Qualitative Evaluation of RADx-UP Projects Addressing COVID-19 Testing Disparities Among Underserved Populations.

In this article, we present findings from a May 2022 to March 2023 qualitative evaluation of Rapid Acceleration of Diagnostics-Underserved Populations (RADx-UP) projects addressing COVID-19 testing disparities among underserved populations. Interviews with academic and community partners from 13 RADx-UP projects revealed that despite the pandemic, projects were able to build trust and relationships with underserved populations. By prioritizing community voices during a public health emergency, RADx-UP projects improved health equity and pandemic preparedness in these communities, successfully conducted community-engaged research, and built long-lasting community partnerships. (Am J Public Health. 2024;114(S5):S410-S415. https://doi.org/10.2105/AJPH.2024.307632).

A Model of Stakeholder Engagement with American Indians and Alaska Natives from the Native-CHART Study.

American Indian (AI) and Alaska Native (AN) community stakeholder engagement has the power to transform health research. However, the engagement and dissemination process is challenging in AIAN communities due to the historical and current negative experiences of AIAN populations in health research (Dillard et al., 2018). Whereas there is a paucity of recommendations about how to engage stakeholders in health research, from agenda-setting to proposal development, study design, recruitment, data collection, analysis, results, and dissemination (Concannon et al., 2014), there is limited information about how these recommendations are operationalized within the context of AIAN health research and practice (Concannon et al., 2014; Forsythe et al., 2016). For the purposes of this article, stakeholders are individuals, organizations, or communities who have a direct interest in the process and outcomes of a project, research, or policy effort (Boaz et al., 2018). Stakeholder engagement is a systematic process involving stakeholders, which provides opportunities for consultation, input, reviews, reactions, support, and assistance with dissemination. Dissemination focuses on how, when, by whom, and under what circumstances evidence spreads throughout agencies, organizations, states, counties, communities, tribes, researchers, policy makers, and service organizations.

Documenting tribal community readiness to support substance abuse prevention.

Documenting community readiness to support substance abuse prevention in tribal communities is needed to maximize the impact of prevention programming. Semi-structured interviews with 26 tribal community members from Montana and Wyoming served as the primary data source for this evaluation. The Community Readiness Assessment was used to guide the interview process, analysis, and results. This evaluation found that community readiness was vague, meaning most community members recognize it as a problem, but there is little motivation to do anything about it. There was a significant increase in overall community readiness between 2017 (pre) and 2019 (post). Findings underscore the need for continued prevention efforts targeted at a community's readiness to address the problem and move them to the next change stage.

Rethinking Recovery: A Qualitative Study of American Indian Perspectives on Peer Recovery Support.

Objectives: This qualitative evaluation was guided by two questions: 1) How does peer recovery support (PRS) support American Indian (AI) people in recovery from substance use disorders? and 2) What makes PRS effective?Methods: We utilized a descriptive qualitative study design to explore the essence of PRS. Semi-structured interviews were conducted with six AI peers to explore the perceptions and lived experiences of recovery from one urban Montana location. Data analysis involved coding all the transcripts using the priori codes developed, then identifying key themes from the coded data.Results: Themes and interview data helped us explore how PRS supports recovery and potential reasons why it is effective for AI populations. Peers indicated that the program helped them maintain their recovery, and the role of peer mentors was critical to their success. Themes of belonging, connection, and compassion were common among peers interviewed. They also felt that recovery is a spiritual process. The peers had limited recommendations for improving the program, except the need for funding sustainability.Conclusions: Understanding how people recover is the first step in addressing the current substance misuse epidemic facing our nation. This evaluation outlined the qualitative impacts of PRS, the spiritual nature of PRS, the context of PRS, and recommendations from peers involved in the program. More work is needed to explore how to sustain PRS programs and integrate PRS into existing community-based settings, like churches, social services, urban AI centers, and other locations.

Are American Indian/Alaska Native Adolescent Health Behaviors Different? A Review of AI/AN Youth Involved in Native STAND Curriculum, 2014-2017 United States.

OBJECTIVES: To explore health behavior profiles of AI/AN youth involved in native students together against negative decisions (STAND), a national culture-based curriculum. METHODS: We analyzed data from 1236 surveys conducted among AI/AN youth at 40 native STAND implementation sites located in 16 states throughout the US from 2014 to 2017. Health profiles included demographics, sexual orientation, sexual activity, STI testing, cigarette use, and suicide attempts in the past 12-months. We used t-tests and chi square tests of independence to compare risk behavior prevalence among the sample. RESULTS: Health behavior profiles of AI/AN youth indicate that 45.6% of youth did not use condoms the last time they had sex, and 82.7% have never been tested for STIs. Differences in cigarette smoking were observed in questioning youth (questioning: 80.3%, straight/heterosexual: 63.8%, LGBTQ2S + : 49.9%, p = 0.03). CONCLUSIONS FOR PRACTICE: Health behaviors related to sex, substance, violence and self-harm, are at least as common for AI/AN youth as those observed in other US teens. Future research should consider similarities and differences in health profiles of AI/AN youth when designing interventions that affect them. Further, our findings underscore the need for culturally-relevant curricula like native STAND, not because their health behavior is different, but because their socio-ecologic environment is different.

