All systems are interrelated: Multilevel interventions with indigenous communities.

Colonial historical trauma and ongoing structural racism have impacted Indigenous peoples for generations and explain the ongoing health disparities. However, Indigenous peoples have been engaging in multilevel, clinical trial interventions with Indigenous and allied research scientists resulting in promising success. In this paper, National Institutes of Health funded scientists in the field of Indigenous health have sought to describe the utility and need for multilevel interventions across Indigenous communities (Jernigan et al., 2020). We posit limitations to the existing socioecological, multilevel frameworks and propose a dynamic, interrelated heuristic framework, which focuses on the inter-relationships of the collective within the environment and de-centers the individual. We conclude with identified calls for action within multilevel clinical trial research.

Predictors of STD Screening From the Indigenist Stress-Coping Model Among Native Adults With Binge Substance Use.

Objective: The American Indian/Alaska Native (AI/AN) population in the U.S. is thriving in spite of settler colonialist efforts of erasure. AI/AN people, however, continue to experience persistent health disparities including a disproportionate burden of substance use and sexually transmitted diseases/infections (STDs/STIs), as well as a disproportionate lack of public health STD screening services and STD prevention interventions grounded in AI/AN social contexts, experiences, and epistemologies. The present study explored how stressors and protective factors based on the Indigenist Stress Coping framework predict STD screening outcomes among Native adults. Methods: We analyzed baseline self-report data from 254 Native adults ages 18-55 years with recent binge substance use who were enrolled in an evaluation of "EMPWR," a two-session STD risk reduction program in a rural, reservation-based community in the U.S. Southwest. Logistic regression models with robust variance were used to estimate odds ratios of lifetime STD testing for the theoretical stressors and cultural buffers. Results: A little over half the sample were males (52.5%, n = 136), with a mean age of 33.6 years (SD = 8.8). The majority (76.7%, n = 195) reported having ever been screened for STD in their life. Discrimination score were significantly associated with lifetime STD testing: The higher discrimination was associated with lower odds of STD testing in the fully adjusted model (aOR = 0.40, 95%CI: 0.18, 0.92). The effects of AI/AN-specific cultural buffer such as participation in traditional practices on STD testing outcomes was in the expected positive direction, even though the association was not statistically significant. Household size was significantly associated with STD screening: The higher the number of people lived together in the house, the higher the odds of STD testing in the fully adjusted model (aOR = 1.19, 95%CI: 1.04, 1.38). Conclusion: Our findings suggest that STD prevention programs should take into consideration AI/AN-specific historical traumatic stressors such as lifetime discrimination encounters and how these interact to drive or discourage sexual health services at local clinics. In addition, larger household size may be a protective factor functioning as a form of social support, and the extended family's role should be taken into consideration. Future research should consider improvement in measurements of AI/AN enculturation constructs.

Exploring theoretical mechanisms of community-engaged research: a multilevel cross-sectional national study of structural and relational practices in community-academic partnerships.

BACKGROUND: Community-Based Participatory Research (CBPR) is often used to address health inequities due to structural racism. However, much of the existing literature emphasizes relationships and synergy rather than structural components of CBPR. This study introduces and tests new theoretical mechanisms of the CBPR Conceptual Model to address this limitation. METHODS: Three-stage online cross-sectional survey administered from 2016 to 2018 with 165 community-engaged research projects identified through federal databases or training grants. Participants (N = 453) were principal investigators and project team members (both academic and community partners) who provided project-level details and perceived contexts, processes, and outcomes. Data were analyzed through structural equation modeling and fuzzy-set qualitative comparison analysis. RESULTS: Commitment to Collective Empowerment was a key mediating variable between context and intervention activities. Synergy and Community Engagement in Research Actions were mediating variables between context/partnership process and outcomes. Collective Empowerment was most strongly aligned with Synergy, while higher levels of Structural Governance and lower levels of Relationships were most consistent with higher Community Engagement in Research Actions. CONCLUSIONS: The CBPR Conceptual Model identifies key theoretical mechanisms for explaining health equity and health outcomes in community-academic partnerships. The scholarly literature's preoccupation with synergy and relationships overlooks two promising practices-Structural Governance and Collective Empowerment-that interact from contexts through mechanisms to influence outcomes. These results also expand expectations beyond a "one size fits all" for reliably producing positive outcomes.

