Living in 2 Worlds

Culturally-Specific Substance Abuse Prevention for Urban American Indian Youth

Principal Investigators: Eddie F. Brown and Stephen S. Kulis

Funding: National Institutes of Health/National Institute on Minority Health and Health Disparities, center grant award P20 MD002316 NIMHD (2007-2012)

Living in 2 Worlds (L2W) is a substance use prevention program for urban American Indian (AI) middle school students. To create L2W, the SIRC research team partnered with the Phoenix Indian Center and two school districts to engage youth, families, elders, and Native community leaders in a community-driven participatory process to identify cultural sources of resilience that protect American Indian youth from substance use and other risk behaviors.  L2W was adapted specifically for Native adolescents living in urban areas using the core components of the keepin’ it REAL curriculum, an existing SAMHSA “Model Program” for substance use prevention in middle schools, retaining the original program’s focus on teaching the effective drug resistance strategies (Refuse, Explain, Avoid, Leave [R-E-A-L]) used most often by youth.  A cultural adaptation model (Castro, Barerra, & Martinez, 2004) guided the creation of the culturally grounded curriculum, with a pilot phase that was followed by a small randomized controlled trial in three Phoenix area middle schools.

Despite the diverse tribal backgrounds of urban American Indian families, ten inter-tribal cultural elements identified by the community were found to resonate widely, and these were infused into the L2W curriculum.  These included the imperative of knowing ancestry, embracing kinship, and emphasizing oral traditions (see Reeves, Dustman, Harthun, Kulis, & Brown, 2014).  These elements were aligned and integrated with the core components of the original keepin’ it REAL curriculum.  L2W emerged with lesson goals, objectives, activities, and prevention messages solidly grounded in urban American Indian inter-tribal cultural values.  Focused on strengthening resiliency, L2W teaches a wide range of drug resistance skills and strategies including risk assessment, decision making, and culturally specific prevention messages in ways designated by the Native community as culturally appropriate and reflecting the social and cultural context navigated by urban American Indian youth. 

To test the degree to which culturally grounding improved youth outcomes, American Indian students in two Phoenix area middle schools received the L2W curriculum and American Indian students in another school received the original, unadapted version of keepin’ it REAL. Classroom lessons for both programs were delivered by Native facilitators in regular academic enrichment classes for Native youth. Participating students (N=107) completed a pretest questionnaire before the 12 manualized curriculum lessons were delivered, and a post-test (85% completion) one month after the final lesson. The adapted L2W intervention, compared to keepin’ it REAL, was assessed with paired t-tests, baseline adjusted general linear models, and effect size estimates (Cohen's d).


  • A full report on the results of the L2W trial appears in Kulis, Ayers, & Harthun (2017; referenced below), examining a range of outcomes: substance use behaviors, attitudinal antecedents of drug use, drug resistance skills, other risk behaviors, and cultural identity and engagement. Although few differences were statistically significant due to the small sample size, differences between the L2W and keepin’ it REAL (kiREAL) groups showed consistently better outcomes in L2W  for substance use behaviors, other risk behaviors, attitudes toward substance use, and American Indian cultural identity.
  • American Indian students receiving L2W, compared to kiREAL, reported significantly less cigarette use greater retention of connections to American Indian spirituality and cultural traditions.  Compared to kiREAL, the improved outcomes in L2W achieved small to medium effect sizes.
  • Results demonstrated that evidence-based substance use prevention programs that are culturally adapted for urban American Indian adolescents, like L2W, can help delay initiation and slow increases in substance use while strengthening Native cultural identity and connection.