Avoiding fights on social media: Strategies youth leverage to navigate conflict in a digital era.

AIMS: Emerging qualitative work documents that social media conflict sometimes results in violence in impoverished urban neighborhoods. Not all experiences of social media conflict lead to violence, however, and youth ostensibly use a variety of techniques to avoid violent outcomes. Little research has explored the daily violence prevention strategies youth use on social media, an important gap given the omnipresence of social media in youth culture. This paper examines youth strategies and factors that avoid violence resulting from social media conflict. METHOD: Four focus groups with 41 teenagers of color solicited strategies to prevent violence resulting from social media conflict. Three coders analyzed data in Dedoose, guided by systematic textual coding using a multi-step thematic analysis. RESULTS: Four approaches emerged to avoiding violence from social media conflict: avoid, de-escalate, reach out for help, and bystander intervention. CONCLUSION: Our findings position youth as key players in efforts to prevent violence from resulting from social media conflict.

Preventing Substance Use in American Indian Youth: The Case for Social Support and Community Connections.

AIMS: This study explored the relationship between social support, community connections, self-esteem, and culture on misuse in American Indian youth. METHODS: The study team developed a culturally-responsive 16-question survey for American Indian youth ages 12-20 living in six American Indian communities in the Great Plains Region of the United States. The study was grounded in primary socialization theory and variables were explored using regression models. RESULTS: A total of 565 American Indian youth completed the participant survey between January 2016 and August 2017. The present study found that community connections were negatively associated with marijuana use in American Indian youth. Higher community connection scores were associated with higher social support and self-esteem scores. CONCLUSIONS: Tribally-led prevention initiatives can fill an important socio-behavioral prevention gap by facilitating social support opportunities for American Indian youth who may not have adequate support from immediate family or friends.

Survey Development: Community Involvement in the Design and Implementation Process.

Documenting Tribal health priorities is needed to inform research agendas, policy efforts, advocacy, and funding. However, published literature rarely documents the methods used to develop surveys in Indigenous communities. This methods paper includes two objectives: (1) increase knowledge and understanding about the importance of community involvement in public health activities; and (2) provide an example of how the Rocky Mountain Tribal Leaders Council Epidemiology Center (RMTEC) worked with one Tribal community to develop a health priorities survey. This paper describes how the RMTEC worked with a Tribal community and Tribal College students to develop, pilot, and revise a health priorities survey. Recommendations focus on the need for more culturally-responsive survey methods, the importance of building Tribal capacity for health research, and the value of piloting surveys in communities prior to implementation.

A qualitative investigation of policy for youth with problematic sexual behavior.

AIMS: Community management of youth with problematic sexual behavior (PSB) is complex. Public policies and service practices have historically utilized adult-focused approaches with limited research outcomes. This descriptive case study aimed to address this gap by documenting current PSB policies and policy reforms for community-based management systems. METHOD: Semi-structured interviews with 219 professionals from eight urban and rural communities throughout the United States served as the primary data source for the study. The three-stage Framework Method was used to guide the data analysis process. RESULTS: This study covered three areas: context of policy development, attitudes, and perceptions of policy for youth with PSB, and existing policy and policy reform initiatives. CONCLUSION: Findings support benefits of collaborative multidisciplinary teams that cross agency policies and procedures on management of cases involving youth with PSB. Implications for practitioners, policymakers, and community members are discussed.

A review of tribal best practices in substance abuse prevention.

American Indian youth experience higher rates of substance use than non-American Indian youth. Researchers, clinicians, and treatment programs embrace evidence-based practices (EBPs) and practice based evidence (PBE) as a primary method for addressing substance abuse and advancing behavioral health. However, less is known about the use of tribal best practices (TBPs) and how they are implemented in American Indian substance use prevention contexts. OBJECTIVE: The main objective of this systematic review was to determine how TBPs are implemented and shared in the context of tribal substance use prevention. The second objective was to document TBP examples from three tribal communities involved in a 5-year substance use prevention initiative. METHODS: A systematic review of published and grey literature was conducted using funding agencies websites, EBSCO Host and national registries. Three tribal communities involved in the initiative documented current TBPs to highlight characteristics of TBPs, costs, and approval processes. RESULTS: TBPs are very limited in the literature. Despite tribal use for thousands of years, TBPs are underrepresented and misunderstood. This review found that the terminology used to describe TBPs is not consistent across agencies, publications, websites, or reports. There is also variation in how TBPs originate in substance use prevention contexts and there is not a primary resource or protocol for sharing TBPs. Continued efforts are needed to support the use and dissemination of TBPs in substance use prevention.

