55 55 64 64 64 64 71 71 71 71 78.84 78.54 76.73 74.01 83.66 83.66 82.56 79.74 86.00 83.66 83.67 81.64 51.52 53.64 50.24 48.69 65.77 68.43 63.21 61.73 72.51 73.33 69.82 68.81 18.03 18.94 19.92 19.53 16.97 17.34 19.10 17.85 15.02 15.95 18.49 17.78 24.82 24.68 26.17 24.63 23.14 21.44 22.31 21.37 22.64 23.67 23.04 22.32 Note. S ¼ self-report form; O ¼ observer form: n¼number of surveys. Assessments were completed at different points in treatment: P1 ¼ on entry; P2 ¼ midway; P3 ¼ at exit. SD ¼ standard deviation. 10.02% average difference in the opposite direction as before at P1 and P2. Contextualization of these differences suggests that the two NWA versions have statistical and practical merit in addictions treatment context, when applied either separately or together. Clients achieved slightly lower scores in the physical quadrant than in the other three (Table 8). Consider that the physical quadrant creates purpose (Table 2) as captured in three subthemes: ways of being (exercising responsibility, learning about the relationship with Spirit, consequential thinking), ways of doing (balance and health through food, cleansing and being active, communication, sharing, and expression of gratitude), and wholeness (nurturing one’s whole being and knowing where one comes from). Lower scores in the physical quadrant suggest that until the NWA is standardized, users may need to ease up slightly in assigning literal value and meaning to physical-quadrant scores in comparison to scores of the other three quadrants. An increase in average scores over time signals that the NWA measures a positive change in wellness during the course of treatment (Figure 2), as is desired for clinical utility. Table 8 and Figure 2 illustrate average wellness for partially independent client groups at each point in treatment, some of whom may have taken the NWA for the first time at P2 or P3. Since data dependencies and potential carryover effects are reduced in this comparison, findings in Downloaded by [Lakehead University] at 09:58 16 March 2016 JOURNAL OF ETHNICITY IN SUBSTANCE ABUSE 23 Figure 2. NWA wellness at quadrant level: Visual depiction of wellness as reported by clients and observers during treatment. Table 8 imply that the NWA can be used at different points during treatment, expecting average scores to shift upward somewhat with time into treatment. Significant change in wellness over time Treatment effectiveness was determined through calculation of differences in scores (deltas) between P1, P2, and P3 where repeat assessments were completed. Client data with a one-time NWA completion are excluded here with smaller sample sizes in analysis as a result. A delta of 0% denotes no change in wellness over time. Patterned Student t-test results (one-tailed, p < .025) revealed that significant positive change occurred in all four quadrants over the course of treatment, demonstrating developmental utility. At P2 in particular, observers had already started to see change in wellness where clients had not. Overall, clients reported an average change in wellness across all possible P1, P2, and P3 deltas of 4.80%, compared to 14.56% for observers. Found deltas by themselves imply that the NWA is sensitive to change. Note that the deltas in Table 9 are larger than NWA time-point differences described above 24 C. FIEDELDEY-VAN DIJK ET AL. Downloaded by [Lakehead University] at 09:58 16 March 2016 Table 9. Treatment changes in NWA wellness and CIPs over time: Pattern of significant positive change in quadrants of wellness and cultural intervention practices as reported by clients and observers during treatment. Quadrant changes S P3-P1 Spiritual S P3-P1 Emotional S P3-P1 Mental S P3-P1 Physical S P3-P2 Spiritual S P3-P2 Emotional S P3-P2 Mental S P3-P2 Physical S P2-P1 Spiritual S P2-P1 Emotional S P2-P1 Mental S P2-P1 Physical O P3-P1 Spiritual O P3-P1 Emotional O P3-P1 Mental O P3-P1 Physical O P3-P2 Spiritual O P3-P2 Emotional O P3-P2 Mental O P3-P2 Physical O P2-P1 Spiritual O P2-P1 Emotional O P2-P1 Mental O P2-P1 Physical CIP changes S P3-P1 CIPs S P3-P2 CIPs S P2-P1 CIPs O P3-P1 CIPs O P3-P2 CIPs O P2-P1 CIPs n Mean Δ SD t Prob>|t| 46 46 46 46 56 56 56 56 38 38 38 38 25 25 25 25 44 44 44 44 24 24 24 24 10.83 11.10 12.84 13.63 0.98 0.17 0.04 1.79 2.46 4.01 5.24 6.32 32.53 29.99 31.95 32.74 9.80 8.50 11.06 11.63 19.93 19.78 17.15 20.78 15.46 13.46 14.36 14.52 10.82 10.76 13.79 11.17 13.11 13.59 14.92 15.00 22.44 21.11 21.42 22.64 19.14 18.30 19.61 17.46 21.80 23.03 22.28 22.74 4.75 5.59 6.06 6.37 0.68 0.12 0.02 1.20 1.16 1.82 2.17 2.59 7.25 7.10 7.46 7.23 3.40 3.08 3.74 4.42 4.48 4.21 3.77 4.47 0.0001** 0.0001** 0.0001** 0.0001** 0.5018 0.9088 0.9820 0.2358 0.2548 