Scales of Practices and Outcomes for Community-Engaged Research.

Despite the growth of research on community-engaged research (CEnR), recent reviews suggest there has been limited development of validated scales to measure key contexts, mechanisms, and outcomes, impairing testing and refinement of theoretical models. The purpose of this study is to present the psychometric properties of scales from the Engage for Equity (E2) project, stemming from a long-term research partnership examining community-engaged research projects. This study used a three-stage, cross-sectional format: (a) a sampling frame of 413 CEnR projects was identified; (b) 210 principal investigators completed a project-level survey and nominated partners for another survey; (c) 457 investigators and partners completed a survey about project contexts, processes, interventions, and outcomes. Factorial validity was established through confirmatory factor analysis supporting seven scales: contextual capacity, commitment to collective empowerment, relationships, community engagement in research actions, synergy, partner and partnership transformation, and projected outcomes. Convergent validity was established through examining covariances among the scales. This study largely yielded results consistent with a previous psychometric study of related measures, while demonstrating improved ceiling effects of the items and refined conceptualization of core theoretical constructs.

Prevalence of Moderate and Acute Suicidal Ideation among a National Sample of Tribal College and University Students 2014-2015.

OBJECTIVES: To examine the relationship between suicide risk and hazardous drinking, depression, and anxiety, adjusting for demographics, among tribal college students across the United States. Methods. We invited tribal college students enrolled in 22 tribal colleges from fall 2014 and 2015 to participate in the Creating Campus Change study, a cross-sectional online/paper survey assessing alcohol use patterns and mental health outcomes. 3,239 students participated in the survey, yielding a response rate of 31.3%. We assessed alcohol use, depression, and general anxiety, along with demographic characteristics. We used the Mini-International Neuropsychiatric Interview to assess suicide risk. Results. 8.5% indicated moderate or high suicide risk. In the final adjusted model, moderate/high depression was significantly associated with moderate/high suicide risk (OR = 6.64; 3.91-11.28, p < 0.001), as was moderate/high general anxiety (OR = 2.80; 1.58-4.97, p < 0.001), and moderate/high hazardous drinking (OR = 2.09; 1.19-3.66, p < 0.001). Conclusions. Students attending tribal colleges who report moderate/high levels of depression, anxiety, or hazardous drinking have a greater risk of suicidality. Identifying factors buffering the risk of suicidality could support policy changes necessary to address this critical public health issue.

Risk and Protective Factors Associated with Moderate and Acute Suicidal Ideation among a National Sample of Tribal College and University Students 2015-2016.

OBJECTIVES: We examined the relationship between suicide risk and disability status, as well as risk and protective factors, adjusting for demographic characteristics, among students attending 22 Tribal Colleges and Universities (TCU; 20 rural and 2 urban) across the United States in fall 2015 and 2016. METHODS: Tribal college students (N = 3,239) participated in a cross-sectional online or paper survey assessing alcohol use patterns and mental health outcomes, yielding a response rate of 31.3%. RESULTS: Of the students surveyed, 8.8% indicated moderate or high suicide risk. Hearing impairment was significantly associated with moderate/high suicide risk (OR = 2.11; 1.24-3.61, P = .006), as was vision impairment (OR = 3.03; 1.92-4.77, P < .001), having a physical/mental/or emotional condition (OR = 2.12; 1.75-2.57, P < .001), experiencing critical appraisal (OR = 1.30; 1.24-1.36, P < .001), and experiencing critical isolation (OR = 1.83; 1.66-2.01, P < .001). Scoring high on resilience (OR = 0.93; 0.92-0.95, P < .001), reporting higher emotional social support (OR = 0.75; 0.70-0.79, P < .001), and reporting higher levels of instrumental social support (OR = 0.69, 0.62-0.76, P < .001) were significantly associated with lower suicide risk. CONCLUSIONS: Students attending tribal colleges who experience hearing impairment, sight impairment, or a physical/emotional/mental condition have a greater risk of suicidality. Students experiencing critical appraisal and critical isolation may benefit from behavioral health interventions to reframe these experiences and develop resiliency skills. Developing avenues of emotional and instrumental social support within TCU settings offers key protective factors to buffer the risk of suicidality. Examining additional ways to build resiliency may also offer protection from suicide risk in this population.