Kulis, S. S., Ayers, S. L., & Harthun, M. L. (2017). Substance use prevention for urban American Indian youth:  An efficacy trial of the culturally adapted Living in 2 Worlds program. Journal of Primary Prevention. doi: 10.1007/s10935-016-0461-4

Kulis, S. S., & Brown, E. F. (2011). Preferred drug resistance strategies of urban American Indian youth of the southwest. Journal of Drug Education, 41, 203-235. doi: 10.2190/DE.41.2.e   Read online PMCID: PMC3170049

Kulis, S. S., Dustman, P.A., Brown, E. F., & Martinez, M. (2013). Expanding urban American Indian youths’ repertoire of drug resistance skills: Pilot results from a culturally adapted prevention program. American Indian and Alaska Native Mental Health Research, 20, 35-54. doi: 10.5820/aian.2001.2013.35.   Read online PMCID: PMC3670795

Kulis, S. S., Hodge, D. R., Ayers, S. L., Brown, E. F., & Marsiglia, F. F. (2012). Spirituality and religion: Intertwined protective factors for substance use among urban American Indian youth. American Journal of Drug and Alcohol Abuse, 38, 444-449. doi: 10.3109/00952990.2012.670338   Read online PMCID:PMC3431460

Kulis, S. S., Reeves, L. J., Dustman, P. A., & O’Neill, M. (2011). Strategies to resist drug offers among urban American Indian youth of the Southwest: An enumeration, classification, and analysis by substance and offeror. Substance Use and Misuse, 46, 1395-1409. doi: 10.3109/10826084.2011.592433.    Read online PMCID: PMC3164593  

Kulis, S. S., Robbins, D. E., Baker, T. M., Denetsosie, S., & Deschine, N. A. (2016). A latent class analysis of urban American Indian youth identities. Cultural Diversity and Ethnic Minority Psychology, 22(2), 215-228. doi: 10.1037/cdp0000024    Read online PMCID: PMC4615273  

Kulis, S. S., & Tsethlikai, M. (2017). Urban American Indian youth spirituality and religion: A latent class analysis. Journal for the Scientific Study of Religion.   doi: 10.1111/jssr.12298

Kulis, S. S., Wagaman, M. A., Tso, C., & Brown, E. F. (2013). Exploring indigenous identities of urban American Indian youth of the southwest. Journal of Adolescent Research, 28, 271–298. doi: 10.1177/0743558413477195   Read online PMCID: PMC3677791

Martinez, M., Ayers, S. L., Kulis, S. S., & Brown, E. F. (2015). The relationship between peer, parent and grandparent norms and intentions to use substances for urban American Indian youth. Journal of Child and Adolescent Substance Abuse, 24(4), 220-227. doi: 10.1080/1067828X.2013.812529   Read online PMCID:PMC4507275

Reeves, L. R., Dustman, P. A., Harthun, M. L., Kulis, S. S., & Brown, E. F. (2014). American Indians’ cultures: How CBPR illuminated inter-tribal cultural elements fundamental to an adaptation effort. Prevention Science, 15(4), 547-556. doi: 10.1007/s11121-012-0361-7   Read online PMCID: PMC3726553

Other related publications

Okamoto, S. K., Helm, S., Giroux, D., Edwards, C., & Kulis, S. (2010). The development and initial validation of the Hawaiian youth drug offers survey. Ethnicity and Health, 15, 73-92. doi: 10.1080/13557850903418828.   Read online PMCID: PMC2888708

Okamoto, S. K., Helm, S., Giroux, D., Kaliades, A., Kawano, K. N., & Kulis, S. (2010). A typology and analysis of drug resistance strategies of rural native Hawaiian youth. Journal of Primary Prevention, 31, 311-319. doi: 10.1007/s10935-010-0222-8    Read online PMCID: PMC3005017

Okamoto, S. K., Kulis, S. S., Helm, S., Edwards, C., & Giroux, D. (2010). Gender differences in drug offers of rural Hawaiian youth: A mixed-methods analysis. Affilia, 25, 291-306. doi: 10.1177/0886109910375210.   Read online PMCID: PMC2919836 815-833

Okamoto, S. K., Kulis, S. S., Helm, S., Lauricella, M., & Valdez, J. K. (2016). An evaluation of the Ho‘ouna Pono curriculum: A pilot study of culturally grounded substance abuse prevention for rural Native Hawaiian youth. Journal of Health Care for the Poor and Underserved, 27(2), . doi: 10.1353/hpu.2016.0061   

