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Effectiveness and appropriateness of culturally adapted approaches to treating alcohol use disorders in Indigenous people

a mixed methods systematic review protocol

Hines, Sonia1,2; Carey, Timothy A.3; Hirvonen, Tanja1,2; Martin, Kathleen1,2; Cibich, Mikaela1,2

Author Information
doi: 10.11124/JBISRIR-D-19-00040
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Alcohol addiction or alcohol use disorder is a common and complex disorder affecting a large number of people worldwide.1 The frequent, heavy, and/or habitual consumption of alcohol can have serious effects on physical and mental health, as well as lead to undesirable social and economic outcomes.2 The problematic use of alcohol is not limited to any one socio-economic or cultural group, yet the harms of excessive drinking are not equally distributed.3,4 Poorer and more disadvantaged people suffer extensive health effects due to alcohol misuse and are also subject to additional law enforcement actions.5 Substance abuse, which includes alcohol abuse/misuse, is conceptualized as an illness in Western countries, and consequently treated as a health problem within the health care system.6

Health care in high-income English-speaking countries such as Australia, New Zealand, the United States of America (USA), and Canada, is largely designed to meet the needs of their majority white populations while often failing to deliver appropriately framed care to Indigenous and First Nations peoples.7,8 This failure to consider a range of cultural needs may result in care being provided that is inappropriate, unwanted, misunderstood, or even harmful, and contributes to health disparities between populations.9 These shortcomings of the health care system and society at large intersect around alcohol misuse and programs designed to prevent it, to the detriment of Indigenous and First Nations people.10

Indigenous peoples in colonized countries such as Australia, New Zealand, Canada, and the USA experience disproportionate amounts of harm due to alcohol misuse.11-14 The reasons for this are multifactorial, but deeply rooted in the structural racism that limits social and economic opportunities, as well as access to appropriate treatment for Indigenous and First Nations people.7,10,15,16 Structural racism refers to socially constructed and reinforced systems that act to stratify access to human needs such as health care, housing, employment, education, and criminal justice, based on racial or ethnic differences.17,18

Indigenous and First Nations people experience a range of adverse outcomes as a result of alcohol misuse.15,16 The alcohol-related burden of harm for Aboriginal and Torres Strait Islander Australians, for example, is broadly more than double that of non-Indigenous people in terms of disability-adjusted life years. For specific harms such as homicide and violence, the rates for Aboriginal and Torres Strait Islander men are more than six times that of non-Indigenous men.19 Other frequently documented harms are over-representation in incarcerated populations, liver disease, and fetal exposure to alcohol, which may cause neurocognitive damage.19-22

High rates of fetal alcohol spectrum disorder (FASD) have been reported in some populations, which is associated with additional harms to children's educational and social potential.16 Harms attributed to FASD may also be a factor in the over-representation of Indigenous peoples in the prison system. The prevalence of FASD in incarcerated Indigenous youth in Canadian correctional settings was found to be considerably greater than for non-Indigenous youth, leading to speculation that there is a causal effect between the FASD-related neurocognitive changes and diminished capacity for impulse control, but it seems more likely that the causes are multifocal and relate to a range of networked factors such as family instability, socio-economic status, and substance abuse.20,23

A strategy found to be popular with some governments is mandatory detention for treatment of those perceived as “problem” or “nuisance” drinkers. In Australia, the specific characteristics of mandatory inpatient treatment laws for those arrested for alcohol-related offenses usually results in a high proportion of those who are forcibly committed to treatment programs being Aboriginal and Torres Strait Islander people.24 Coerced treatment, as occurs with mandatory detention laws, has little supporting evidence and does not appear to be an effective health measure.22

A range of treatment modalities has been used to address alcohol misuse issues in general populations. Behavioral therapies, with the aim of achieving and maintaining total abstinence, such as 12-step programs and cognitive behavioral therapy, are in wide use, as are residential “detoxification” centers. Pharmacological therapies such as naltrexone and nalmefene for first-line treatment, and disulfram and baclofen for second-line treatment, are often used in conjunction with behavioral therapies.25 Other therapies aim to reduce alcohol use and minimize its impact on health and daily life.