Drug and Alcohol Policies at Tribal Colleges: A Descriptive Study Assessing Variations in Alcohol and Drug Policy by Setting.

This paper explores drug and alcohol policies at Tribal Colleges and Universities (TCUs). A research team conducted a needs assessment of Alcohol and Other Drug (AOD) use and policies in 27 TCUs, surveying key informants on perceived AOD prevalence. Student body size did not affect levels of AOD training or treatment. Larger TCU size increased the likelihood of on-campus housing, which increased the prevalence of zerotolerance policies and greater access to AOD services. Reservation policies, local resources, and cultural practices did not appear to affect TCU AOD policies. Designed properly, these policies can support desirable academic outcomes for TCU students.

Engage for Equity: Development of Community-Based Participatory Research Tools.

We developed a set of four community-based participatory research (CBPR) partnership tools aimed at supporting community-academic research partnerships in strengthening their research processes, with the ultimate goal of improving research outcomes. The aim of this article is to describe the tools we developed to accomplish this goal: (1) the River of Life Exercise; (2) a Partnership Visioning Exercise; (3) a personalized Partnership Data Report of data from academic and community research partners; and (4) a Promising Practices Guide with aggregated survey data analyses on promising CBPR practices associated with CBPR and health outcomes from two national samples of CBPR projects that completed a series of two online surveys. Relying on Paulo Freire's philosophy of praxis, or the cycles of collective reflection and action, we developed a set of tools designed to support research teams in holding discussions aimed at strengthening research partnership capacity, aligning research partnership efforts to achieve grant aims, and recalling and operationalizing larger social justice goals. This article describes the theoretical framework and process for tool development and provides preliminary data from small teams representing 25 partnerships who attended face-to-face workshops and provided their perceptions of tool accessibility and intended future use.

Engage for Equity: A Long-Term Study of Community-Based Participatory Research and Community-Engaged Research Practices and Outcomes.

Community-based participatory research (CBPR) and community-engaged research have been established in the past 25 years as valued research approaches within health education, public health, and other health and social sciences for their effectiveness in reducing inequities. While early literature focused on partnering principles and processes, within the past decade, individual studies, as well as systematic reviews, have increasingly documented outcomes in community support and empowerment, sustained partnerships, healthier behaviors, policy changes, and health improvements. Despite enhanced focus on research and health outcomes, the science lags behind the practice. CBPR partnering pathways that result in outcomes remain little understood, with few studies documenting best practices. Since 2006, the University of New Mexico Center for Participatory Research with the University of Washington's Indigenous Wellness Research Institute and partners across the country has engaged in targeted investigations to fill this gap in the science. Our inquiry, spanning three stages of National Institutes of Health funding, has sought to identify which partnering practices, under which contexts and conditions, have capacity to contribute to health, research, and community outcomes. This article presents the research design of our current grant, Engage for Equity, including its history, social justice principles, theoretical bases, measures, intervention tools and resources, and preliminary findings about collective empowerment as our middle range theory of change. We end with lessons learned and recommendations for partnerships to engage in collective reflexive practice to strengthen internal power-sharing and capacity to reach health and social equity outcomes.

Building Capacity for Productive Indigenous Community-University Partnerships.