0.0770 0.0368 0.0135* 0.0001** 0.0001** 0.0001** 0.0001** 0.0015** 0.0036** 0.0005** 0.0001** 0.0002** 0.0003** 0.0010** 0.0002** 46 56 38 25 44 24 9.07 4.60 1.00 7.93 2.74 6.01 23.16 15.42 21.44 10.03 11.39 5.59 2.66 2.23 0.29 3.95 1.59 5.26 0.0109* 0.0297 0.7758 0.0006** 0.1185 0.0001** Note. S ¼ self-report form; O ¼ observer form n ¼ number of surveys. Assessments were completed at different points in treatment: P1 ¼ on entry; P2 ¼ midway; P3 ¼ at exit. Change between two treatment points is expressed as delta (Δ). SD ¼ standard deviation; t ¼ Student’s t statistic for testing the hypothesis that the population mean is 0. Prob, p ¼ probability. *p < .025; **p < .005; specified as one-tailed or directional to test the significance of positive change. in relation to Table 8. This latter comparison indicates that the NWA is able to measure treatment effectiveness. The delta differences are echoed by an increase in CIPs, as evident by the statistically significant deltas (p < .025 for increased CIPs on average). Found significance in CIP deltas were largely attributed to smaller standard deviation scores with progress in treatment; clients increasingly conformed to practicing cultural interventions. In other words, clients who practiced cultural interventions at the start of treatment did not necessarily increase the number of practices, but those who did not practice much or at all at P1, increased their number of practices by P3. The findings indicate that the increased conformity in CIPs and the increase in quadrant scores toward wellness from P1–P3 make a strong case JOURNAL OF ETHNICITY IN SUBSTANCE ABUSE 25 for claiming that the NWA is able to demonstrate the importance of cultureas-intervention toward wellness. Downloaded by [Lakehead University] at 09:58 16 March 2016 NWA score structure exploration Exploratory factor analysis (EFA) The factor structure of the NWA was statistically explored through principal components analysis of the six iterations of data since the cultural underpinning for wellness was not used in measurements in general and in the NWA specifically until now. In light of the subject-to-variable ratio of 177:66 or 2.7:1, interpretative caution was exercised where subsample sizes dip markedly below 100 (e.g., O_P1 and O_P2). Varimax rotation—an orthogonal (i.e., perpendicular) process whereby survey statements are optimally set at right angles —was applied to effectively address correlation between cultural statements and to aid in interpretation of resulting factors. Results strongly support one overarching factor—wellness. Both the scree plot and Eigenvalue criterion of minimum 1.00 suggested an interpretable 9–14 factor solution depending on the iteration, with factor loadings generally above 0.40 (Table 10). Closer inspection of statements within multiple factor loadings disclosed that they grouped along different cultural concepts. The findings support the propositioned deeper underlying structure for the quadrants, subthemes, and descriptors as outlined. This structure formation of wellness serves as organization for the theoretical foundation of the NWA. The EFA results suggest Indigenous culture, which lies at the apex of Native wellness, can be used for measuring and tracking Indigenous peoples’ wellness while in treatment for addictions. The foundation for a whole and healthy person as a desired outcome is culture-as-intervention. It is acceptable to use the quadrants and subthemes for wellness reporting and development because culture was found to be embedded in every aspect of the wellness structure formation. Table 10. Stability in the NWA factor structure across S and O versions and time: Consistency in the number of factors identified from the 66 statements in each iteration and the variance these factors explain. Interpretable factor solution S_P1 S_P2 S_P3 O_P1 O_P2 O_P3 Number of factors Percentage variance explained 13 12 9 9 12 14 57.11% 55.46% 55.79% 59.76% 55.64% 56.78% Note. S ¼ self-report form; O ¼ observer form. Assessments were completed at different points in treatment: P1 ¼ on entry; P2 ¼ midway; P3 ¼ at exit. 26 C. FIEDELDEY-VAN DIJK ET AL. Downloaded by [Lakehead University] at 09:58 16 March 2016 Generalizability and fairness of the NWA The NWA was statistically analyzed to ensure and confirm fairness among the different demographics (gender, broad age category, favoring of Indigenous language, treatment return times, and length of the treatment program) at the six iterations. Significant differences in average scores for demographic groups yielded summative insights described later. Differences are best read against the baseline of total sample mean scores for overall wellness