Analyses have identified strategies for improving health services for Indigenous people; chief among these is culturally safe care that is specifically tailored to the context.26 Alcohol addiction is a chronic relapsing condition that usually requires ongoing treatment, so it is vital that treatment therapies are appropriate, meaningful, and effective.21 Many supposedly evidence-based therapies for substance abuse have not been specifically designed for or tested in Indigenous and First Nations communities.27 This absence of cultural considerations may be a contributor to the failure of some programs to engage with clients and influence their behavior.

A preliminary search of PROSPERO, MEDLINE, the Cochrane Database of Systematic Reviews and the JBI Database of Systematic Reviews and Implementation Reports was conducted to find current evidence on this topic. In terms of culturally specific programs designed for treating alcohol addiction in Indigenous, Aboriginal, and First Nation peoples, a scoping review found a number of studies conducted in the USA and Canada, focused on therapies combining Western and culturally-based designs through activities such as sweat-lodges, drumming, storytelling, and art.28 The scoping review included no studies from Australia or New Zealand and was conducted in 2012, hence it provides minimal current and relevant evidence for this review; however, it is indicative of the body of work in publication. A more recent systematic review focused on culturally sensitive substance misuse treatments for a broad minority youth population.29 While the results of Steinka-Fry et al.'s29 review were promising – the findings from seven studies showed participants receiving culturally sensitive treatments had greater reductions in substance use – the differing inclusion criteria mean that the results are not directly applicable to the population of interest to this review.29 No other comparable systematic reviews, and in particular, no reviews with qualitative components have been found, despite extensive searching.

The objective of this review is to investigate, in terms of both quantitative and qualitative evidence, the effectiveness and appropriateness of culturally adapted approaches for treating alcohol use disorders in Indigenous peoples in Canada, New Zealand, Australia, and the USA.


Alcohol use disorder: Alcohol consumption that meets at least two of the 11 alcohol use disorder criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).30

Indigenous peoples: Also known as Aboriginal and First Nations peoples, the United Nations no longer uses a set definition, but uses an understanding of the term based on a range of criteria:

  • “Self- identification as Indigenous peoples at the individual level and accepted by the community as their member.
  • Historical continuity with pre-colonial and/or pre-settler societies.
  • Strong link to territories and surrounding natural resources.
  • Distinct social, economic, or political systems.
  • Distinct language, culture, and beliefs.
  • Form non-dominant groups of society.
  • Resolve to maintain and reproduce their ancestral environments and systems as distinctive peoples and communities.”31(p.1)

Culturally adapted: In a health context, “culturally adapted” is defined as systematic modification of a treatment or intervention in a way that takes into account language, context, and culture to make the treatment or intervention contextually relevant to each person's cultural life.32 This encompasses terms such as culturally informed, culturally sensitive, culturally enhanced, culturally grounded, culture specific, and culturally focused.33

Review question

In Australia, New Zealand, Canada, and the USA, what is the effectiveness of culturally safe or culturally adapted approaches for treating alcohol abuse in Indigenous people, and how do Indigenous people who participate in these adapted programs perceive them?

Inclusion criteria


The review will consider qualitative and quantitative studies that include adult and/or adolescent participants (aged 10 years and over, using the World Health Organization definition of adolescence34) in alcohol treatment programs. Participants may be abusing one or more substances and have other comorbid conditions. Eligible participants will be from Indigenous, Aboriginal, or First Nations cultural groups in the country where the study has been conducted.


The quantitative arm of this review will consider studies that evaluate the effect of substance abuse treatment programs in acute or community health settings where the programs are described as “culturally safe,” “culturally competent,” “culturally appropriate,” “culturally adapted,” or other similar descriptors, if it is indicated that the specific culture of the clientele was an important factor in the design and implementation of the program. The programs may be of any duration or configuration, inpatient or outpatient, group or single participant.