American Indian and Alaska Native Life Expectancy: Writing a New Narrative.

This Viewpoint examines disparities and inequalities regarding life expectancy in American Indian and Alaska Native populations and what can be done to address them.

Reproductive behaviors among school-based health center clients in New Mexico.

Introduction: School-based health centers (SBHCs) are an evidence-based model for providing contraceptives to adolescents. SBHCs ability to provide reproductive health services is often limited by school district policies, state laws, and health center policies. Methods: We used data from the Teens Exploring and Managing Prevention (TEMPO) study to document demographic characteristics and birth control methods among patients at four SBHCs in New Mexico. A total of 264 teens were included in the baseline data collection at SBHCs in New Mexico. A baseline survey was administered via iPad, that specifically focused on questions related to sexual experiences and sexual health topics. Baseline questions included demographic questions, gender identity, sexual orientation, reasons for visits, reproductive practices, and birth control methods. Descriptive statistics were calculated, including means and standard deviations for continuous variables and categorical frequencies. Results: Our findings present reproductive health behaviors among New Mexican patients attending schools with SBHCs. More than 74% of respondents were Hispanic or Latino. The most common reason teens went to the SBHC was for birth control, and just 62% of teens reported using birth control methods in the past. Discussion: These behaviors are essential for policymakers to consider as they address policy gaps, the complex landscape of parental permission, reproductive rights, and health as a human right.

Participatory training evaluation: Steps from the Center for Native American Health Native-CHART symposium.

This paper presents a case example of the Native-CHART Training Evaluation and describes the process of planning and administering a paper evaluation during the Native-CHART symposium in November 2019 led by the Center for Native American Health (CNAH) and an external evaluator. Training evaluation methodologies and the data collection instrument were grounded in the Health Belief Model (HBM) where health-related chronic disease and risk factor knowledge translates to perceived susceptibility, benefits, barriers, and self-efficacy. Kirkpatrick's Four-level Training Evaluation Model explored learning, reaction, behaviors, and results. The evaluation aims centered around the following questions: 1)Who attended the symposium, and why did they attend? 2)What knowledge did participants gain at the symposium? 3)Will attendees change their behaviors as a result of attending the symposium? 4) What parts of the symposium were most valuable? And 5) How can the symposium be improved? Data collected at the symposium answered these questions. After the Native-CHART symposium, CNAH staff and the external evaluator met to reflect on the steps necessary to plan and implement a participatory training evaluation. From these discussions, eight steps emerged. This paper presents these steps along with recommendations for future work. Participatory and collaborative approaches in training evaluation and the steps included in this case example may be useful to evaluators, communities, and programs working on designing and evaluating various trainings with Tribal populations.

Tribally-led mobile outreach: improving access to harm reduction services in one rural reservation community.

American Indian and Alaska Native populations in the United States face significant disparities related to opioid use disorder and opioid-related mortality. Inequitable access to medications and harm reduction strategies due to structural, societal, and geographical factors prevent Tribal communities from obtaining needed services, and further contribute to the opioid epidemic. One Tribal Healing Center in the Rocky Mountain region identified mobile outreach to build upon existing opioid prevention, treatment, and harm reduction efforts. The Healing Center purchased a mobile outreach vehicle and worked with a combination of clinical staff, peer recovery support specialists, and Tribal elders to reach identified high-risk areas on the reservation. As of December 2023, the mobile outreach vehicle has disseminated 150 Narcan kits, 150 Fentanyl testing strips, 20 self-care kits, and 500 brochures detailing Healing Center services. Preliminary results from this formative evaluation demonstrate the success of MOV efforts and the process required to purchase and launch an MOV campaign.

Research ethics and indigenous communities.

Institutional review boards (IRBs) function to regulate research for the protection of human participants. We share lessons learned from the development of an intertribal IRB in the Rocky Mountain/Great Plains Tribal region of the United States. We describe the process through which a consortium of Tribes collaboratively developed an intertribal board to promote community-level protection and participation in the research process. In addition, we examine the challenges of research regulation from a Tribal perspective and explore the future of Tribally regulated research that honors indigenous knowledge and promotes community accountability and transparency. We offer recommendations for researchers, funding agencies, and Tribal communities to consider in the review and regulation of research.

Critical reflections from a community-based participatory research course.

