Fall 2017 Newsletter (Plain Text)

We Can Only Succeed by Working Together

There isn’t a day that goes by when I’m not reminded of what a polarized, disengaged, and fractious society we’ve become. We talk past one another, not to one another. We volunteer help only in the direst of emergencies. And we’ve somehow accepted a norm that says to get ahead, we have to shove someone else behind.

Of course I’m speaking generally, and there are outstanding exceptions to these trends everywhere you look, but there’s no denying that the concepts of teamwork and camaraderie are not what they once were.

So I wasn’t surprised when themes of collaboration, communication, and education emerged from workshop discussions at September’s Montana Health Research Summit, sponsored by CAIRHE and Montana INBRE (see story on page 2). We are starved for togetherness! When faced with the immense challenges of addressing health disparities and improving health outcomes in our state, the participants in that struggle believe that we have to combine our strengths and engage with one another.

No single entity can go it alone.

The same is true for the individual careers of our research faculty. At the University of Wisconsin School of Medicine and Public Health, where I spent the first 20 years of my career, a culture of mentoring—and team mentoring, at that—was the undisputed standard. Trying to succeed on your own was not only frowned upon, but was also the quickest path to failure.

I’ve found that MSU doesn’t have the same kind of mentoring culture (again, with lots of notable exceptions), but we at CAIRHE are working to change that. Mentoring of junior investigators is a large part of what we do as a center, and in time we hope our approach will spread outward across our campus. We will succeed by helping others get ahead.

It’s all too easy to accept the trends of isolation and antipathy, but I hope you’ll join us instead as—together—we work with our partners around the university and state to make Montana a better place.

Alex Adams

State Health Researchers Gather for Inaugural Summit

Nearly 100 health researchers, public health professionals, and community representatives convened in Big Sky on September 14-16 for the Montana Health Research Summit, an event co-sponsored by CAIRHE and Montana INBRE.

Designed to promote networking and collaboration among researchers and key stakeholders from across the state, the Summit featured presentations, informal meeting time, and workshop discussions in the areas of mental health and substance abuse, environmental health, nutrition and food sovereignty, and infectious diseases.

Dr. Brian Bothner, director and principal investigator of Montana INBRE, opened the conference by asking for participants’ active involvement. “This weekend should be a meeting of the minds,” Bothner said. “We need to seek out one another, make our work known to others, and learn about the work of researchers with similar interests. We want to hear about the needs in tribal and non-tribal rural communities, then find new ways that we can continue to work together.”

Sense of Community

One common theme in many of the Summit’s presentations, which were spread over two days, was the importance of strong partnerships in community-based participatory research (CBPR) projects. Dr. Jack Westfall, director of the High Plains Research Network at the University of Colorado School of Medicine, said research done in collaboration with communities and remote medical practices requires “windshield time,” or hours of driving for face-to-face meetings with partners—even for an appointment of only a few minutes. It’s a crucial first step in building trust, he said.

“You can’t make people trust you overnight,” Westfall explained. “But you can trust them, and you can be trustworthy. Trust is a gift we give people. The way that we, as academics, get people to trust us is to give trust and be trustworthy.”

Dr. Daniel Dickerson (Inupiaq), a research psychiatrist with the Integrated Substance Abuse Programs at UCLA, described two of his current abuse prevention projects serving urban American Indians in Los Angeles. Both projects integrate evidence-based treatment with cultural activities, such as drumming, that have intense meaning and can’t be used casually.

“We have to be very mindful not to misuse traditional practices or represent them the wrong way,” Dickerson said. “So that’s where CBPR is so important. We always look to the community and ask them what would be appropriate, what they would like, and how we should carry out that intervention the right way, in a way that’s respectful.”

Anna Whiting Sorrell (Confederated Salish and Kootenai), director of operations, planning, and policy for the Confederated Salish and Kootenai Tribal Health Department, made a heartfelt plea for cooperation with tribal communities. Speaking from the perspective of a community suffering from a recent suicide epidemic, Whiting Sorrell spoke, in part, on the principle “The heart of the problem lies in the community, and the solution will come from the same.”

“But how does that happen?” she asked the audience. “The challenge for you is to figure out how we make that happen.” Culture alone won’t save a community in crisis, she said, because if it were true, the health disparities so prevalent today wouldn’t exist. “We have to understand what is underneath that. What has caused the suicides and the substance abuse in our communities. How do we heal that? How do we let people heal that? And once that is healed, you can figure out what the best practice is to give voice to that. Help us come up with that.”