and CIPs provided in Table 7. Male clients practiced 5%–10% more CIPs than female clients, and under18-year-olds checked fewer CIPs than older age groups. (Some CIPs are gender and/or age restricted.) Clients with Indigenous-language dominance checked 7%–11% more CIPs than their counterparts. A similar number of CIPs were practiced regardless of whether clients were in treatment for the first time or repeatedly. Clients in longer treatment programs practiced more CIPs. (Observers noted more CIPs than clients in short treatment programs specifically.) In scrutinizing demographic fairness when applying the NWA, foreseeable gender-based exceptions were found in NWA quadrants and subthemes. Females reported lower emotional community; males reported lower mental intuition (Table 3). Another notable exception was that when all results were considered together, those under18 years of age scored lower in wellness than older clients. Finally, length of the treatment program mattered significantly to change in wellness. Overall, wellness as measured through the quadrants and subthemes in the NWA rendered no statistically significant gender, age, or treatment return-time differences. This underscores the fairness of assessing clients in addiction treatment with the NWA. Discussion Efforts to improve wellness are critical for recovery and healing from addictions. Researchers theorized about and empirically demonstrated the role of Indigenous culture and cultural intervention practices (CIPs) as an underpinning for wellness at all levels through the development and validation of the Native Wellness Assessment (NWATM). The psychometric and utility merits of the NWA were detailed within the unified validation framework. Specifically, evidence was provided based on (1) relevance and representation of test content, (2) regularities in survey statement responses, (3) feasibility of the internal score structure, and (4) generalizability and fairness, with some references to test consequences as far as the NWA enables users to consider implications. Comments on evidence based on (5) relation to other variables and (6) intended and unintended consequences still remain and are offered as limitations and suggestions for ongoing research. Researchers showed that the NWA addresses a gap in the field for an Indigenous assessment that can be JOURNAL OF ETHNICITY IN SUBSTANCE ABUSE 27 used and repeated in addictions treatment and other Indigenous contexts as bolstered by culture-as-intervention. Downloaded by [Lakehead University] at 09:58 16 March 2016 The power of culture-as-intervention The results’ repeated emphasis on culture as underpinning for wellness deserves attention. From an Indigenous worldview, a singular culture does not exist. Indigenous nations have distinct sacred knowledge, beliefs, and traditions, although commonalities may be similar among them (Lowe, 2002). When these are asserted, they may aid in fostering the renaissance of Indigenous culture (Cunningham & Stanley, 2003), achieve reconciliation, and support the implementation of cultural intervention practices (CIPs) effectively in treatment and community-based programs. At a communal base, culture is a way of human life as variously expressed in spiritual, psychological, social, and material practices in order to create hope, belonging, meaning, and purpose in balance. This mirrors the project definition of wellness. Indigenous culture is embedded in the land, language, and nation of peoples and, most importantly, in the unique experiences of culture-as-intervention, which prompts reflection and internalization. Unified concepts of culture Taking this base a step further, Dumont (2014) identified primary unified concepts that describe Indigenous culture. These commonly held cultural concepts underpin wellness and, upon close inspection, were found to represent some of the factor loadings of this research. They are paramount in appreciating that 1. Life on Earth is fundamentally seen as centrally bonded though a caring Spirit, which is in and throughout all life and Creation and so all life is motivated by Spirit; 2. The circle, more than any other symbol, is most expressive of the Indigenous worldview and denotes a continuous flow of life, as is wellness; 3. Indigenous culture is virtuously voiced and transmitted through original language; 4. All universal things (human and nature) are inclusively relational and connected as personhood; and 5. Throughout continuous stages of life, everybody is predisposed to have the desire to be respectfully harmonious and in balance with Creation. Indigenous culture-as-intervention was articulated and communicated through culturally specific