'Trauma sits in your body and makes you shut down:' sexual and reproductive health professionals' views of the impact of trauma on the sexual health of Native American older adolescent and young adult women.

A history of colonisation and corresponding traumas has resulted in disparate rates of violence and sexual health inequities among many Native American populations. As a result, Native American adolescents and young adults specifically, experience higher rates of STIs, HIV and unintended pregnancy relative to their non-Hispanic White counterparts. To address these inequities, sexual health education programmes should reflect Native American cultural values and traditional teachings to align with community assets and protective factors. The objective of this study was to describe sexual and reproductive health professionals' perspectives on how trauma collectively affects the sexual health of older adolescents and young adult Native American women between the ages of 15-25 years. We purposively sampled sexual and reproductive health professionals who worked with members of this priority population. Individual in-depth interviews were conducted, recorded, and transcribed. Transcripts were analysed using thematic analysis. The themes identified in the interviews include the impact of trauma and colonisation on sexual health, strategies for combatting trauma, promoting sexual health, and supporting the development of culturally congruent sexual health education curricula. Findings point to the need for culturally relevant, trauma-informed sexual health education interventions to help promote sexual and reproductive health equity for Native American adolescent and young adult women.

Assessing the Effectiveness of the Respecting the Circle of Life Project on Condom and Contraception Self-efficacy Among American Indian Youth.

Respecting the Circle of Life (RCL) is a teen pregnancy prevention program that was evaluated for effectiveness on sexual health risk behaviors through a two-arm randomized control trial (RCT) with American Indian (AI) youth ages 11-19. The objective of this study is to investigate the effects of RCL compared to a control group on items of condom and contraception self-efficacy. Linear regression analysis was used to compare differences in each item that included condom and contraception self-efficacy scales among the intervention and control participants at baseline, 3 and 9 months post intervention. Youth enrolled in the intervention reported higher levels of condom and contraception self-efficacy across almost all individual items. Exceptions include items related to partner negotiation of condom self-efficacy at 3 months (p = 0.227) and 9 months (p = 0.074) post intervention. Findings indicate RCL is effective at improving overall condom and contraception self-efficacy but did not impact the specific component of partner negotiation for either condom or contraception self-efficacy. This inquiry provides rationale to further explore components of RCL related to partner negotiation.

Implementation Fidelity and Theory-Informed Dose Effects of a Teen Pregnancy Prevention Program for Native American Youth.

In 2019, Native youth had the highest rate of teen pregnancy of all racial/ethnic groups. "Respecting the Circle of Life" (RCL) is one of the first evidence-based teen pregnancy prevention programs for Native teens and there is interest in replicating the program across tribal communities. To inform replication, it is important to consider process data including quality, fidelity, and dosage as these may all moderate impact of the program. Participants were Native youth aged 11-19 and a trusted adult. This study includes participants randomized to the RCL program only (N = 266). Data sources include independent observations, facilitator self-assessments, attendance logs, and self-report assessments completed by enrolled youth at baseline and 3 months post assessment. Data was compiled and summed by cohort. Dosage was number of minutes participating in activities separated by theoretical constructs. Linear regression models were utilized to assess moderation of the effects of the intervention dosage on outcomes of interest. Eighteen facilitators delivered RCL. One hundred eighteen independent observations and 320 facilitator self-assessments were collected and entered. Findings indicate RCL was implemented with high fidelity and quality (4.40 to 4.82 out of a 5-point Likert scale; 96.6% of planned activities completed). Dosage was high with an average completion of 7 out of 9 lessons. There was no association between theoretical construct dosage and outcomes of interest. Overall, this study indicates RCL was delivered with high fidelity, quality, and dosage in this trial. This paper informs future replication of RCL and provides support for hiring paraprofessionals from the local community as facilitators, delivering the RCL to peer groups of the same age and sex, delivering the RCL with short duration and high frequency, and encouraging youth to attend all RCL lessons, but continue to serve youth who have missed one or more lessons.

Measuring the effects of the COVID-19 pandemic on Diné and White Mountain Apache school personnel, families, and students: protocol for a prospective longitudinal cohort study.