Okamoto, S. K., Helm, S., Kulis, S. S., Delp, J., & Dinson, A. (2012). Drug resistance strategies of rural Hawaiian youth as a function of drug offerers and types of substances: A community stakeholder analysis in rural Hawaii. Journal of Health Care for the Poor and Underserved, 23, 1239–1252.  doi: 10.1353/hpu.2012.0102   Read online PMCID:PMC3831367

Rayle, A. D., Kulis, S. S., Okamoto, S. K., Tann, S. S., LeCroy, C.W., Dustman, P. A., & Burke, A.M. (2006). Who is offering and how often? Gender differences in drug offers among American Indian adolescents of the Southwest. Journal of Early Adolescence, 26, 1-22. doi: 10.1177/0272431606288551. Read online PMCID: PMC3042715


Living in 2 Worlds Research Team (SIRC)

Eddie Brown, D.S.W., ASU American Indian Studies, Principal Investigator

Stephen Kulis, Ph.D., ASU Sanford School of Social & Family Dynamics, Co-Principal Investigator

Patricia Dustman, Ed.D., SIRC Project Director & Curriculum Development

Stephanie Ayers, Ph.D., SIRC Associate Director of Research

Mary Harthun, MA, SIRC Professional Development Specialist & Curriculum Development

Leslie Reeves, MA, SIRC Community Research Liaison & Curriculum Development

Danielle Robbins, Ph.D., SIRC Biostatistician

Curriculum Facilitators

Meredith Robbins, Phoenix Indian Center

Timothy Hunts-in-Winter, Mesa Public School District

SIRC School Liaisons

Crescentia Tso, (Lead), Graduate Assistant

Tahnee Baker, Graduate Assistant

Novia Cleveland, Graduate Assistant

DesiRae Deschine, Graduate Assistant

Nicholet Deschine, Graduate Assistant

Charmayne Gene, Graduate Assistant

Sheera Gilboa, Graduate Assistant

Durina Keyonnie, Graduate Assistant

Delitha Livingston, Graduate Assistant

Simon Tapaha, Graduate Assistant

Jearlyn Tsosie, Graduate Assistant

National and Local Expert Reviewers

Janette Beals, Ph.D., Centers for American Indian & Alaska Native Health, Aurora, Colorado

Patricia Hibbeler, CEO, Phoenix Indian Center, Phoenix, Arizona

Warren Kontz, Human Services Center Director, Inter Tribal Council, Phoenix, Arizona

Hilary Weaver, Ph.D., Associate Professor, School of Social Work, SUNY, Buffalo, New York

Living in 2 Worlds Advisory Board

Della Acunia-Sockyma, Gila River Indian Community Representative

Deborah Baker, Hopi Nation Representative

Judy Basham, Phoenix Union High School District Coordinator

Bernice Begay, Phoenix Union High School District

Jolyana Begay-Bitsuie, Phoenix Indian Center          

Laverne Dallas, Gila River Indian Community Representative

John Deneka, Phoenix Indian Center

Yvonne Fortier, Native American Connections

Gwenda Gorman, National Native American AIDS Prevention Center

Trina Hart, Gila River Indian Community Representative

Patricia Hibbeler, Phoenix Indian Center

Sam Hogue, Phoenix Union High School District

Tim Hunts-in-Winter, Mesa Public School District

Warren Kontz, Inter Tribal Council Director

S. Jo Lewis, Phoenix Indian Center

Debbie Manuel, Salt River Pima Maricopa Indian Community Representative

Debora Norris, Arizona Department of Education

Myrna Pavatea, , Pascua Yaqui Nation Representative

Teresa Price, Mesa Public Schools

Meredith Robbins, Phoenix Indian Center

Robert Robin, Native Americans for Community Action

Patty Roe, Pascua Yaqui Representative

Gary Rush, Phoenix Union High School District

Tim Terry, Gila River Indian Community Representative

Edith Thomas, Gila River Indian Community Representative

Dorothy Watkins, Washington Elementary School District

Lolita Whitesinger, Washington Elementary School District