Storytelling in addiction prevention: A basis for developing effective programs from a systematic review

Storytelling in addiction prevention: a basis for developing effective programs from a systematic review Herrera-Sánchez, Isabel María, Medina-Anzano, Silvia, and Rueda-Méndez, Samuel Abstract Introduction: Drug misuse is a complex social and health problem. People who use drugs have very specific profiles according to their life cycle and sociocultural circumstances. For this reason, contextualized approaches are needed in the intervention of addictions that take on board the particularities of consumption patterns and their circumstances. The storytelling technique as a narrative communication strategy can serve as a main methodological intervention component that enhances this contextualized approach. This technique recognizes how the stories we tell from our experiences help us to organize and make sense of our lives. Methods: A systematic review of the literature with narrative analysis is performed to identify the adopted approaches in research studies that specifically use the storytelling technique and to lay the basis for a storytelling-based preventive strategy. Results: In the scientific literature, community and personal narratives have been approached as transformative and change processes in mutual help groups, mainly with alcohol problems, using narrative research methodology. Other topics of interest have included: the evaluation of interventions and therapeutic processes for drug use targeting high-risk populations using different methodologies (pilot research, quasi-experimental designs, participatory community research); and the analysis of the processes behind identity construction and reconstruction coupled with the exploration of shared visions, values and consumption knowledge in high-risk populations using the ethnographic technique or grounded theory. Conclusion: Narratives based on community and personal stories, when are shared, incorporate the contextual and cultural issues associated with drug addiction. It is accordingly proposed to examine whether storytelling-based intervention generates a greater identification and a willingness to change, especially in more vulnerable groups with remarkable life trajectories. Keywords: storytelling, drug misuse, systematic review The authors declare that they have no conflict of interest. Workplace address Departamento de Psicología Social. Facultad de Psicología. Universidad de Sevilla C/ Camilo José Cela, s/n, 41018, Sevilla (España) Tel. (34) 954557201. Fax. (34) 954557111 [email protected] This is an Accepted manuscript of: Herrera-Sánchez, I., Rueda-Méndez, S. & Medina-Anzano, S. (2019). Storytelling in addiction prevention: A basis for developing effective programs from a systematic review. Human Affairs, 29(1), 32-47. https:// doi.org/10.1515/humaff-2019-0004 INTRODUCTION The latest European report on drugs opens with a meaningful point of departure: the dynamic character of drug problems represents a major challenge that needs to be addressed (European Monitoring Centre for Drugs and Drug Addiction, 2018). People who take drugs develop different consumption patterns associated with multiple risk factors and varying circumstances. By adopting the community psychology approach, ecological diversity should be taken into account when dealing with the problems of use and misuse of substance, referring to “an appreciation of culture, context, and differences, including the complex intersectionalities of identity and substance misuse” (Olson, Bradley, Emshoff, & Rivera, 2017, p. 402). Research into the prevention of drug abuse has shown significant progress by allowing the development of evidence-based programs. However, the literature has documented how many of these programs that have worked well in one social context have not generated the same results when attempted to be extended to other contexts (Biglan & Hinds 2009; Tobler et al., 2000). These problems are most evidenced when programs have been adapted from the rural context to the urban context (Komro et al., 2008), or have been attempted to extrapolate their core mechanisms of intervention to minority and low-income groups (Cho, Halfors, & Sánchez, 2005; Spoth, Guyll, Chao, & Molgaard 2003). Once again, the findings of these studies point to the importance of the intervention context. For this reason, it is necessary to conceptualize the problem by approaching it from its historical, social and personal perspectives in order to understand the issue and offer effective responses. A narrative communication strategy like storytelling favors this contextualized and idiographic approach. This technique acknowledges how telling stories about our lives is a natural human process. These stories are intrinsically linked to our own identity (McAdams, 2001); they create shared meanings of health and illness (Murray, 1999); and they foster a sense of belonging. From an empowerment approach (Rappaport, 1995), narratives based on strengths and capabilities encourage active and positive development. Thus, the characteristics that the narratives project can exert an influence on processes of change. This technique has experienced growing application in fields such as