BACKGROUND: This paper describes the protocol for a longitudinal cohort study, "Project SafeSchools" (PSS), which focuses on measuring the effects of COVID-19 and the return to in-person learning on Diné (Navajo) and White Mountain Apache (Apache) youth, parents, and educators. The early surges of the COVID-19 pandemic led to the closure of most reservation and border town schools serving Diné and Apache communities. This study aims to: (1) understand the barriers and facilitators to school re-opening and in-person school attendance from the perspective of multiple stakeholders in Diné and Apache communities; and (2) evaluate the educational, social, emotional, physical, and mental health impacts of returning to in-person learning for caregivers and youth ages 4-16 who reside or work on the Diné Nation and the White Mountain Apache Tribal lands. METHODS: We aim to recruit up to N = 200 primary caregivers of Diné and Apache youth ages 4-16 and up to N = 120 school personnel. In addition, up to n = 120 of these primary caregivers and their children, ages 11-16, will be selected to participate in qualitative interviews to learn more about the effects of the pandemic on their health and wellbeing. Data from caregiver and school personnel participants will be collected in three waves via self-report surveys that measure COVID-19 related behaviors and attitudes, mental health, educational attitudes, and cultural practices and beliefs for both themselves and their child (caregiver participants only). We hypothesize that an individual's engagement with a variety of cultural activities during school closures and as school re-opened will have a protective effect on adult and youth mental health as they return to in-person learning. DISCUSSION: The results of this study will inform the development or implementation of preventative interventions that may help Diné and Apache youth and their families recover from the negative impact of the COVID-19 pandemic, and positively impact their health and wellness.

Improving communication between American Indian youth and caregivers to prevent teenage pregnancy.

American Indian (AI) youth are at increased risk for poor reproductive health outcomes. Parental communication and monitoring are established predictors of sexual risk-taking among adolescents. No program evaluations of sexual risk avoidance programs have focused exclusively on AI youth and parents. This study assesses the impact of the Respecting the Circle of Life (RCL) Teenage Pregnancy Prevention program on parent-youth communication and parental monitoring through a randomized controlled trial with AI youth ages 11-19 and their trusted adults (parents/caregivers) (N = 518). RCL consists of 8-peer group and one parent-youth session. Trusted adult participants completed the Parental Monitoring Scale and the Parent Adolescent Communication Scale at baseline and 3 and 9 months post-intervention via self-report. Intervention impact was evaluated using linear regression models, which included an indicator for study group. At 3 months post, trusted adults in the intervention reported significantly higher levels of sexual health communication (P = 0.042) and spoke to their child more often about how to get condoms (P = 0.001), get birth control (P = 0.014) and protect themselves from human immunodeficiency virus (P = 0.005) compared with trusted adults in the control condition. Program impact varied by age and sex. This study adds to literature and extends findings on RCL impact.

'Empowering our people' to address depression, violence, and sexual risk among Native Americans with recent binge alcohol use.

Background: This study was launched in response to an American Indian (AI) community's concern regarding the comorbid occurrence of substance use, poor mental health, and other risk factors on sexual health. The purpose of this manuscript was to assess the relationship between alcohol use, violence, depression and STI/HIV risk behaviors on the frequency of unprotected sex acts and number of sexual partners among AI adults.Methods: Specifically, this analysis examines sociodemographic characteristics, experience of sexual and physical violence, binge drinking, depression, and sexual risk taking among n = 281 AI adults ages 18-55. Regression models examine associations between the aforementioned risk factors, number of sex partners and number of unprotected sex acts, by depression status and sex, among participants.Results: Frequent binge drinking predicted frequency of unprotected sex for both males and females; ever experiencing physical violence was a powerful predictor of unprotected sex for females, but not males. Ever experiencing physical violence strongly predicted having multiple sexual partners for females but was related to decreased number of sexual partners for males. Females ever experiencing sexual violence had more sexual partners; this was not observed for males. Binge drinking predicted frequency of unprotected sex acts, regardless of depression status.Discussion: Interventions for AI adults seeking to reduce sexual health risk should reflect past violence victimization in sexual decision making, primarily among women. The significant role of binge alcohol use for modifying sexual decisions should be of prime focus and interventions should be personalized to address individuals' own alcohol use patterns. Additional research should explore how binge alcohol use moderates the relationship between depression and sexual risk.

Community Perspectives on Social Influences on Suicide Within a Native American Reservation.

Relative to the general population, Native Americans (NA) bear a disproportionate burden of suicide-related mortality rates. NA males and females aged 15 to 24 years experience suicide rates nearly 3 times than the U.S. all races rates in this age group. Although efforts have been made to understand and reduce suicide in tribal communities, a large portion has focused on individual characteristics with less attention given to social factors that may also inform suicide. This article aims to build on a local conceptual model of NA youth suicide by examining additional potential social factors through qualitative interviews. Findings from the thematic analysis resulted in the identification of seven perceived social influences: contagion, violence and abuse, discrimination and bullying, negative expectations, spirituality, social support, and cultural strengths. Public health approaches to reduce suicide should consider local social factors that resonate with tribal communities to build resilience.