Her moving speech received a standing ovation.

The following evening, Dr. Dennis Donovan, director of the Alcohol and Drug Abuse Institute at the University of Washington, described a successful culture-based intervention to reduce substance use among American Indian youth. As principal investigator of the Healing of the Canoe project, Donovan worked closely with the Suquamish and Port Gamble S’Klallam Tribes in Washington for more than a decade—the very sort of partnership that Whiting Sorrell had encouraged at the conference the day before. Over the past three years, Healing of the Canoe has expanded to a training program involving 317 people from 43 tribes.

“In the end, tribal members said of us, ‘We told them what we needed them to do, and then they did it,’” Donovan said. “To me, that’s a pat on the back, and one we’re very appreciative of.”

Broadening the Health Pipeline

Other presenters spoke on the greater inclusion of Native voices in U.S. health professions as a way to advance health equity. Dr. Erik Brodt (Minnesota Ojibwe) of the School of Medicine at Oregon Health and Science University (OHSU) noted that the number of American Indian/Alaska Native applicants to U.S. medical schools has declined by 70 percent since 1996. “If this was happening to any other underrepresented or disadvantaged community, people would be losing their jobs,” he said. He added that American Indians make up a fraction of 1 percent of faculty at U.S. medical schools, where mentors are few and historical examples of successful programs to educate American Indians in medicine are almost nonexistent.

Brodt directs the Northwest Native American Center of Excellence, which works to increase Native voices in health professions, in part, by recruiting AI/AN students and faculty to medical schools. Two affiliated programs that Brodt described, We R Native and We Are Healers, connect with 55,000 Native youth subscribers on social media, a number that’s “growing every single day,” he said.

OHSU houses the only government-funded Native American center of excellence for health professional education, Brodt said. “I take that as a charge to collaborate, not to isolate,” he explained. “I want to try and identify ways that we can work together to advance this initiative. My vision is to create a forum where we can share ideas and come up with solutions so that we can also work with Montana on this.”

Later in the day, Montana INBRE presented a panel discussion featuring four Native graduate students from MSU: Robert Dorsey, Melinda Smith, Francine Spang-Willis, and Dionne Zoanni. Building on Brodt’s themes, they described their own paths in STEM and health disciplines and the challenges and opportunities they’ve faced. Spang-Willis, a graduate student in Psychology, credited her faculty mentor at Rocky Mountain College, Dr. Arthur DeRosier, for inspiring her as an undergraduate.

“His willingness to create a space for me to share my voice and knowledge is one reason why I have a passion for learning and for helping people today,” she said.

From Funding to Final Delivery

The Summit was not without content on the nitty-gritty of research activity. “As researchers, we all know the importance of grant funding,” said Dr. Alex Adams, director of CAIRHE. “If we don’t have the money for what we want to do in our communities, even the best of ideas won’t get off the ground.”

Her remarks prefaced a two-hour grant-writing workshop by Dr. Jared Jobe, a Virginia-based consultant who draws from his storied career as a scientist and program officer at the National Institutes of Health (NIH) and other federal agencies. Jobe advised junior faculty to not lose sight of the science behind the laudable work they hope to do in communities.

“The NIH doesn’t fund programs; they fund experiments,” he said, adding that investigators should always design the science of a grant proposal first, followed by the personnel, timeline, and budget.

Dr. Aaron Wernham, CEO of the Montana Healthcare Foundation, focused the public health discussion squarely on Montana by referencing some early data from the recent State Health Assessment and the forthcoming State Health Improvement Plan by the Montana Department of Public Health and Human Services (DPHHS). Wernham encouraged faculty investigators to involve not only their partner communities in the research process, but also stakeholders across the health delivery system—including Medicaid and other state personnel, tribal health directors, Indian Health Service officials, and hospitals and clinics.

“You can have the most effective intervention in the world, but if you’re not delivering it effectively, it’s not improving health,” he said. “As you’re designing research, be thinking about stakeholders that may help you understand where the intervention you have in mind fits into the delivery system.”