education, community-based intervention, public health and social marketing. In formal education, the experience of storytelling can, among other functions, help to shape one's own experience in an understandable way, particularly in childhood, or offer a feasible model of language and thought (Collins, 1999). In community setting, stories are viewed as a critical awareness tool addressing issues that affect social well-being and social stability (Gregori-Signes & Alcantud-Díaz, 2016). Different problem areas have been addressed in the field of public health. These include initiatives aimed at empowering young people for preventing diabetes; gaining a better understanding of asthma; and helping participants at the early stages of dementia to build their confidence and communication skills (Gubrium, Hill, & Flicker, 2014). In the area of health communication, narrativebased strategies as opposed to scientific logic-based communication strategies are easier for audiences to comprehend, they generate more interest, and they invite more opportunities for identification (Dahlstrom, 2014). Stories have always been present in studies that analyze the issue of drugs and in interventions that prevent or treat addiction. The aim of this systematic review is to identify the different adopted approaches in research studies that specifically use the storytelling technique. These include empirical studies covering factors associated with drug use and recovery as well as interventions that tackle preventive addictions. The end goal is to conduct a narrative synthesis to determine the bases and strategies that underlie a storytelling-based intervention of a fundamentally preventive nature. METHOD A systematic search of articles was performed across six databases using the ProQuest platform: Nursing & Allied Health Database, PsycINFO, MEDLINE®, Health & Medical Collection, PsycARTICLES, and Psychology Database. The term “storytelling” was used in combination (AND) with each of the following terms: addict*, drug*, substance abuse, tobacco, smoking, alcohol*, drinking, cocaine, heroine, cannabi*, MDMA, and amphetamine*. Articles evaluated by experts (from peer-review journals) and published before 1 January 2018 were chosen as an “Additional Limit”. All paired searches were then run using a single search command (OR) to generate a single output file of all the results, thus allowing us to eliminate duplicates. We required that all studies were written in English. After an initial review of the titles, abstracts and main subjects, we removed those articles that did not address the main topic of study. This task was performed by just one researcher. During the subsequent eligibility phases, two further researchers participated as a higher level of consensus was required for selection purposes. The studies included in this review had to meet the following criteria: a) risk factor studies; b) studies that analyze the processes surrounding addiction and addiction recovery; and c) studies on the implementation and effects of intervention. All had to clearly identify the storytelling technique and meet the methodological quality requirements of the research. Theoretical reviews, commentaries, reports, descriptions of techniques and case studies were excluded. These criteria were included for feasibility reasons, to cover the widest possible number of studies without compromising quality. To determine the quality of the study, a pluralist approach was adopted to encompass the multiple admissible angles and perspectives, using quality-driven criteria specific to each approach (Wong, Greenhalgh, Westhorp, & Pawson, 2014). Research studies that lacked rigor according to their specific standards were rejected. Given the variety of studies subject to review, a narrative synthesis was conducted (Popay et al., 2006), which consisted of “an approach to the systematic review and synthesis of findings from multiple studies that relies primarily on the use of words and text to summarize and explain the findings of the synthesis” (p.5). The analysis process covered the following stages: a) a preliminary synthesis; b) an exploration of relationships; c) an evaluation of synthesis robustness; and d) the development of an emerging theory of suggestion-based intervention. RESULTS The database search resulted in 3,719 records once the duplicates were filtered out. Following a preliminary review of each record, 184 were preselected; we were left with 29 after applying the inclusion and exclusion criteria. The flow diagram is shown in Figure 1. The narrative analysis of the selected articles focused on: detecting the approaches underlying these studies; the storytelling methods; the methodological aspects (method, context, population, substance); and the results or effects reached. For each of these elements, thematic categories were identified as shown in Table 1. In the case of the results or effects, due to the diversity of the studies, the main conclusions were systematized. These categories served as a rubric for the narrative synthesis of the study. Table 2 is the result of the narrative synthesis which emerged from the analysis. We now move onto the main findings by commenting on the approaches underlying the studies yielded and