The quantitative arm of this review will consider studies that compare the intervention to other modes of treatment, generally operationalized as standard care. Studies comparing two or more styles of cultural adaptation or approach will also be eligible for inclusion.


The quantitative arms of this review will consider studies that evaluate the effect of culturally safe substance abuse programs on alcohol-free days, drug-free days, and relapse rates as primary outcomes. Secondary outcomes will be patient engagement rates, participation rates, and/or attendance rates (which may also be reported as non-attendance or failure to attend rates).

Phenomena of interest

The phenomena of interest to the qualitative arm of this review are the meaningfulness, relevance, or appropriateness of attendance at, or participation in, an alcohol treatment program designed or modified to be culturally relevant or appropriate, as reported by the Indigenous and First Nations participants in the program. The perceptions or opinions of staff or others, such as family members, will not be included in this review.


The context of interest to the qualitative arm of this review will be the lived experience of participating in a culturally adapted alcohol treatment program. The programs may be of any duration or configuration, inpatient or outpatient, group or single participant. Programs eligible for inclusion will be explicitly adapted in the content and/or delivery methods to meet the needs of the cultural backgrounds of the specific participants in the study.

Types of studies

This review will consider both experimental and quasi-experimental study designs including randomized controlled trials, non-randomized controlled trials, before and after studies, and interrupted time-series studies. This review will also consider qualitative studies including, but not limited to, designs such as phenomenology, grounded theory, ethnography, qualitative description, action research and feminist research.

Studies published in any language will be included and translations obtained where necessary to facilitate inclusion into an English-language publication. Studies published since 1998 will be included, as little was published on this concept prior to that date.


This systematic review will be conducted in accordance with the JBI methodology for mixed methods systematic reviews using a convergent segregated approach.35

Search strategy

The search strategy aims to find both published and unpublished studies. An initial limited search of MEDLINE and CINAHL has been undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe articles. This informed the development of a search strategy, which will be tailored for each information source. A full search strategy for MEDLINE is detailed in Appendix I. The reference lists of all studies selected for critical appraisal will be screened for additional studies.

Information sources

The databases to be searched will include APAIS-ATSIS: Australian Public Affairs Information Service - Aboriginal and Torres Strait Islander (Informit), ATSIHealth: Aborginal and Torres Strait Islander Health, Australian Indigenous HealthInfoNet, CINAHL (EBSCOhost), CINCH-ATSIS, Embase, Global Health, Health & Society (Informit), Indigenous Australia (Informit), Lowitja Institute Literature Search, MEDLINE (Ovid, PsycINFO, and PsycEXTRA.

Sources of unpublished studies and gray literature to be searched include ProQuest Dissertations and Theses, MedNar, EBSCO Open Dissertations, Open Access Theses and Dissertations, and Trove.

Study selection

Following the search, all identified citations will be collated and uploaded into EndNote X9 (Clarivate Analytics, PA, USA) and duplicates removed. Titles and abstracts will then be screened by two independent reviewers for assessment against the inclusion criteria for the review. Studies that may meet the inclusion criteria will be retrieved in full and their details imported into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; JBI, Adelaide, Australia). The full text of selected studies will be retrieved and assessed in detail against the inclusion criteria. Full-text studies that do not meet the inclusion criteria will be excluded, and reasons for exclusion will be provided in an appendix in the final systematic review report. The results of the search will be reported in full in the final report and presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.36 Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.

Assessment of methodological quality

Selected studies will be critically appraised by two independent reviewers at the study level for methodological quality in the review using standardized critical appraisal instruments from JBI for the following study types: experimental studies and qualitative studies.37,38 Any disagreements that arise will be resolved with a third reviewer. No quantitative studies will be excluded on the basis of critical appraisal; however, quantitative studies of lower methodological quality will be identified within the review report and sub-group analyses conducted where data allow. Qualitative studies will be excluded based on critical appraisal, and this decision will be based on excluding studies that do not reflect the voices of participants adequately or have conclusions at odds with the stated voices of participants.