State officials from DPHHS were among those attending workshop discussions at the end of the Summit focused on the current state of research in Montana in areas of mental health and substance abuse, environmental health, nutrition and food sovereignty, and infectious diseases. The workshops highlighted many areas of progress, but clearly there is a lot of work yet to be done and significant room for statewide collaboration, the discussion moderators reported.

Dr. Monica Skewes, associate professor in MSU’s Department of Psychology and a CAIRHE investigator, co-moderated the mental health and substance abuse discussion with Dr. Matt Byerly, director of the Center for Mental Health Research and Recovery. Skewes said one of the biggest challenges in their discipline is figuring out evidence-based treatments that work in unique communities beset by substance abuse, suicide, and related crises. “In general, we need to treat not just an individual to get them to change, but instead treat the family, the community, and the whole system to give rise to better health,” Skewes said.

Later this year, Summit organizers will disseminate talking points from each workshop discussion, followed by posting on the CAIRHE and INBRE websites, Adams said.

First Step on a Long Road

Results from a post-Summit evaluation survey indicate that participants found the conference valuable as a forum for new ideas and networking. For example, 93 percent of respondents rated the quality of presentations (now available as videos online) as either high or very high. “Overall, I thought the Summit was a great opportunity to connect,” said one participant.

Bothner and Adams both emphasized that the Summit was only a first step. “We can’t expect a single conference to change the course of collaborative health research in our state overnight,” Bothner said. “But it’s our hope that this initial meeting will start to bring health researchers, community stakeholders, and tribal, state, and county officials closer in a spirit of true cooperation and partnership for the benefit of all.”

CAIRHE Adds 3 Pilot Projects for 2017-18

CAIRHE has added three pilot projects to its funded research for 2017-18, bringing its total number of pilot projects to six. As part of the additions, four investigators are receiving research support from the Center for the first time.

Funding began September 1 at the start of CAIRHE’s fourth year as a center. The new investigators are Carmen Byker Shanks, Ph.D., RDN, associate professor in the Department of Health and Human Development; Neha John-Henderson, Ph.D., assistant professor in the Department of Psychology; Maggie Thorsen, Ph.D., assistant professor in the Department of Sociology and Anthropology; and Andreas Thorsen, Ph.D., assistant professor in the Jake Jabs College of Business & Entrepreneurship.

CAIRHE also is continuing past-year pilot project support for Drs. Colter Ellis, Kaylin Greene, Kelly Knight, and Monica Skewes.

“We’re delighted to bring four talented new investigators into our Center this year,” said CAIRHE Director Alex Adams. “Each is pursuing a line of research that is new to us, which will broaden our reach into new areas of the state and region.”

In her project Promoting Dietary Quality at FDPIR Through a Fruit and Vegetable Intervention, Byker Shanks will implement a multi-phase effort to increase dietary quality among local participants in the Food Distribution Program on Indian Reservations (FDPIR) on the Flathead Reservation of the Confederated Salish and Kootenai Tribes. Her work builds on several years of collaboration with local partners and MSU scientist Selena Ahmed, Ph.D. Byker Shanks and Ahmed received CAIRHE funding in 2016 for a dissemination project (see Fall 2016 Newsletter).

John-Henderson’s project, Understanding the Relationship Between Sense of Belonging and Health in the Blackfeet Tribal Community, will continue secondary data analyses of a stress and health dataset on the Blackfeet Reservation to uncover how sense of belonging to the local community may associate with biomarkers of disease risk. The data were collected by Blackfeet Community College students with support of a Native American Research Centers for Health (NARCH) grant from the National Institutes of Health.

Multi-Criteria Evaluation of Efficiency, Access, and Outcomes at Health Centers, the project led by Maggie and Andreas Thorsen, will improve understanding of how variation across federally qualified health centers impacts efficiency and patient health outcomes. Their work will develop models to better understand the strengths and challenges facing Montana’s integrated healthcare system, and it should yield policy recommendations for improving health and reducing disparities in Montana, Maggie Thorsen said.

“Population health inequalities are impacted by how well our healthcare system delivers services to all people,” she said. “We feel that there are many complex problems facing our healthcare system that require solutions from multiple disciplines.”

All pilot projects were submitted as applications in April 2017 in response to CAIRHE’s Request for Proposals last December. Each funded proposal received prior approval from the CAIRHE External Advisory Committee and the NIH. Funding is for one year, with the possibility of competitive renewal for an additional year.