INTRODUCTION: Training for new and existing researchers in community-based participatory research (CBPR) approaches requires flexibility and a departure from traditional research methods courses. The literature has not fully reported how universities teach CBPR or the impact of CBPR courses on students and researchers. METHOD: In this paper, I use a reflective, inquiry-based methodology to find meaning from my experience in a doctoral level CBPR course offered by a southeastern university. RESULTS: Five recommendations, complementary to guiding CBPR principles emerge. These include: Know the inherent challenges, find meaning and purpose, seek to understand complexities, recognize the implications, and use CBPR as a means to redress power. DISCUSSION: The reflection process and recommendations may be useful for institutions, funding agencies, policy makers, and community-engaged researchers.

Complementary Alternative Medicine: A Culturally Centered Approach to Managing Chronic Pain from One American Indian Community.

This evaluation explored the benefits of Complementary Alternative Medicine (CAM) within a reservation-based, State-certified outpatient treatment provider. The three CAM strategies provided were massage, acupuncture, and chiropractic therapies. The evaluation team worked with a peer recovery support specialist and tribal evaluation intern to co-create a one-page, eight-question, fixed-response instrument based on previous work in the community. Surveys were collected by the peer support specialist post-session with individuals receiving CAM therapies. Surveys assessed self-reported impacts, reasons for attending CAM sessions, and mental, physical, spiritual, and emotional health before and after CAM sessions. Paired t-tests were used to examine significant differences in mean scores before and after CAM sessions. A total of 40 participants completed the survey between March 2021 and March 2022. The evaluation found a significant increase in the mean scores for all measured self-reported health ratings: physical, spiritual, emotional, and mental. The greatest increase observed was for physical health (M = 5.32, SD = 2.53) and physical health after (M = 8.38, SD = 1.60) based on self-report data; t(78) = 6.46, p = .0001. CAM sessions positively influenced participants; 83% (n = 33) reported being more hopeful about their overall health and wellness. The holistic approach demonstrated promising results and potential benefits of CAM on overall wellness and belonging. Further research is needed to explore how CAM may be implemented as a culturally centered approach to managing chronic pain often associated with opioid use disorder.

Rising Above: COVID-19 Impacts to Culture-Based Programming in Four American Indian Communities.

The COVID-19 pandemic has disproportionately impacted American Indian and Alaska Native (AI/AN) communities. Tribes, tribal organizations, AI/AN youth and community-serving programs, and tribal health organizations have responded and adapted programs and services in response to the COVID-19 pandemic. This paper explores how COVID-19 impacted Native PRIDE, an American Indian non-profit organization, and the tribal communities involved in the Intergenerational Connections Project (ICP). Native PRIDE utilized a mixed-method Indigenous Evaluation Framework (IEF) to reflect on COVID-19 impacts. Qualitative data collected during the COVID-19 pandemic and quantitative data from an online survey helped Native PRIDE explore impacts and recommendations for future programming. With a focus on context and relationship, this paper explores what was felt, observed, and known by program participants and Native PRIDE staff in the delivery of ICP during the COVID-19 pandemic. Results from this evaluation are a reminder of the importance of strengthening cultural resilience by providing access and opportunities for AI/AN youth, elders, and adults.

Tribal Perspectives on Hypertension: Results From the Center for Native American Health Native-CHART Needs Assessment.

PURPOSE AND OBJECTIVES: American Indian/Alaska Native (AI/AN) hypertension contributes to cardiovascular disease, the leading cause of premature death in this population. The purpose of this article is to document strategies, concerns, and barriers related to hypertension and cardiovascular disease from Native-Controlling Hypertension and Risks through Technology (Native-CHART) symposiums facilitated by the Center for Native American Health (CNAH). The objectives of this evaluation were to combine Health Needs Assessment (HNA) data and explore barriers and strategies related to hypertension while assessing changes in participants' perspectives over time (2017-2021). APPROACH: CNAH followed an iterative process each year for planning the HNA, facilitating the HNA, and refining and reflecting on HNA findings over time. This involved 3 interconnected steps: (1) developing a shared understanding for the HNA, "Why are we here?," (2) facilitating the HNA during annual symposiums "What do we do?," and (3) reflecting on "What did we learn?". EVALUATION METHODS: Data were collected using a culturally centered HNA co-created by the CNAH team and tribal partners. Qualitative data analysis utilized a culturally centered thematic approach and NVivo software version 12.0. Quantitative data analysis included summarizing frequency counts and descriptive statistics using Microsoft Excel. RESULTS: Over the 5-year period, 212 Native-CHART symposium participants completed HNAs. Data collected from HNAs show persistent barriers and concerns and illuminate potential strategies to address AI/AN hypertension. Future efforts must explore effective strategies that build on community strengths, culture and traditions, and existing resources. This is the path forward. IMPLICATIONS FOR PUBLIC HEALTH: CNAH's culturally centered and unique HNA approach helped assess participant perspectives over time. CNAH facilitated symposiums over multiple years, even amid a global pandemic. This demonstrates resilience and continuity of community outreach when it is needed the most. Other universities and tribal partners could benefit from this iterative approach as they work to design HNAs with tribal populations.