spirit-heart-mind-body NWA statements. Grouped as different subthemes within the four quadrants or directions of the Sacred Medicine Wheel, these statements can indicate a person’s present or developing state of wellness. Since CIPs are Indigenous expressions of spirit-heartmind-body at work, wellness can be achieved through Indigenous cultural 28 C. FIEDELDEY-VAN DIJK ET AL. Downloaded by [Lakehead University] at 09:58 16 March 2016 intervention practices also. These understandings are critical to the development and validation of the NWA as a measure of wellness with cultural underpinnings. As an Indigenous construct, wellness is an inclusive state or position of balance, wherein spirit-heart-mind-body work together through the primary, unified concepts of culture. This renders culture, in and by itself, as an intervention toward wellness through expressions (CIPs) and behavior (cultural statements). Hence, culture-as-intervention is written as a hyphenated phrase to denote one concept at the apex of wellness instead of as three separate words as one would do in the context of a research experiment. It also implies that when culture-as-intervention lies at the apex of treatment programs for addictions, the NWA can be used to facilitate and monitor the process over time. Validation insights and strengths Both the self-report (S) and observer (O) versions brought value to the NWA and insights about clients in treatment for addictions. Clients consistently scored themselves more highly on entry to treatment, which may have a ceiling effect and could indicate early willingness to self-identify with Indigenous culture when observers stand more critical toward demonstrable cultural identification as it pertains to wellness. Observers tended to score clients higher in wellness during treatment than the clients did themselves, reporting a greater change more quickly. However, observers’ scores remained consistently below the clients’ own. Staff’s desire to see positive change as evidenced in comparatively high R2 at P2 may have biased observers midtreatment, although their experience of client progress in treatment and quicker perception of signs of progress in wellness may have kept their observations in check. Self- and observer scores were strongly aligned at exit from treatment. Differences in S and O scores underscore the importance of initiating a conversation with clients about differences between their selfperceptions and staff observations to qualify perspectives, further develop client self-awareness, and capitalize on another opportunity to learn about the client. Sharing the results of both versions with clients midway through treatment could encourage them to see that their wellness is improving, that they are doing well. The quadrants of wellness are interconnected and inseparable from within an Indigenous worldview. One could argue that the reported internal consistency and correlations (r > 0.85) do not signal redundancy, but rather indicate the spirit-heart-mind-body at work interactively. When a cultural practice helps release the body from the effect of an addiction, the benefit circles fluidly through the bonded connection of spirit, heart, and mind as well. Culture-asintervention simultaneously underpins all quadrants, rendering the reported high correlations as desirable. Distinguishing between the spiritual, emotional, Downloaded by [Lakehead University] at 09:58 16 March 2016 JOURNAL OF ETHNICITY IN SUBSTANCE ABUSE 29 mental, and physical has discerning value but becomes arbitrary when living one’s life from within an Indigenous worldview. This helps explain and justify why combinations of all four quadrants and 13 subthemes were interspersed throughout the cultural factors. The cultural statements as grouped by exploratory factor analysis (EFA) appeared to subscribe more closely to the primary, unified concepts that describe Indigenous culture and can be taught and practiced in addiction treatment. Indigenous culture itself is viewed as a continuous critical intervention in a person’s journey toward wellness via the quadrants, subthemes, and CIPs. Culture-as-intervention weaves through all quadrants toward wellness. Together, the quadrants and CIPs form an intricate balance in pursuit of wellness through the primary, unified concepts of culture. Reported quadrant, subtheme and CIPs averages expressed as percentages and mean differences between them set interpretational guidelines early on when (a) a norm base is growing and (b) further research is planned, paving the way for standardization of NWA scores in the near future for use in the context of addictions treatment and for general applications. Quadrants, subthemes, and CIPs