Project Highlights

Here’s a summary of activity among CAIRHE’s faculty investigators during the summer and fall.

Elizabeth Rink, Ph.D., MSW (The Fort Peck Sexual Health Project), reviewed the results from her team’s in-school survey of youth on the Fort Peck Reservation with the project’s community advisory board (CAB), which made recommendations for further analysis. Following extensive discussion with tribal partners, Rink wrote an R01 grant proposal for an intervention project at Fort Peck (called NenUnkUmbi/EdaHiYedo (“We Are Here Now”) and submitted it to the National Institutes of Health in August. The initial score is very encouraging, with further news about potential funding coming in January. For the remainder of the year, Rink’s project will fine-tune a pilot test of the “We Are Here Now” intervention in Brockton, Mont., in conjunction with Brockton High School, the CAB, and the Fort Peck Language and Culture Department. In November, consultants from Oregon Health Sciences University will provide training to project partners in Brockton in the Native Stand curriculum that will be the basis of the first level of the intervention.

Rink is working on three manuscripts related to her CAIRHE project, with planned submission by April of next year.

The Guardians of the Living Water project, under the direction of Vanessa Simonds, Sc.D., completed its third annual summer camp on the Crow Reservation, where camp leaders guided students as they tested water quality in and around their homes and a local spring, then presented results to their parents. The project’s after-school program this year will focus on increasing critical health literacy skills in youth who have attended one or more of the previous sessions. Simonds and her project team have submitted two manuscripts that are under review. In addition, they made two presentations at the annual meeting of the American Public Health Association in Atlanta in early November.

Elizabeth Kinion, Ed.D., MSN (Increasing Access to Oral Health Care: Evaluating the Outcomes of a Community Health Specialist Program), staged recruiting efforts for her project on the Fort Belknap Reservation. In early November Kinion and former student Jennifer Show, DNP, will present a talk, “Challenges and Opportunities When Addressing Oral Health Care on a Rural American Indian Reservation,” at a continuing dental education conference in Great Falls, Mont.

Colter Ellis, Ph.D., and Kelly Knight, Ph.D. (Responding to Secondary Trauma ...), continue to meet regularly with CABs in Southwest Montana and on the Blackfeet Reservation. Earlier this year they completed a Blackfeet community needs assessment and presented at Days of the Piikani at Blackfeet Community College. In November they will make two invited presentations about their ongoing work: one to Montana Concerns of Police Survivors (COPS), and a second in Washington, D.C., at a meeting of the Administration for Children and Families, U.S. Department of Health and Human Services.

Ellis and Knight also are revising two manuscripts for publication; drafting toolkits for their dual projects while planning retreat events where they will roll out those toolkits; and developing an innovative survey for secondary trauma.

Kaylin Greene, Ph.D. (Substance Use and Driving Among Rural Young Adults), published a report, Drinking and Driving in the Big Sky State: Key Insights from Young Adults, for dissemination among communities and other stakeholders across Montana (see page X). She also has two papers related to her CAIRHE project that are currently under review.

Maggie Thorsen, Ph.D., and Andreas Thorsen, Ph.D. (Multi-Criteria Evaluation of Efficiency, Access, and Outcomes at Health Centers), submitted a paper, “Operational efficiency, patient composition and regional context of U.S. health centers: Associations with access to early prenatal care and low birth weight,” for consideration at the Population Association of America annual meeting. They also will adapt the paper for submission to a peer-reviewed journal. A portion of their CAIRHE pilot project contributed to an October presentation at the Institute for Operations Research and Management Sciences (INFORMS) annual meeting in Houston. They have hired a graduate research assistant, Srinivasan Sridhar, and they are preparing a grant application for submission to the Patient-Centered Outcomes Research Institute early next year.

Carmen Byker Shanks, Ph.D. (Promoting Dietary Quality at FDPIR Through a Fruit and Vegetable Intervention), has been conducting weekly research team meetings and has partnered with the Western Montana Growers Coop to source fresh and local fruits and vegetables for the project’s intervention. To date, the project has completed 1 month of pre-intervention work and 1 month of the intervention, and it is currently in month 2 of intervention, which includes nutrition education. She and her team are finalizing a manuscript about dietary quality on the Flathead Reservation.