This paper describes capacity development as a key aspect of community-based research with indigenous communities. University research engagement with indigenous communities includes extensive, and often negative, historical antecedents. We discuss strategies for developing effective, egalitarian, and balanced indigenous community-university relationships to build research capacity of these communities, and to create sustainable partnerships to improve health and wellness, and to reduce health disparities. We draw on the experience of eight investigators conducting research with indigenous communities to assess effective strategies for building and enhancing partnerships, including (1) supporting indigenous investigator development; (2) developing university policies and practices sensitive and responsive to Indigenous community settings and resources, and training for research; (3) developing community and scientifically acceptable research designs and practices; (4) aligning indigenous community and university review boards to enhance community as well as individual protection (e.g., new human subjects training for Indigenous research, joint research oversight, adaptation of shorter consent forms, appropriate incentives, etc.); (5) determining appropriate forms of dissemination (i.e., Indian Health Services provider presentation, community reports, digital stories, etc.); (6) best practices for sharing credit; and (7) reducing systematic discrimination in promotion and tenure of indigenous investigators and allies working in indigenous communities.

Characteristics and Practices Within Research Partnerships for Health and Social Equity.

BACKGROUND: As federal research funding focuses more on academic/community collaborations to address health inequities, it is important to understand characteristics of these partnerships and how they work to achieve health equity outcomes. OBJECTIVES: This study built on previous National Institutes of Health-funded research to (a) describe partnership characteristics and processes of federally funded, community-based participatory research (CBPR) or community-engaged research projects; (b) explore characteristics of these projects by stage of funding; and (c) build on previous understanding of partnership promising practices. METHODS: Between fall 2016 and spring 2017, we completed a cross-sectional analysis and principal component analysis of online survey data from key informants of federally funded CBPR and community-engaged research projects. Respondents for 179 projects (53% response rate) described project characteristics (e.g., type of partner, stage of partnership, and population) and the use of promising practices (e.g., stewardship, advisory board roles, training topics) by stage of partnership. RESULTS: Projects involved community, healthcare, and government partners, with 49% of respondents reporting their project was in the early stage of funding. More projects focused on Black/African American populations, whereas principal investigators were mostly White. The more established a partnership (e.g., with multiple projects), the more likely it employed the promising practices of stewardship (i.e., community safeguards for approval), community advisory boards, and training on values and power. CONCLUSIONS: Community engagement is a developmental process with differences between early-stage and established CBPR partnerships. Engaging in active reflection and adopting promising partnering practices are important for CBPR partnerships working to improve health equity. The data provided in this study provide key indicators for reflection.

Toward Health Equity: A National Study of Promising Practices in Community-Based Participatory Research.

OBJECTIVES: In the first nationwide study of community- academic research partnerships, we identified contextual and partnership practices that were significantly correlated with successful partnership outcomes guided by a community-based participatory research (CBPR) conceptual model. METHODS: Data collection included three stages: 294 community-engaged research (CEnR) projects in 2009 identified from federally funded grant databases; 200 (68.0%) principal investigators (PI) completed a key informant survey that included measures of power/resource sharing and structural characteristics of projects; 312 (77.2% of invited) community partners and 138 PI (69.0% of invited) responded to a survey including research context, process, and outcome measures. RESULTS: Context and process correlates accounted for 21% to 67% of the variance in the specific outcomes. Seven categories of research partnership practices were positively associated with successful synergy, capacity, and health outcomes: power sharing, partnership capacity, bridging social capital, shared values, community involvement in research, mutuality, and ethical management. CONCLUSIONS: Through empirical testing of an innovative, multidisciplinary CBPR model, key context and process practices were identified that confirm the positive impact of partnership evaluation and self-reflection on research outcomes. Further, these findings provide academic and other key stakeholders with real-world practical recommendations to engage agencies, groups, and individuals who suffer most from inequities and may have unrecognized or indigenous knowledge, experience, and leadership to contribute to health and social research and to the creation of paths to wellness.

Culture-centeredness in community-based participatory research: contributions to health education intervention research.