Social Network Differences Between American Indian Youth Who have Attempted Suicide and Have Suicide Ideation.

Suicide is a crucial public health concern for American Indian and Alaska native (AIAN) communities. AIANs have the highest suicide rate compared to all other ethnic groups in the United States. Social relations are a salient fixture of AIAN culture. The primary aims of this study were to describe the personal networks of AI youth that have recently had a suicide attempt or suicidal ideation and to identify key network differences between the two groups. This study uses personal networks collected among AIs living on a reservation in the Southwest. Our sample included 46 American Indians that have recently attempted suicide or had suicidal ideation. We explored social network characteristics of the two groups descriptively as well as comparatively (t-tests). Our findings suggest that AI youth that have attempted suicide nominate more friends in their networks that have used alcohol and drugs compared to the networks of AI youth that have recent suicide ideation. Additionally, AI youth that recently attempted suicide have used alcohol and drugs with their network peers at a higher rate than youth that have had recent suicide ideation. Lastly, AI youth that have attempted suicide recently were significantly more likely to have more nominated friends in their networks that they had reached out to when they were struggling with suicide compared to their peers that have experienced recent suicide ideation. These results indicate a promising method moving forward to identify unique intervention strategies that extend beyond the individual.

"Empowering Our People": Impact of a Culturally Adapted Evidence-Based Intervention on Sexually Transmitted Infection Risks Among Native Americans With Binge Substance Use.

BACKGROUND: The objective of this study was to evaluate a culturally adapted evidence-based intervention called EMPWR (Educate, Motivate, Protect, Wellness and Respect) for impacts on sexually transmitted infection (STI) screening and sexual health risk behaviors. METHODS: We enrolled Native American adults with recent binge substance use from a rural, reservation community in the Southwest into a 1:1 randomized controlled trial conducted on July 2015 to June 2019. All participants were offered non-clinic-based self-administered STI screening. Data were collected via self-report at baseline, 3 months, and 6 months after the intervention. Baseline and end line data are presented. RESULTS: Three hundred one participants were enrolled and had a mean age of 33.8 years; 46.5% of the sample were female, and 9.1% were employed at baseline. EMPWR participants were more likely to complete STI self-screening than control participants (38.2% vs. 23.8%, P = 0.0275). EMPWR participants reported fewer unprotected sex acts in the past 3 months (9.3 vs. 16.0, P = 0.001) and were more likely to refuse sex if their partner was not tested (23.6% vs. 12.4%, P = 0.049). The between-group difference in STI positivity 1 year after study completion was nearing statistical significance (intervention: 39.5% vs. control: 59.6%, P = 0.0575). CONCLUSIONS: The culturally adapted evidence-based intervention, EMPWR, increased uptake of STI screening and refusal of sex if partner was not STI tested and decreased the frequency of unprotected sex acts among Native American adults with recent binge substance use living on a rural reservation. Future research is needed to examine EMPWR impacts among other Native American subgroups and its potential for advancing sexual health equity in this high-priority population.

Prevention of Sexually Transmitted Diseases and Pregnancy Prevention Among Native American Youths: A Randomized Controlled Trial, 2016-2018.

Objectives. To evaluate the efficacy of the Respecting the Circle of Life program (RCL) among Native American youths 11 to 19 years of age residing in a rural reservation community in the southwestern United States. Methods. Between 2016 and 2018, we conducted a randomized controlled trial of the RCL program with 534 Native youths. Participants completed assessments at baseline and 9 and 12 months after the intervention. We conducted intention-to-treat analyses based on study group randomization. Results. At 9 months, intervention participants had significantly better condom use self-efficacy (P < .001), higher intentions to use condoms (P = .024) and abstain from sex (P = .008), and better contraceptive use self-efficacy (P < .001) than control participants, as well as better condom use (P = .032) and contraceptive use (P = .002) negotiation skills. At 12 months, intervention participants had significantly better sexual and reproductive health knowledge (P = .021), condom use self-efficacy (P < .001), contraceptive use self-efficacy (P < .001), and contraceptive use negotiation skills (P = .004) than control participants. Intervention participants reported significantly more communication with their parents about sexual and reproductive health than control participants at both 9 and 12 months (P = .042 and P = .001, respectively). Conclusions. The RCL program has a significant impact on key factors associated with pregnancy prevention among Native youths and should be used as an adolescent pregnancy prevention strategy. Trial Registration.  Clinical Trials.gov identifier: NCT02904629. (Am J Public Health. 2021;111(10): 1874-1884. https://doi.org/10.2105/AJPH.2021.306447).