how the practice of storytelling takes shape. The results section closes by presenting the main premises that emerged from the analysis. (Insert Figure 1) (Insert Table 1) (Insert Table 2) Regarding the approaches underlying the studies yielded, a first category made up of research focused on constructing meanings that revolve around consumer practices (visions, values, myths, beliefs, schema). In light of this, an analysis of discursive practices has helped detect the culturally shared meanings surrounding consumer practices from a generational perspective (Tolvanen & Jylhä, 2005; Tutenges & Rod, 2009; Burnett, Ott Walter, & Baller, 2016; Momper, Dennis, & Mueller-Williams, 2017), analyzing their implications for consumption itself (Tutenges & Sandberg, 2013). On another level, Mitev (2007) set out to identify how implicit mythology is projected in literary works within users’ personal narratives, whereas Kean and Albada (2003) sought to determine the effects by looking for a connection between media, personal experience and schema formation. Considering socially isolated and disadvantaged groups, Roche, Neaigus, and Miller (2005) wanted to identify a form of adaptation to the environment in the shared stories among drug-using women who engage in sex work, whereas Rance, Gray, and Hopwood (2017) focused on how people who inject drugs, victims of stigma and social hostility are put at a disadvantage when it comes to making sense of their social experience. A second category gave us studies that explore how telling personal and communitybased stories are an important part of recovery processes in mutual help groups, mainly Alcoholics Anonymous (AA) groups. Rafalovich (1999) analyzed the identity transformation process through sharing stories. Lederman and Menegatos (2011) focused on the intrapersonal impact of AA narratives by adopting a retrospective approach much like Weegmann and Piwowoz-Hjort (2009). Arminen (2004) examined the functions of second stories in reconstructing group identity and in reinterpreting shared problems. Christensen and Elmeland (2015) found differences in how narratives of addiction recovery play out between people who attend self-help groups and those who decide to do it alone. Strobbe and Kurtz (2012) and Humphreys (2000) placed transformative storytelling at community narrative levels, whereas Swora (2002) positioned these stories as social practices that build their own social structure. These processes of change are also considered in Dunlop and Tracy’s (2013) study, which analyzed positive selftransformation processes following a difficult experience, identifying the relationship between self-redemption and behavior change in the narratives. Based on a narrative persuasion approach, Ma and Nan (2017) wanted to see how non-smokers respond to health messages (narrative vs. non-narrative) with the intention to persuade others to quit smoking, examining the moderating role of social distance. In intervention studies, narratives were introduced alongside evidence-based interventions with an aim to contextualize the messages (Leukefeld et al., 2003; Houston et al., 2011; Cherrington et al., 2015). Moghadam, Sari, Balouchi, Madarshahian, and Moghadam (2016) addressed storytelling-based education as a core component in prevention. Lastly, we notably find studies that incorporate storytelling with the support of community-based participatory strategies to develop culturally adapted interventions. Nelson and Arthur (2003) developed the program “Storytelling for Empowerment” as a way of encouraging positive cultural identity. This program was later adapted within the framework of the mHealth platform, incorporating the principles of community-based participatory research (Cordova et al., 2015, 2016). In a study conducted by Andrews, Bentley, Crawford, Pretlow, and Tingen (2007), members of the community were enlisted to help develop a culturally sensitive intervention involving African American women who live in subsidized housing. The program “Life Story Intervention” by Haight, Black, and Sheridan (2010) was devised in collaboration with community professionals, introducing sociocultural theory as a key premise of evidence-based interventions and local narrative traditions in order to address the mental health symptoms of children whose parents take amphetamines. Montgomery, Manuelito, Nass, Chock, and Buchwald (2012) expressed the view that an intervention is more likely to succeed if its methods are consistent with the cultural practices of the native communities and if young people are seen as active producers of the educational content. Further analysis in this narrative review is how the practice of storytelling takes shape when gathering narrative data or as an intervention component. The first category of studies were those in which researchers invited participants to relate their experiences for different purposes: to analyze the events that unfold in the narratives (Tutenges & Sandberg, 2013); to identify the moral discourses and shared cultural expectations between generations (Tolvanen & Jylhä, 2005); and to see how they mimic literary plots (comedy, romance, tragedy, irony) between the events and the different ways of telling stories (Mitev, 2007). In