Health education research emphasizes the importance of cultural understanding and fit to achieve meaningful psycho-social research outcomes, community responsiveness and external validity to enhance health equity. However, many interventions address cultural fit through cultural competence and sensitivity approaches that are often superficial. The purpose of this study was to better situate culture within health education by operationalizing and testing new measures of the deeply grounded culture-centered approach (CCA) within the context of community-based participatory research (CBPR). A nation-wide mixed method sample of 200 CBPR partnerships included a survey questionnaire and in-depth case studies. The questionnaire enabled the development of a CCA scale using concepts of community voice/agency, reflexivity and structural transformation. Higher-order confirmatory factor analysis demonstrated factorial validity of the scale. Correlations supported convergent validity with positive associations between the CCA and partnership processes and capacity and health outcomes. Qualitative data from two CBPR case studies provided complementary socio-cultural historic background and cultural knowledge, grounding health education interventions and research design in specific contexts and communities. The CCA scale and case study analysis demonstrate key tools that community-academic research partnerships can use to assess deeper levels of culture centeredness for health education research.

We Should Know Ourselves: Burmese and Bhutanese Refugee Women's Perspectives on Cervical Cancer Screening.

Refugee women are at increased risk for cervical cancer and have low rates of cervical cancer screening both in their countries of origin and in the U.S. Using the Behavioral Model for Vulnerable Populations as a conceptual framework, we conducted eight focus groups with Burmese and Bhutanese refugee women to gather information about factors influencing cervical cancer screening (31 Burmese and 27 Bhutanese participants). Less than one-third (28%) reported being screened for cervical cancer before coming to the U.S. and only 45% reported being screened after resettling in the U.S. Participants had limited knowledge about cervical cancer and the need for screening, and faced multiple barriers including competing priorities and cost. However, trusted providers and interpreters were seen as means of facilitating screening. Cervical cancer screening among Bhutanese and Burmese refugee women could be improved with culturally tailored health education and increased access to female providers and trained interpreters.

Results From a Pilot Video Intervention to Increase Cervical Cancer Screening in Refugee Women.

Many refugee women emigrate from countries with high cervical cancer incidence rates and have low rates of cervical cancer screening both before and after resettlement. Refugee women face many barriers to cervical cancer screening, including limited knowledge of cervical cancer and screening recommendations and cultural and linguistic barriers to being screened. Our pilot study aimed to develop and evaluate educational videos to promote cervical cancer screening among Karen-Burmese and Nepali-Bhutanese refugees, two of the largest groups of refugees arriving to the United States in recent years. We developed culturally tailored narrative videos for each ethnic group. Karen-Burmese and Nepali-Bhutanese women ( N = 40) were recruited through community health educators to participate in a pre- and posttest study. We assessed changes in cervical cancer knowledge and intentions to be screened, and satisfaction with the videos. We found that women were significantly more likely to report having heard of a test for cervical cancer and indicated significantly greater intentions to be screened after watching the video. Their knowledge about cervical cancer and screening also improved significantly, and they reported high levels of acceptability with the video. Our results suggest that culturally tailored narrative educational videos were acceptable to the target audiences and may be effective in increasing cervical cancer screening among refugee women. Further research should assess how health care and social service providers could implement video-based interventions to encourage women to be screened for cervical cancer during early resettlement.

Development of a Mixed Methods Investigation of Process and Outcomes of Community-Based Participatory Research.

This article describes a mixed methods study of community-based participatory research (CBPR) partnership practices and the links between these practices and changes in health status and disparities outcomes. Directed by a CBPR conceptual model and grounded in indigenous-transformative theory, our nation-wide, cross-site study showcases the value of a mixed methods approach for better understanding the complexity of CBPR partnerships across diverse community and research contexts. The article then provides examples of how an iterative, integrated approach to our mixed methods analysis yielded enriched understandings of two key constructs of the model: trust and governance. Implications and lessons learned while using mixed methods to study CBPR are provided.

Provider Perspectives on Promoting Cervical Cancer Screening Among Refugee Women.