Diné (Navajo) female perspectives on mother-daughter communication and cultural assets around the transition to womanhood: a cross-sectional survey.

BACKGROUND: The inclusion of protective factors ("assets") are increasingly supported in developing culturally grounded interventions for American Indian (AI) populations. This study sought to explore AI women's cultural assets, perspectives, and teachings to inform the development of a culturally grounded, intergenerational intervention to prevent substance abuse and teenage pregnancy among AI females. METHODS: Adult self-identified AI women (N = 201) who reside on the Navajo Nation completed a cross-sectional survey between May and October 2018. The 21-question survey explored health communication around the transition to womanhood, cultural assets, perceptions of mother-daughter reproductive health communication, and intervention health topics. Univariate descriptive analyses, chi squared, and fisher's exact tests were conducted. RESULTS: Respondents ranged in age from 18 to 82 years, with a mean age of 44 ± 15.5 years. Women self-identified as mothers (95; 48%), aunts (59; 30%), older sisters (55; 28%), grandmothers (37; 19%), and/or all of the aforementioned (50; 25%). 66% (N = 95) of women admired their mother/grandmother most during puberty; 29% (N = 58) of women were 10-11 years old when someone first spoke to them about menarche; and 86% (N=172) felt their culture was a source of strength. 70% (N = 139) would have liked to learn more about reproductive health when they were a teenager; 67% (N = 134) felt Diné mothers are able to provide reproductive health education; 51% (N = 101) reported having a rite of passage event, with younger women desiring an event significantly more than older women. Responses also indicate a disruption of cultural practices due to government assimilation policies, as well as the support of male relatives during puberty. CONCLUSIONS: Results informed intervention content and delivery, including target age group, expanded caregiver eligibility criteria, lesson delivery structure and format, and protective cultural teachings. Other implications include the development of a complementary fatherhood and/or family-based intervention to prevent Native girls' substance use and teen pregnancy.

Rigorous evaluation of a substance use and teen pregnancy prevention program for American Indian girls and their female caregivers: a study protocol for a randomized controlled trial.

BACKGROUND: Early sexual initiation is associated with higher risk for sexually transmitted infection, teen pregnancy, domestic violence and substance use in later adolescence and early adulthood. Native American adolescents are more likely to have early sexual initiation compared to other racial/ethnic groups. Few programs designed with and for Native adolescents to delay sexual initiation and substance use have been tested through rigorous evaluations. This is the protocol for the randomized controlled trial of the Asdzáán Be'eena' program, a teen pregnancy and substance use prevention program for young Native girls and their female caregivers. METHODS: N = 410 female adolescents ages 10-14 and their female caregivers will be enrolled in the study and randomized to the intervention or control arm. The intervention consists of the 11-session Asdzáán Be'eena' program. The control arm consists of mailed non-monetary incentives. All participants will complete evaluations at baseline and 3 follow-up timepoints (immediate, 6 and 12 months post intervention). Evaluations include measures to assess protective factors associated with delayed sexual initiation and substance use. DISCUSSION: This is one of the first rigorous evaluations of a gender-specific, culturally tailored teen pregnancy and substance use primary prevention program for Native girls and their female caregivers. If proven efficacious, Native communities will have a culturally appropriate program for promoting protective factors associated with delayed substance use and sexual risk taking. TRIAL REGISTRATION: NCT04863729 ; April 27, 2021.

Feasibility, Acceptability, and Preliminary Impact of Asdzáán Be'eená: An Intergenerational, Strength-Based, and Culturally Grounded Program to Improve the Health of Navajo Families.