challenging contexts, storytelling has served to identify positive self-change experiences following a negative experience as self-redemption narratives (Dunlop & Tracy, 2013). In therapeutic settings, people are invited to talk about their lives or to simply talk (Haight et al., 2010). Burnett et al. (2016), Houston et al. (2011), and Cherrington et al. (2015) used digital format as opposed to face-to-face strategies. Stories told in social circles and which often surface in informal conversations (Tutenges & Rod, 2009), or those characteristic of interpersonal communication in native communities (Momper et al., 2017), are also a source of analysis. This is also the case in interventions. In Andrews et al. (2007), informal and interactive group sessions that promoted storytelling were used as a teaching method. Montgomery et al. (2012) introduced native elder traditions to pass on knowledge through stories in their educational interventions. Storytelling as a specific practice in mutual help settings becomes its own entity in the scientific addictions literature. Stories are told to emphasize helping others and to include personal life stories in community-based narratives. Lederman and Menegatos (2011) analyzed the reflective accounts of members of AA to stay sober, whereas Strobbe and Kurtz (2012) used personal stories in the Big Book of AA as the sole source. Arminen (2004) focused on the “second stories” that emerged in response to an original story and which contributed to mutual help and social support. Humphreys (2000) focused his analysis on the content, structures and function(s) of AA stories. Fictional stories are also part of stories that are told for different purposes. Kean and Albada (2003) asked participants to write a story to capture their representation of the object. Ma and Nan (2017) used simulated stories to illustrate health consequences. Cordova et al. (2015) introduced culturally congruent stories into a mHealth application. And in Moghadam et al. (2016), already formulated stories were complemented by group storytelling. By examining these research studies and as a result of the outcome analysis, the following premises emerged which point to the suitability of storytelling in preventive interventions: 1. Stories are a gateway to health intervention efforts and particularly when working with marginalized communities by incorporating risk reduction and health promotion messages in oral traditions (Nelson & Arthur, 2003; Roche et al., 2005; Haight et al., 2010). These may include topics deemed threatening or which remain hidden (Tutenges & Rod, 2009) and which call for closer scrutiny of and attention to the community’s values and culture (Andrews et al., 2007). 2. Narratives should be based on strengths and capabilities to encourage active and positive development. Thus, programs need to adopt a positive social function (Burnett et al., 2016) and contemplate community involvement whereby the participants themselves can decide how to share their personal stories of drug and alcohol use. Although these experiences are different and unique to the individual, they follow a clearly identifiable cause and effect trajectory (Tutenges & Sandberg, 2013), which play a contributing role in self-reflection on personal and social identity (Rafalovich, 1999; Arminen, 2004; Tutenges & Rod, 2009; Momper et al., 2017). These stories enable a critical assessment of negative consequences (Tutenges & Rod, 2009) and have the potential to delineate the boundaries and establish levels of acceptability regarding risk behaviors (Roche et al., 2005). However, they also project moral discourses that hold over time for each generation (Tolvanen & Jylhä, 2005) where the real and the imaginary meet (Humpreys, 2000; Kean & Albada, 2003; Roche et al., 2005). The stories remain tied to the context in which they occur (Burnett et al., 2016; Cherrington et al., 2015; Momper et al., 2017), meaning that it is particularly relevant to take on board the potential injustices and challenges that this process entails in marginalized groups (Rance et al., 2017). 3. Narratives act as motivators that go beyond the intrapersonal impact that the storytelling process itself generates (Lederman & Menegatos, 2011). These stories boast a considerable potential for change among those who listen to and share these experiences (Nelson & Arthur, 2003; Arminen, 2004; Weegmann & Piwowoz-Hjort, 2009; Strobbe & Kurtz, 2012; Moghadam et al., 2016), and which prove more effective when coupled with other techniques (Houston et al., 2011; Cherrington et al., 2015; Cordova et al., 2015). These told stories reinforce addiction recovery through a process of sharing positive accounts of people’s personal lives in mutual help contexts. They turn into persuasive stories at an intrapersonal level (Lederman & Menegatos, 2001; Dunlop & Tracy, 2013), an interpersonal level (Arminen, 2004; Weegmann & Piwowoz-Hjort, 2009), and at the level of the community’s own social structure (Swora, 2002). Intentionally transmitted stories, which reflect a desired community narrative, are intended to be seen as prototypes (Strobbe & Kurtz, 2012). CONCLUSION These results lead us to reflect on current practices in addiction prevention and health