In related news, Byker Shanks received U.S. Department of Agriculture funding as co–principal investigator for a Montana Team Nutrition training grant. She has published three papers this year related to a short-term dissemination project (with Selena Ahmed, Ph.D.) funded by CAIRHE in Summer 2016. Byker Shanks received tenure and promotion to associate professor at MSU last spring.

Monica Skewes, Ph.D. (The Fort Peck Substance Abuse and Resilience Project), and her team have been collecting survey data at Fort Peck since May, with about 150 surveys completed to date. Following analysis and preparation of manuscripts for publication, they will use the findings in a future grant proposal. She also has submitted a manuscript reporting findings from previous interview data, in addition to several other manuscripts in preparation. She presented at the annual convention of the Western Psychological Association last spring.

In other work, Skewes will lead a subcontract to MSU as one part of an NIH NARCH grant to Northwest Indian College in Bellingham, Wash. The goal of that project is to understand resilience and recovery from opioid dependence among tribal members from three Coast Salish reservation communities in Washington State.

CAIRHE mentor Jessi Smith, Ph.D., recently received funding as co-PI of an NIH R01 grant for a project titled “Promoting Motivation for Underrepresented Groups in Undergraduate Biology and Chemistry Courses.” The project will test an intervention in introductory science classrooms, including chemistry at MSU, that especially help first-generation and underrepresented minority students.

CAIRHE Requests Proposals for Pilot Projects, Research Projects

CAIRHE has issued its annual request for proposals for both one-year pilot projects and five-year research projects. The latter, if selected, will form the basis for CAIRHE’s renewal of its NIH Centers of Biomedical Research Excellence grant, to be submitted in September 2018.

Proposals should be consistent with CAIRHE’s mission of reducing health disparities in tribal and/or nontribal rural communities, and they should have a high likelihood of leading to independent funding from external (non-MSU) sponsors.

For complete details and instructions, visit http://www.montana.edu/cairhe/rfp/index.html.

Frances Kim Joins CAIRHE, Offers Support to Multiple Projects

Frances Kim, a 2017 MPH graduate from Columbia University, has joined CAIRHE as project coordinator, currently serving two of the center’s research projects.

Since joining CAIRHE in July after moving directly from New York, Kim has assisted Vanessa Simonds, Ph.D., and her Guardians of the Living Water project with data management and analysis, as well as on-site assistance with student programs on the Crow Reservation. Among other activity, that project team is preparing a paper for submission this fall.

Kim also assists Elizabeth Kinion, Ed.D., and her oral health project at the Fort Belknap Reservation through participant recruitment efforts and data management using REDCap, a Web application for building and managing databases. REDCap is new to MSU, and Kim will become CAIRHE’s resident expert serving all of its projects.

“Public health has been a pivotal career inspiration for me,” Kim said, “The idea that I can create changes on a community level is great, but I also feel like this job allows me to help dismantle institutionalized barriers to minority groups receiving care—more specifically through CAIRHE’s community-based participatory research focus. I think I’ve been incredibly lucky working at CAIRHE so soon after my MPH. It’s not very common, at least in my graduate program in epidemiology and applied biostatistics, to have such an involved and dynamic public health role.”

A native of Toronto who moved to San Diego when she was 15, Kim has adjusted quickly to the smaller population and slower pace of Bozeman. “It doesn’t hurt that I can leave my house and see mountains all around me to climb, hike, and just admire on a daily basis,” she said.

CAIRHE Director Alex Adams said that Kim’s expertise will be a boon to CAIRHE’s project leaders. “Having someone to manage data collection in our communities in a secure, compliant, and thoughtful way allows our investigators to focus on their science and community partnerships with confidence,” she said. “We are delighted that Frances has had an impact right away.”

Amber Noseep Serves as CAIRHE’s Student Assistant

Amber Noseep, an MSU undergraduate from Fort Washakie on the Wind River Reservation in Wyoming, has worked for CAIRHE since June as the center’s student research and administrative assistant.

A nursing major who will enroll in the BSN program at the MSU College of Nursing, Billings Campus, next May, Noseep assists Grants Management Specialist Maya Bronston with accounting work and Project Leader Vanessa Simonds with research project tasks.

“Quote from Amber,” said Noseep, who is Eastern Shoshone.

After receiving her nursing degree in 2020, Noseep plans to work in an emergency room setting for a year and then apply to graduate school in nursing anesthesia.