scores can also motivate further land-based activity, instigate longer-term residential funding, and argue for incentives toward better food quality and gardening programs at treatment centers, incorporating the inclusion of Indigenous knowledge and skill of cultural practitioners as necessary in the workforce addressing substance use. Limitations and opportunities NWA validity is well demonstrated through the first four of six aspects of the unified validation model. The remaining two aspects signal future opportunities for ensuring continual NWA validation. Relation to other variables More factors were statistically identified than the five named and described in the project definition of culture (see Dumont, 2014). Results suggest that there is possibly room to expand the number of primary, unified concepts in the culture definition through additional careful reflection in collaboration with Indigenous knowledge keepers and/or further breakdown of the present five unified cultural concepts. A smaller number than 13 cultural factors may be considered for appraisal through confirmatory factor analysis (CFA) in ongoing research. The NWA structure’s convergence and divergence with other measures of both culture and wellness were not explored during piloting and will be a valuable addition to ongoing NWA validation endeavors. For convergent validity, the two measures identified in the scoping review—the American Indian Cultural Involvement Index (Boyd-Ball et al., 2011) and the 30 C. FIEDELDEY-VAN DIJK ET AL. Downloaded by [Lakehead University] at 09:58 16 March 2016 Cherokee Self-Reliance Questionnaire (Lowe et al., 2012)—may be reasonable contenders, along with the Orthogonal Cultural Identification Scale developed by Oetting and Beauvais in 1990–91 (Venner, Wall, Lau, & Ehlers, 2006) for Native American youth. Western-based cultural assessments, or those that are sensitive to particular cultures but not necessarily Indigenous cultures, may be contemplated for divergent validity, provided they are of good psychometric standing. Higginbottom et al. (2011) offered 13 tools or models that provide further direction for deliberation. In similar fashion, the NWA should be validated against other measures of wellness and treatment outcomes also and tried against nonpsychometric criterion-related appraisals customarily used by treatment center staff and Health Canada to further compare its discriminatory and predictive powers. Intended and unintended consequences Inclusion of a control group of Indigenous peoples not in addiction treatment, and an experimental group of Indigenous peoples participating in communitybased programs in future validation studies, would test that changes measured with the NWA result from treatment alone and/or pertain to Native wellness in a wider context. Returning clients had similar wellness scores to those entering treatment for the first time, indicating that treatment and NWA assessment are beneficial to both groups. This finding has a critical implication for treatment design and its measurement of success. For example, a modified stepped-wedge design could accommodate return clients as a positive indicator, which involves trials whereby specific treatment aspects may be sequentially rolled out based on circumstantial relevance and likelihood of treatment effectiveness. Differences in NWA scores among age groups necessitate separate youth and adult NWA norms in the future. Although observers did not report wellness differences based on language dominance, clients with Indigenous language dominance consistently reported higher overall wellness, especially in the Spiritual quadrant. This emphasizes the benefits of language-based initiatives as an important contributor to culture-as-intervention. The need for translated versions of the NWA, and subsequently language-based norms, needs to be assessed. In Canada, translation into French and at least one Indigenous language such as Nehiyawewin (Cree) or another language where English proficiency is low, may be a practical starting point. Researchers will need to ensure that translation efforts meet standards of semantic, content, and technical equivalence through translation from English by a Native speaker and back translation into English by an independent Native speaker, both from the region where the translated version will be dominantly used. Ongoing research efforts to keep NWA content valid and relevant should include treatment-center feedback on any recurring language issues based on educational level, wellness, and addictive states. These efforts should also Downloaded by [Lakehead University] at 09:58 16 March 2016 JOURNAL OF ETHNICITY IN SUBSTANCE ABUSE 31 