Native American youth endure a complex interplay of factors that portend greater risk-taking behaviors and contribute to marked health disparities experienced in adolescence. The Asdzáán Be'eená ("Female Pathways" in Navajo) program was developed as a primary prevention program to prevent substance use and teen pregnancy among Navajo girls. The Asdzáán Be'eená program consists of 11 lessons delivered to dyads of girls ages 8 to 11 years and their female caregivers. Feasibility, acceptability, and preliminary impact on risk and protective factors were assessed through a pre-/post study design. Data were collected from girls and their female caregivers at baseline, immediate, and 3 months postprogram completion. Forty-seven dyads enrolled in the study, and 36 completed the 3-month evaluation. At 3 months postprogram, girls reported significant increases in self-esteem, self-efficacy, parent-child relationship, social support, cultural, and sexual health knowledge. Caregivers reported increased family engagement in Navajo culture and parent-child communication and improved child functioning (fewer internalizing and externalizing behaviors). Findings suggest Asdzáán Be'eená has potential to break the cycle of substance use and teen pregnancy in Native communities by improving protective and reducing risk factors associated with these adverse health outcomes. Additional rigorous efficacy trials are necessary to establish program effectiveness.

Predictors of Sexually Transmitted Infection Positivity Among Substance-Using Native American Adults.

BACKGROUND: Sexually transmitted infections (STIs) are a public health crisis with Native Americans suffering a high burden of disease. Studies across gender and racial/ethnic groups have found varying risk factors associated with STI positivity. Understanding how risk factors are associated with STI positivity can help design interventions for those most at risk. METHODS: Participants were Native American binge substance using adults enrolled in a randomized controlled trial evaluating a brief intervention to increase STI screening and reduce sexual risk-taking behaviors. Participants completed a self-report assessment at baseline that included questions about sexual risk factors and STI testing behaviors and diagnosis. This analysis includes those who had ever completed an STI test at baseline. Bivariate and multivariate analyses using logistical regression were utilized to identify associations between risk factors and past STI diagnosis. RESULTS: A total of 193 people were included in the analysis. Over half (50.6%) of the participants had ever been diagnosed with an STI. Risk behaviors varied by gender. More women with a self-reported history of STI reported having sex with someone they thought had an STI, past experience of physical/sexual violence, and having passed out from drinking. Men with a self-reported history of STI were more likely to report past marijuana and other drug use. Among women with a self-reported history of STI, having sex with someone they thought had an STI was associated with STI positivity, whereas other drug use was associated with STI positivity among men with a self-reported history of STI. CONCLUSIONS: Findings provide information for those working to reduce STIs in Native Communities to better identify and design programs for those at highest risk for STIs. Additional studies examining gender dynamics and sexual risk taking among native adults are warranted.

Self-efficacy and response-efficacy: critical components of sexual and reproductive health interventions targeting condom use intention among American Indian adolescents.

The Respecting the Circle of Life (RCL) intervention is a comprehensive, skills-based sexual/reproductive health program shown to be effective for reducing sexual risk among American Indian (AI) adolescents (13-19 years of age). This paper seeks to identify critical program components of the RCL intervention for replication of impacts on condom use intention (CUI) when scaling to additional communities. RCL was tested among AI adolescents through a cluster randomized controlled trial (N = 267) embedded in an 8-day basketball camp. Data were collected at baseline, immediately post-camp, at 6 and 12 months post-camp. Previously established predictors of CUI that were statistically significantly impacted by RCL at the post-camp time point were tested as mediators of RCL impact on CUI. Condom use self-efficacy and response efficacy fully mediated the effect of RCL on CUI. The indirect path through condom use self-efficacy had the greatest effect on CUI, explaining 79% of the direct effect. When stratified by gender, there was only evidence of mediation among girls. Results indicate condom use self-efficacy and response efficacy are critical components of the RCL intervention for AI girls, and sexual/reproductive health programs should include practical skills training to improve these constructs to maximize intervention impact on CUI.

Predictors of Responsiveness Among American Indian Adolescents to a Community-Based HIV-Risk Reduction Intervention Over 12 Months.

This analysis explored predictors of responsiveness to the Respecting the Circle of Life (RCL) intervention, a sexual and reproductive health program for American Indian (AI) youth. Data were collected over 12-month follow-up with 267 AI youth aged 13-19. We used mixed effects regression models to examine: (1) whether trajectory patterns of HIV/AIDS knowledge, condom beliefs, condom use self-efficacy, condom use intention and partner negotiation skills differed by baseline levels categorized into low, medium, and high scorers, and (2) the characteristics of youth who made no improvement over the post-intervention period. Results indicate the RCL intervention had greater longitudinal impact among subgroups with low and medium initial scores. High initial scores in knowledge, beliefs, efficacy, intention and skills predicted unresponsiveness to the RCL intervention. Youth differences in age, gender and school truancy (skipping/suspension) did not predict responsiveness to RCL. Results have important prevention science implications: (1) AI youth at greater risk (i.e., those with low initial levels of knowledge, beliefs, self-efficacy, intention and skills) are likely to respond to RCL and should be the target of replication and dissemination efforts. (2) Responsiveness analyses can guide adaptation of RCL and other sexual and reproductive health programs for AI youth to improve efficacy among unresponsive subgroups (i.e., high initial scorers). (3) RCL is equally likely to impact AI youth across different ages, genders and school status, thus validating population-wide implementation strategies.