Data extraction

Data will be extracted from papers included in the review using the standardized data extraction tools available in JBI SUMARI by two independent reviewers.37,38 The data extracted will include specific details about the interventions, populations, study methods, and outcomes of significance to the review question and specific objectives. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. Authors of papers will be contacted to request missing or additional data, where required.

Qualitative data will be extracted from papers included in the review using the standardized data extraction tool from JBI SUMARI by two independent reviewers.38 The data extracted will include specific details about the populations, context, culture, geographical location, study methods, and phenomena of interest relevant to the review question and specific objectives. Findings and their illustrations will be extracted and assigned a level of credibility.

Data synthesis and integration

Qualitative synthesis

Qualitative research findings will, where possible, be pooled using JBI SUMARI with the meta-aggregation approach.38 This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings and categorizing these findings on the basis of similarity in meaning. These categories will then be subjected to a synthesis in order to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible, the findings will be presented in narrative form.

Quantitative synthesis

Studies will, where possible be pooled in statistical meta-analysis using JBI SUMARI. Effect sizes will be expressed as either odds ratios (for dichotomous data) and weighted (or standardized) final post-intervention mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard chi-squared and I2 tests. Statistical analyses will be performed using the random effects model.39 Sensitivity analyses will be conducted to test decisions made regarding study inclusion. Where statistical pooling is not possible, the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate. A funnel plot will be generated using RevMan 5.0 (Copenhagen: The Nordic Cochrane Centre, Cochrane) to assess publication bias if there are 10 or more studies included in a meta-analysis. Statistical tests for funnel plot asymmetry (Egger test, Begg test, Harbord test) will be performed, where appropriate.

Integration of quantitative evidence and qualitative evidence

This review will follow a convergent segregated approach according to the JBI methodology for mixed methods systematic reviews using JBI SUMARI.35 The synthesized quantitative findings will be compared and contrasted with the meta-aggregated qualitative findings to produce an overall configured analysis.35 Where configuration is not possible, the findings will be presented in narrative form.


The Centre for Remote Health wishes to respectfully acknowledge the past and present Traditional Custodians of the land on which we work, the Arrente people. It is a privilege to be standing on Arrente country.


This review is funded by the Harm Minimisation Unit of the Northern Territory Department of Health. The funding body will have no input into the findings of the review.

Appendix I: Search strategy for MEDLINE

Search conducted 15/07/19

  2. aborigin$.mp.
  3. torres strait
  4. native or Indians, North American/
  5. or Inuits/
  7. first
  8. 1 or 2 or 3 or 4 or 5 or 6 or 7
  9. or AUSTRALIA/
  10. or CANADA/
  11. New or New Zealand/
  12. United States/ or United States of
  13. 9 or 10 or 11 or 12
  16. “Outcome Assessment (Health Care)”/ or outcome or Treatment Outcome/
  21. grounded or Grounded Theory/
  23. qualitative
  24. action
  25. feminist
  26. 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24 or 25
  27. cultural or Cultural Competency/
  28. cultural
  29. cultural
  30. culturally
  31. cultural
  32. culturally
  33. cultural or Culture/
  34. culturally
  35. culturally
  36. 27 or 28 or 29 or 30 or 31 or 32 or 33 or 34 or 35
  37. Alcohol Drinking/ or Alcoholism/ or Substance-Related Disorders/ or alcohol or Alcohol-Related Disorders/
  38. or Substance Withdrawal Syndrome/
  39. Substance Abuse Treatment Centers/ or alcohol
  40. Alcohol Withdrawal Delirium/ or Alcohol Withdrawal Seizures/ or alcohol
  41. Residential Treatment/ or Residential Facilities/ or residential alcohol treatment
  42. alcohol or Counseling/
  43. 37 or 38 or 39 or 40 or 41 or 42
  44. 8 and 13 and 26 and 36 and 43
  45. limit 44 to yr = “1998 - 2020”

Records retrieved: 80


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Alcohol; cultural adaptation; cultural appropriateness; Indigenous health; substance abuse

© 2020 Joanna Briggs Institute.