include proportional representation of First Nations, Metis and Inuit populations as in NWA piloting participants skewed disproportionately toward First Nations, even when this group dominates in number among Indigenous populations in Canada. The NWA provides for gender identification other than male or female though demographic categorization and gender-inclusive statement wording, as well as in the conceptualization of wellness and culture-as-intervention throughout NWA development. Pilot sample sizes did not allow for more detailed statistical analysis on gender. However, gender is tied to self-identity and rooted in Indigenous understanding of community and family as inclusive of all relations. Gender is an important consideration for the NWA research agenda going forward (Brotman, 2015) and for treatment centers that offer coed programs. The finding that the length of the treatment program matters significantly needs to be addressed. CIPs and wellness development showed a meaningful initial effect, a plateau midway, and a prolonged effect over time. This indicates that treatment programs in the approximate range of 7 to 10 weeks achieve optimal results with culture-as-intervention. Whether particular CIPs can be accommodated in a concentrated period may matter in wellness and should be further investigated. The few demographic differences in NWA scores draw attention to possible cultural underpinnings that may be differentiating within reasonable explanations such as lived experience, role in Indigenous communities, and the reality that cultural teaching and learning are continuous. Alternatively, client access to culture may be hindered by dominance of religion in the community blocking cultural practices, or youth may be living in a non-Indigenous institution through child welfare or the justice system in Canada. While the different types of statistical validation reported here solidify the scientific and Indigenous strength of the NWA, validation of its current edition with refined statements and improved CIP ratings would need to be confirmed with new samples. More conclusive regression models of based on larger samples could offer more insights into the drivers of wellness and inform treatment programs. Another way to validate the NWA is to consider the descriptive characteristics of its structure formation with theoretical underpinning of culture-as-intervention and demonstrated ability to measure the effect of treatment. Through AMIS, continuing data collection among growing numbers of clients and involving more service providers is possible. NNAPF, the national partnership foundation for addressing addictions with NNADAP/YSAP treatment centers and programs in Canada, is initiating ongoing validation of the NWA, ensuring its relevance and contributing to the sustainable offering of effective CIPs. Under a unified validity theory, validation is an ongoing process, and the piloted results reported here help regulate and govern NWA Downloaded by [Lakehead University] at 09:58 16 March 2016 32 C. FIEDELDEY-VAN DIJK ET AL. applications while allowing for change. Developing a validated NWA broke new ground in effectively linking shifts in experience of CIPs, and scored responses to the quadrants and subthemes, to wellness through the conception of culture-as-intervention. NWA inferences will need continual validation updates to ensure the meaning of scores remains pure to wellness (i.e., having value implications) and suitable to different contexts (i.e., having social consequences and requiring norms) (Hubley & Zumbo, 2011; Messick, 1989). Staff members at treatment centers and community-based programs are encouraged to use the NWA among Indigenous peoples. During piloting, treatment center staff reported that the NWA served as a means for improving their own understanding of Indigenous culture and directing their focus when observing indicative behaviors in clients. Anecdotally, the NWA was a good training resource for both Indigenous and non-Indigenous service providers during piloting, demonstrating educational utility. Conclusion The NWA distinguished itself as a landmark assessment that is ready for use among Indigenous populations in pursuit of wellness. Continued building of evidence for culture-as-intervention through AMIS will ensure outcome data can be supported and used effectively to improve client wellness and program efficacy. NWA reporting combined with accessible client information will enable stakeholders to better understand and demonstrate client needs, guide decision making to better respond to those needs, and improve services and related polices at treatment center and network levels. The NWA can inform