摘要：Objectives. To evaluate the effectiveness of a multilevel intervention designed to prevent underage alcohol use among youths living in the Cherokee Nation. Methods. We randomly assigned 6 communities to a control, Communities Mobilizing for Change on Alcohol (CMCA; a community-organizing intervention targeting alcohol access) only, CONNECT (a school-based universal screening and brief intervention) only, or a combined condition. We collected quarterly surveys 2012–2015 from students starting in 9th and 10th grades and ending in 11th and 12th grades. Response rates ranged from 83% to 90%; 46% of students were American Indian (of which 80% were Cherokee) and 46% were White only. Results. Students exposed to CMCA, CONNECT, and both showed a significant reduction in the probability over time of 30-day alcohol use (25%, 22%, and 12% reduction, respectively) and heavy episodic drinking (24%, 19%, and 13% reduction) compared with students in the control condition, with variation in magnitude of effects over the 2.5-year intervention period. Conclusions. CMCA and CONNECT are effective interventions for reducing alcohol use among American Indian and other youths living in rural communities. Challenges remain for sustaining intervention effects. American Indians (AIs) suffer from significant health disparities related to alcohol. 1,2 Early prevention is critical, because early onset is a risk factor for problematic use into adulthood, 3 and AIs have a higher rate of early onset than do other groups. 4 In addition, rural youths and rural youths who are a racial minority in their community are at increased risk for alcohol use and getting drunk. 5 Despite increased risk, rural communities and AI populations have been underrepresented in clinical and community trial research. 6 To address this gap, we designed a trial with the Cherokee Nation that involved rural and racially diverse communities in northeastern Oklahoma in the 14-county jurisdictional service area of the Cherokee Nation, the second largest AI tribe in the United States. The location is not a reservation; rather it is the area of Indian Territory to which the Cherokees were forcibly relocated in 1838–1839. 7 Following the Dawes Act of 1887, the commonly held tribal land was divided, and a family allotment was provided to individual AIs registered on the Dawes Rolls. Presently, 40% of the 333 094 members of the Cherokee Nation live in this jurisdictional service area, and Cherokee citizens constitute a significant proportion of the population. The trial was initiated through a partnership between university-based prevention scientists and Cherokee Nation Behavioral Health psychologists. Together, we implemented a rigorous trial to evaluate the effectiveness of 2 distinct strategies to reduce underage drinking and associated consequences among youths living in rural, racially diverse communities within the Cherokee Nation. We selected 2 evidence-based strategies that are adaptable to local culture. Communities Mobilizing for Change on Alcohol (CMCA) is a community-organizing intervention designed to reduce alcohol access, use, and consequences among underage youths. 8–10 Community organizing has been used effectively in multiple other health intervention trials 11–13 and appeared to be an optimal strategy to engage diverse citizens in these multicultural communities. The second strategy, called CONNECT, was an individually delivered screening and brief intervention (SBI) in schools; it was supported by findings of a recent systematic review. 14 We implemented SBI universally among all students along with motivational interviewing because it is responsive to individual student needs and readiness to change.