“In a short time Amber has been a great asset to our office,” Bronston said. “We know she’s going to do great work in her nursing career after graduation, and we wish her all the best.”

CAIRHE Introduces New External Evaluator

Julie Lucero, Ph.D., MPH, assistant professor in the School of Community Health Sciences at the University of Nevada, Reno, has begun work as CAIRHE’s external evaluator, providing crucial formative and summative assessments of the center’s progress.

Herself a CBPR investigator who works with American Indian, Hispanic, and LGBT communities, Lucero’s own research seeks modifiable social determinants to reduce the impact of health inequities within marginalized populations. She served as associate director of the Center for Participatory Research at the University of New Mexico Health Sciences Center from 2009 to 2015.

In her work for CAIRHE, she is assisted by graduate student Kathrine Wright.

“Dr. Lucero understands what we’re trying to do as a center,” said James Burroughs, CAIRHE program coordinator. “As we look ahead to our next five years, she will be able to provide us with valuable guidance on what we’re doing right and where we can be better.”

Lucero and Wright attended the Montana Health Research Summit in Big Sky in September, and they will return to Bozeman in February to meet with CAIRHE investigators. Along with the External Advisory Committee and Mentor Council, the evaluation team will serve as important, impartial advisers to Director Alex Adams—helping to ensure that the center is effective in meeting its goals and objectives, Burroughs said.

CAIRHE, Montana INBRE Appoint New Rural Community Research Associate

Susan Higgins has joined CAIRHE and Montana INBRE as a community research associate, part of both programs’ ongoing effort to build research relationships among rural communities in Montana.

Higgins will work closely with faculty investigators, facilitating their productive, trusting partnerships with local groups according to best practices in community-based participatory research, said CAIRHE Director Alex Adams.

“Sue is a proven organizer and a catalyst for cooperative projects of any kind,” Adams said. “She will bring people together around the state to help our two programs develop and refine the research that Montana needs.”

By focusing on rural, non-tribal communities, Higgins will complement longtime CRA Emily Salois, who is a respected adviser to faculty and tribal partners around the state. Together Salois and Higgins will strengthen the Community Engagement Core at a time of significant research growth at MSU, Adams said.

Higgins brings to the position a 35-year background in natural resources management and policy in Montana, including recent consulting work and eight years of program management with the Center for Large Landscape Conservation and The Tributary Fund, where she facilitated research activities, among other duties. She has authored guides for practitioners and educators, as well as a recent paper on best practices for research scientists working in faith and indigenous communities.

“I am honored to take on the work for CAIRHE and INBRE to connect their outstanding research capabilities to the real and vital on-the-ground healthcare needs of our rural Montana communities,” Higgins said. “Learning from communities about what makes science and research relevant to them, and bridging that story, is about the most exciting work we can do.”

Higgins will be based on the MSU campus in Bozeman, with frequent travel around the state. On her first day on the job in early November, she represented CAIRHE and INBRE at the 2017 Montana Healthy Communities Conference in Helena. She resides in Bozeman with her family.

Greene Publishes Report for Communities

CAIRHE project leader Kaylin Greene, Ph.D. (Substance Use and Driving Among Rural Young Adults), has published a report for a statewide layperson audience from her study of alcohol and marijuana use and driving among young adults.

The report, Drinking and Driving in the Big Sky State: Key Insights from Young Adults, states that Montana has one of the highest self-reported rates of driving after drinking too much—nearly twice the national average. As a result, Montana has one of the highest rates of young adults killed in crashes that involve alcohol-intoxicated drivers. Greene co-authored the report with collaborator Matthew Rossheim, Ph.D., of George Mason University and MSU research assistant Samuel Murphy.

“In addition to getting these results back to communities,” Greene said, “we’ve shared this report with diverse groups—from public health providers to DUI Task Force members across the state of Montana.”

Greene’s study has determined that young adults believe that drinking and driving is different in rural areas compared to more populous parts of the state. Because they believe that harming someone else is less likely with fewer drivers on the road, for example, young drivers may think that the behavior is excusable and tolerated by others, including law enforcement.

Other portions of the report examine when and why young people drink and drive, why some young adults choose not to drink and drive, and what programs currently address the problem. Suggestions for new initiatives include addressing Montana’s excessive drinking culture and the culture of drinking and driving in rural areas.

The full report is available on CAIRHE’s website at the link above.