Many refugees in the United States emigrated from countries where the incidence of cervical cancer is high. Refugee women are unlikely to have been screened for cervical cancer prior to resettlement in the U.S. National organizations recommend cervical cancer screening for refugee women soon after resettlement. We sought to identify health and social service providers' perspectives on promoting cervical cancer screening in order to inform the development of effective programs to increase screening among recently resettled refugees. This study consisted of 21 in-depth key informant interviews with staff from voluntary refugee resettlement agencies, community based organizations, and healthcare clinics serving refugees in King County, Washington. Interview transcripts were analyzed to identify themes. We identified the following themes: (1) refugee women are unfamiliar with preventive care and cancer screening; (2) providers have concerns about the timing of cervical cancer education and screening; (3) linguistic and cultural barriers impact screening uptake; (4) provider factors and clinic systems facilitate promotion of screening; and (5) strategies for educating refugee women about screening. Our findings suggest that refugee women are in need of health education on cervical cancer screening during early resettlement. Frequent messaging about screening could help ensure that women receive screening within the early resettlement period. Health education videos may be effective for providing simple, low literacy messages in women's native languages. Appointments with female clinicians and interpreters, as well as clinic systems that remind clinicians to offer screening at each appointment could increase screening among refugee women.

Establishing the psychometric properties of constructs in a community-based participatory research conceptual model.

PURPOSE: The purpose of this study is to establish the psychometric properties of 22 measures from a community-based participatory research (CBPR) conceptual model. DESIGN: The design of this study was an online, cross-sectional survey of academic and community partners involved in a CPBR project. SETTING: CPBR projects (294) in the United States with federal funding in 2009. SUBJECTS: Of the 404 academic and community partners invited, 312 (77.2%) participated. Of the 200 principal investigators/project directors invited, 138 (69.0%) participated. MEASURES: Twenty-two measures of CBPR context, group dynamics, methods, and health-related outcomes were examined. ANALYSIS: Confirmatory factor analysis to establish factorial validity and Pearson correlations to establish convergent and divergent validity were used. RESULTS: Confirmatory factor analysis demonstrated strong factorial validity for the 22 constructs. Pearson correlations (p < .001) supported the convergent and divergent validity of the measures. Internal consistency was strong, with 18 of 22 measures achieving at least a .78 Cronbach α. CONCLUSION: CBPR is a key approach for health promotion in underserved communities and/or communities of color, yet the basic psychometric properties of CBPR constructs have not been well established. This study provides evidence of the factorial, convergent, and discriminant validity and the internal consistency of 22 measures related to the CBPR conceptual model. Thus, these measures can be used with confidence by both CBPR practitioners and researchers to evaluate their own CBPR partnerships and to advance the science of CBPR.

Evaluating community-based participatory research to improve community-partnered science and community health.

BACKGROUND: Since 2007, the National Congress of American Indians (NCAI) Policy Research Center (PRC) has partnered with the Universities of New Mexico and Washington to study the science of community-based participatory research (CBPR). Our goal is to identify facilitators and barriers to effective community-academic partnerships in American Indian and other communities, which face health disparities. OBJECTIVES: We have described herein the scientific design of our National Institutes of Health (NIH)-funded study (2009-2013) and lessons learned by having a strong community partner leading the research efforts. METHODS: The research team is implementing a mixed-methods study involving a survey of principal investigators (PIs) and partners across the nation and in-depth case studies of CBPR projects. RESULTS: We present preliminary findings on methods and measures for community-engaged research and eight lessons learned thus far regarding partnership evaluation, advisory councils, historical trust, research capacity development of community partner, advocacy, honoring each other, messaging, and funding. CONCLUSIONS: Study methodologies and lessons learned can help community-academic research partnerships translate research in communities.

Examining the influences of gender, race, ethnicity, and social capital on the subjective health of adolescents.

We investigate the factors that influence adolescent self-assessed health, based upon surveys conducted between 2000 and 2004 of high-school seniors in Washington State (N=6853). A large proportion of the sample (30%) was first and second generation immigrants from Asia, Latin America, and Eastern Europe. Findings include a robust negative effect of female gender on self-reported health that is largely unmodified by demographic, developmental, social capital, and parental support variables, gender differences in the covariates of self-reported health, and the tendency of male adolescents of Cambodian and Vietnamese origin to report lower levels of self-reported health despite controls for other health-related individual characteristics. Social capital dimensions such as positive school affiliation, social network cohesion, and a safe learning environment were found to covary with the self-reported health of adolescent females.