promotion, which tend to offer segmented information relative to the conceptual constructs that derive from theoretical models. This constitutes a generalized practice for selecting health messages according to the emphasis that theoretical models place on what should be changed and how, without taking into account the surrounding circumstances in an attempt to serve generalization. The literature provides examples of programs that fail when developed in contexts different to where the intervention originated. For this reason, strategies of change should be sensitive to the culture; they should consider the obstacles of participation that highly stigmatized groups must overcome; and they should reinforce the discursive practices that unfold when experiences are shared. The stories are full of meanings that tap into personal experiences and the cultural, social and historical values of the group of belonging. As such, it would be reasonable to assume that if identification is strengthened through these stories, then a willingness to change is more likely. The main limitation of the systematic revision comes from using the term storytelling as the only search descriptor, excluding other possible related terms such as narrative communication. This procedure may have excluded other studies of relevance. The diversity of the selected studies is another limitation, that is, they are not exclusively implementation or effectiveness studies. For this reason, a narrative synthesis has been used that could extract the most relevant aspects according to the objective of the review. Despite this, this review allows for the delineation of a future line of research aimed at determining the effectiveness of the storytelling-based strategy as a motivating mechanism for change by eliciting the identification with history. This is especially relevant with specific groups (low resources, at risk groups, ethnic groups...) because they enhance their own personal stories of improvement. As a direct practical implication, the designers of preventive programs with multiple components are encouraged to incorporate this strategy as a method of developing a culturally adapted intervention. REFERENCES Andrews, J. O., Bentley, G., Crawford, S., Pretlow, L., & Tingen, M. S. (2007). Using community-based participatory research to develop a culturally sensitive smoking cessation intervention with public housing neighborhoods. Ethnicity & Disease, 17(2), 331–337. Arminen, I. (2004). Second stories: The salience of interpersonal communication for mutual help in Alcoholics Anonymous. Journal of Pragmatics, 36(2), 319-347. Biglan, A. & Hinds, E. (2009). Evolving prosocial and sustainable neighborhoods and communities. Annual Review of Clinical Psychology, 5, 169-196. Table 2. Narrative synthesis of selected studies before 1 January 2018 Approaches underlying the studies Storytelling Methodology Context / Participants / Substance Results / Effects Construction of meanings surrounding consumer practices Fictional stories Kean & Albada (2003) Experimental design Kean & Albada (2003) College campus / College students / Alcohol Kean & Albada (2003). USA The stories connect the real world with scenes marked by television (Kean & Albada, 2003). Shared experiences Roche et al. (2005) Tolvanen & Jylhä (2005) Mitev (2007) Tutenges & Sandberg (2013) Rance et al. (2017) In digital storytelling Burnett et al. (2016) Narrative study Tolvanen & Jylhä (2005) Mitev (2007) Rance et al. (2017) Grounded Theory Roche et al. (2005) Burnett et al. (2016) Mixed methods Tutenges & Sandberg (2013) College campus / College students / Alcohol Mitev (2007). Hungary Burnett et al. (2016). USA Homes, service housing or nursing homes / Elderly people / Alcohol Tolvanen & Jylhä (2005). Finland Marginalized groups / Drug use Roche et al. (2005). USA Rance et al. (2017). Australia Tourist destination / Young tourists / Alcohol Tutenges & Sandberg (2013). Bulgaria The stories delineate the boundaries and establish acceptability of risk behaviors (Roche et al., 2005). The stories inject unalterable moral discourse over time (Tolvanen & Jylhä, 2005). Credible stories can be constructed by relying on literary plots (Mitev, 2007). The stories act as a script in behavior (Tutenges & Sandberg, 2013). Inequality discourse as another form of social injustice (Rance et al., 2017). The stories create meaning around the excessive alcohol consumption behavior to frame it in an acceptable way (Burnett et al, 2016). Stories shared in social circles Tutenges & Rod (2009) Momper et al. (2017) Thematic analysis with focus groups Momper et al. (2017) Ethnographic method Tutenges & Rod (2009) Indian reservation / American Indians / Alcohol Momper et al. (2017). USA Urban and rural areas / Teenagers / Alcohol Tutenges & Rod (2009). Denmark Intergenerational transfer of learnings and personal experiences (Momper et al., 2017). Identity, critical awareness (Tutenges & Rod, 2009). Table 2 (continued) Approaches underlying the studies Storytelling Methodology Context / Participants / Substance Results / Effects Narratives and processes of change in addiction recovery Stories of support Humphreys (2000) Swora (2002) Arminen (2004) Weegmann & Piwowoz-Hjort (2009) Lederman & Menegatos (2011) Strobbe & Kurtz (2012) Narrative study Humphreys (2000) Swora (2002) Weegmann & Piwowoz-Hjort (2009) Arminen (2004) Strobbe & Kurtz (2012) Grounded Theory Lederman & Menegatos (2011) AA members / Alcohol Humphreys (2000). USA Swora (2002). USA Lederman & Menegatos (2011). USA AA meetings / Alcohol Arminen (2004). Finland Addiction Treatment Centre / Alcohol Weegmann & Piwowoz-Hjort (2009). UK Big Book 4th edition/Alcohol Strobbe & Kurtz (2012) Comprising personal stories from former members that also give shape to the personal accounts of new members (Humphreys, 2000). A performance genre that creates a sense of community (Swora, 2002). They are the basis for mutual help and social support via co-constructing experiences (Arminen, 2004). Stories rebuild self-identity (Weegmann & Piwowoz-Hjort, 2009). Narrative coherence and fidelity in AA stories (Lederman & Menegatos, 2011). Community narratives act as prototypes in selfhelp contexts (Strobbe & Kurtz, 2012). Shared experiences Rafalovich (1999) Dunlop & Tracy (2013) Christensen & Elmeland (2015) Grounded theory Rafalovich (1999) Mixed methods (with narrative) Dunlop & Tracy (2013) Christensen & Elmeland (2015) Narcotics Anonymous meetings Rafalovich (1999). USA AA meetings / Alcohol Dunlop & Tracy (2013). Canada AA members / Alcohol Christensen & Elmeland (2015). Denmark The addict’s identity in self-help contexts is articulated through moments of equality, understanding and personal investment (Rafalovich, 1999). Narratives exploring negative experiences interpreted as conducive to a positive change in self-explain long-term behavior change (Dunlop & Tracy, 2013). Identification is important in AA members for staying sober, whereas those who seek unaided recovery are concerned about showing abusive use but not problematic use (Christensen & Elmeland, 2015). Table 2 (continued) Approaches underlying the studies Storytelling Methodology Context / Participants / Substance Results / Effects Narrative persuasion Fictional stories Ma & Nan (2017) Experimental design Ma & Nan (2017) College campus / College students / Tobacco Ma & Nan (2017). USA Without confirming that the narratives (vs. nonnarrated) would be more persuasive than nonnarratives when people thought about socially close smokers (Ma & Nan, 2017). Narratives and processes of change integrated with other evidencebased programs Stories of experience Leukefeld et al. (2003) Accounts of experiences in digital storytelling Houston et al. (2011) Cherrington et al. (2015) Experimental design Leukefeld et al. (2003) Pilot project and evaluation Houston et al. (2011) Randomized controlled trial Cherrington et al. (2015) Rural counties/ At-risk groups/ Drug use Leukefeld et al. (2003). USA Hospital / African American / Tobacco Houston et al. (2011). USA Cherrington et al. (2015). USA Gaining access to a group of rural people at a high risk for contracting HIV/AIDS (Leukefeld et al., 2003). Success relative to gathering narratives to be mapped to behavioral constructions (Houston, 2011). Insufficient as an independent intervention (Cherrington et al., 2015). Narratives and processes of change as core intervention component True story construction Moghadam et al. (2016) Quasi-experimental Moghadam et al. (2016) High school / Students / Drug use Moghadam et al. (2016). Iran Significant fall in willingness toward addiction among adolescents who participated in the intervention (Moghadam et al., 2016). Table 2 (continued) Approaches underlying the studies Storytelling Methodology Context / Participants / Substance Results / Effects Culturally adapted prevention Fictional stories Nelson & Arthur (2003) Cordova et al. (2015) Cordova et al. (2016) Quasi-experimental Nelson & Arthur (2003) Community-based participatory research Cordova et al. (2015) Cordova et al. (2016) Schools / Youth with risk factors / Drug use Nelson & Arthur (2003). USA Youth-centered community health care/ Adolescents and young people / Drug use Cordova et al. (2015). USA Cordova et al. (2016). USA Reduction in the consumption of alcohol and marijuana and a correlation with the number of program contact hours (Nelson & Arthur, 2003). Highlight the barriers and facilitators (Cordova et al., 2015). Program usability and acceptability (Cordova et al., 2016). Drug interventions culturally adapted Stories of support Andrews et al. (2007) Stories of experience Haight et al. (2010) Fictional stories Montgomery et al. (2012) Community-based participatory research Andrews et al. (2007) Mixed methods Haight et al. (2010) Pilot project and evaluation Montgomery et al. (2012) Public housing neighborhoods/ African American women / Tobacco Andrews et al. (2007). USA Foster care / Children from methamphetamine-involved families. Haight et al. (2010). USA Native communities / American Indian and Alaskan Native youth / Tobacco Montgomery et al. (2012). USA Surface structure changes enhanced interest, acceptance and viability, whereas the deep structure facilitated context adaptation and strengthened the study’s impact and general efficacy (Andrews et al. 2007). Slight improvement in behavior problems among children participating in the intervention (Haight et al., 2010). Involving native youth in the intervention (Montgomery et al., 2012).