Risk and Protective Factors Associated With Lifetime Sexual Experience Among Rural, Reservation-Based American Indian Youth.

Early sexual initiation is a catalyst for sexually transmitted infection and unintended pregnancy. American Indian/Alaska Native (AI/AN) youth initiate sex prior to age 13 more often than other U.S. youth, contributing to current inequalities in sexual health. Identifying what factors were associated with lifetime sexual experience among AI/AN youth can inform the development of primary prevention programming to delay sexual initiation, alleviate the costs of early sexual activity, and improve sexual health outcomes in this population. We analyzed cross-sectional data from 267 AI youth ages 13-19, recruited from a rural, reservation-based community. We used multivariate logistic regression models to estimate associations between independent variables and lifetime sexual experience (vaginal and/or anal sex) across the following categories: sociodemographic, knowledge, attitudes/perceptions, beliefs, intentions, skills, behaviors, and theoretical constructs. The sample was 56.2% female, mean age 15.1 years (SD = 1.7), and 22.5% were sexually experienced. In our final model, condom use self-efficacy (attitude/perception factor) and intentions to remain abstinent until marriage (intention factor) were associated with lower odds of lifetime sexual experience. Age (sociodemographic factor), intention to have sex (intention factor), use of any contraception (behavior factor), and higher response efficacy (theoretical construct) were associated with lifetime sexual experience. Of these, intention to have sex was the strongest indicator. These results both corroborate and contrast with other research conducted among rural, reservation-based AI/AN youth. Our findings show programs targeting intentions may have the greatest impact among reservation-based AI youth, and justify program delivery stratified by age group in this setting.

Exploration of Pathways to Binge Drinking Among American Indian Adolescents.

Binge drinking is a serious public health problem among American Indian adolescents, yet few theoretical models specific to this population and type of problematic drinking have been tested. The White Mountain Apache Tribe has begun surveillance of binge drinking and a related line of research to inform tailored prevention efforts. The goal of this paper is to use structural equation modeling to understand the relationships between different individual, family, peer, and cultural factors that predict or protect against binge drinking behavior among Apache adolescents ages 10-19 years old. A cross-sectional case-control study was completed with N = 68 Apache adolescents who required medical attention due to a recent binge event (past 90 days) and N = 55 controls with no lifetime history of binge drinking. The hypothesized model was estimated with Mplus using the WLSMV robust least squares estimator. In the final model, stressful life events were related to family functioning and peer relationships. In turn, family functioning affected peer relationships and adolescent impulsivity, which were both associated with greater risk of binge drinking. The path between peer relationships and having engaged in binge drinking was statistically significant for those expressing lower cultural identity, but not for those reporting higher cultural identity. Findings suggest preventive interventions should emphasize teaching coping skills to manage life stressors and handle impulsivity, strengthening families, and changing peer dynamics with social network-based approaches as well as social skill training. The model highlights the potentially important role of culture in strengthening positive peer relationships to reduce binge drinking risk.

Decreases in Suicide Deaths and Attempts Linked to the White Mountain Apache Suicide Surveillance and Prevention System, 2001-2012.

OBJECTIVES: We evaluated the impact of a comprehensive, multitiered youth suicide prevention program among the White Mountain Apache of Arizona since its implementation in 2006. METHODS: Using data from the tribally mandated Celebrating Life surveillance system, we compared the rates, numbers, and characteristics of suicide deaths and attempts from 2007 to 2012 with those from 2001 to 2006. RESULTS: The overall Apache suicide death rates dropped from 40.0 to 24.7 per 100 000 (38.3% decrease), and the rate among those aged 15 to 24 years dropped from 128.5 to 99.0 per 100 000 (23.0% decrease). The annual number of attempts also dropped from 75 (in 2007) to 35 individuals (in 2012). National rates remained relatively stable during this time, at 10 to 13 per 100 000. CONCLUSIONS: Although national rates remained stable or increased slightly, the overall Apache suicide death rates dropped following the suicide prevention program. The community surveillance system served a critical role in providing a foundation for prevention programming and evaluation.