health and community-based programs and policy for Indigenous youth and adults in addiction treatment in Canada and beyond. Competing interests The author(s) declare that they have no competing interests. Authors’ contributions All authors helped to write, edit, and approve of the final version of the article prior to publishing within their respective expertize. Specifically, CD and CH conceived of the Honoring Our Strengths: culture-as-intervention in Addiction Treatment project; BF managed the data collection and capturing; CFvD performed the data verification, statistical analyses, interpretation of empirical findings involved in validating the NWA and main writing of the manuscript; MR comanaged the writing of the manuscript and main editing with CM; BS JOURNAL OF ETHNICITY IN SUBSTANCE ABUSE 33 formatted the tables; MF organized the references; DM ensured compliance with author guidelines for writing the manuscript. Downloaded by [Lakehead University] at 09:58 16 March 2016 Acknowledgments Members of the Honoring Our Strengths: Indigenous culture-as-intervention research team include nominated principal investigator: Colleen Dell (University of Saskatchewan); co-PI: Peter Menzies (Independent, formerly Centre for Addiction and Mental Health), Carol Hopkins (National Native Addictions Partnership Foundation), Jennifer Robinson (Assembly of First Nations; former designate, Jonathan Thompson); coapplicants: Sharon Acoose (First Nations University of Canada), Peter Butt (University of Saskatchewan), Elder Jim Dumont (Nimkee NupiGawagan Healing Centre), Marwa Farag (University of Saskatchewan), Joseph P. Gone (University of Michigan at Ann Arbor), Christopher Mushquash (Lakehead University), Rod McCormick (Thompson Rivers University, formerly University of British Columbia), David Mykota (University of Saskatchewan), Nancy Poole (BC Centre of Excellence for Women’s Health), Bev Shea (University of Ottawa), Virgil Tobias (Nimkee NupiGawagan Healing Centre); knowledge users: Kasi McMicking (Health Canada), Mike Martin (National Native Addictions Partnership Foundation), Mary Deleary (Independent, formerly Nimkee NupiGawagan Healing Centre), Brian Rush (Centre for Addiction and Mental Health), Renee Linklater (Centre for Addiction and Mental Health), Sarah Steves (Health Canada; former designate, Darcy Stoneadge); collaborators (treatment centers): Willie Alphonse (Nengayni Wellness Centre), Ed Azure (Nelson House Medicine Lodge), Christina Brazzoni (Carrier Sekani Family Services), Virgil Tobias (Nimkee NupiGawagan Healing Centre; former designate, Mary Deleary), Patrick Dumont (Wanaki Centre), Cindy Ginnish (Rising Sun), Hilary Harper (Ekweskeet Healing Lodge; Acting Director, Yvonne Howse), Yvonne Rigsby-Jones (Tsow-Tun Le Lum), Ernest Sauve (White Buffalo Youth Inhalant Treatment Centre), Zelda Quewezance (Saulteaux Healing and Wellness Centre), Iris Allen (Charles J. Andrew Youth Treatment Centre), Rolanda Manitowabi (Ngwaagan Gamig Recovery Centre Inc./Rainbow Lodge); collaborators (leadership): Chief Austin Bear (National Native Addictions Partnership Foundation), Debra Dell (Youth Solvent Addiction Committee), Val Desjarlais (National Native Addictions Partnership Foundation; former designate, Janice Nicotine), Rob Eves (Canadian Centre on Substance Abuse; former designate, Rita Notarandrea), Elder Campbell Papequash (Saskatchewan Team for Research and Evaluation of Addictions Treatment and Mental Health Services Advisor); contractors (methodology): Elder Jim Dumont (Nimkee NupiGawagan Healing Centre), Randy Duncan (University of Saskatchewan), Carina Fiedeldey-Van Dijk (ePsy Consultancy), Laura Hall (University of Saskatchewan), Margo Rowan (University of Saskatchewan); management: Barbara Fornssler (University of Saskatchewan; former designate, Michelle Kushniruk); article editing: Marcia Darling (Toronto). This work was inspired by the devotion of Elder Jim Dumont and the treatment center project partners to walk with First Nations’ people on the path to wellness guided by culture-as-intervention. With respect to this article, the authors most appreciatively thank Mike Martin for his assistance in facilitating the pilot testing process; Randy Duncan for his measurement expertise and work with the IKG in helping to revise early drafts of the instrument; and Roisin Unsworth (University of Saskatchewan) for her work in compiling information from the literature involving the application and validation of instruments to assess wellness. Funding This work was supported by the Canadian Institutes of Health Research (funding reference number AHI 120535). 34 C. FIEDELDEY-VAN DIJK ET AL. 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