Conceptualizing Indigenous strengths-based health and wellness research using group concept mapping.

BACKGROUND: In recent years public health research has shifted to more strengths or asset-based approaches to health research but there is little understanding of what this concept means to Indigenous researchers. Therefore our purpose was to define an Indigenous strengths-based approach to health and well-being research. METHODS: Using Group Concept Mapping, Indigenous health researchers (N = 27) participated in three-phases. Phase 1: Participants provided 218 unique responses to the focus prompt "Indigenous Strengths-Based Health and Wellness Research…" Redundancies and irrelevant statements were removed using content analysis, resulting in a final set of 94 statements. Phase 2: Participants sorted statements into groupings and named these groupings. Participants rated each statement based on importance using a 4-point scale. Hierarchical cluster analysis was used to create clusters based on how statements were grouped by participants. Phase 3: Two virtual meetings were held to share and invite researchers to collaboratively interpret results. RESULTS: A six-cluster map representing the meaning of Indigenous strengths-based health and wellness research was created. Results of mean rating analysis showed all six clusters were rated on average as moderately important. CONCLUSIONS: The definition of Indigenous strengths-based health research, created through collaboration with leading AI/AN health researchers, centers Indigenous knowledges and cultures while shifting the research narrative from one of illness to one of flourishing and relationality. This framework offers actionable steps to researchers, public health practitioners, funders, and institutions to promote relational, strengths-based research that has the potential to promote Indigenous health and wellness at individual, family, community, and population levels.

Prevalence of Mental Health Disorders and Treatment Utilization among Urban Lesbian, Gay, Bisexual, and Transgender American Indians and Alaska Natives.

We examined prevalence of mental health treatment utilization among 447 lesbian, gay, bisexual, transgender, and Two-Spirit (LGBTT-S) American Indian/Alaska Native (AI/AN) adults and the association of mental health treatment utilization with socio-demographic factors, social support, and mental health diagnoses. We derived data from the HONOR Project, a multi-site cross-sectional survey of Native LGBTT-S adults from seven U.S. metropolitan cities. Rates of lifetime mental health treatment utilization were higher for women (87%), those who were college educated (84%), and homeowners (92%). Cisgender women and transgender AI/AN adults had a higher prevalence than cisgender men of major depression, generalized anxiety, and panic disorder. Rates of subthreshold and threshold posttraumatic stress disorder were significantly higher for transgender adults. Lower positive social support and higher emotional social support were associated with greater odds of mental health treatment utilization. Mental health diagnoses and lifetime mental health treatment utilization was positively associated.

Substance-Specific Risk Factors among Young Adults: Potential Prevention Targets across Cannabis-Permissive Environments.

PURPOSE: This study examined levels of substance-specific risk factors such as perception of harm from substance use among young adults in a range of cannabis-permissive environments. The main objective was to inform future preventive interventions aimed at reducing cannabis use in the context of increasingly permissive environments. METHODS: Data came from the Community Youth Development Study (CYDS) collected in 2016 when participants were about 23 years old (n = 1,722 participants residing in 46 U.S. states). Young adults self-reported their perceptions about the harms related to cannabis, alcohol, and cigarette use; attitudes about and ease of access to cannabis and other substances; and perceived wrongfulness and social acceptability of cannabis, alcohol, and cigarette use and of selling of cannabis and other illegal drugs. RESULTS: Young adults in more permissive cannabis contexts reported higher levels of all cannabis-specific risk factors (e.g., greater access to and more favorable attitudes about cannabis use), except for perception of harm from regular cannabis use. However, permissiveness of the cannabis environment was not associated with heightened levels of risk factors for other substance use (such as alcohol, cigarettes, and opioids). CONCLUSIONS: Future preventive interventions for young adults living in more permissive cannabis contexts may need to focus on cannabis-specific risk factors in particular and go beyond considerations of harm from regular use. Future studies should replicate these findings with other samples.

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.

Indigenous Research Ethics Requirements: An Examination of Six Tribal Institutional Review Board Applications and Processes in the United States.

Tribal Institutional Review Boards (TIRBs) in the United States assert their rights within sovereign nations by developing ethical research processes that align with tribal values to protect indigenous knowledge systems and their community from cultural appropriation, exploitation, misuse, and harm. We reviewed six TIRB applications and processes to gain a better understanding about their requirements and research ethics. We located 48 activated and deactivated TIRBs in a database, mapped them in relation to tribal reservation lands, and then conducted in-depth content analysis. Our analysis demonstrates the importance of building relationships, becoming fully acquainted with the TIRB's operating environment before seeking research approval, and issues related to tribal data management practices.

Promising Practices for Promoting Health Equity Through Rigorous Intervention Science with Indigenous Communities.

Research in indigenous communities is at the forefront of innovation currently influencing several new perspectives in engaged intervention science. This is innovation born of necessity, involving efforts to create health equity complicated by a history of distrust of research. Immense diversity across indigenous cultures, accompanied by variation in associated explanatory models, health beliefs, and health behaviors, along with divergent structural inequities add further complexity to this challenge. The aim of this Supplemental Issue on Promoting Health Equity through Rigorous, Culturally Informed Intervention Science: Innovations with Indigenous Populations in the United States is to highlight the promising new approaches and perspectives implemented by a group of engaged researchers and their community partners, as they seek to move intervention research forward within indigenous communities. Case studies presented are from projects led by members of the National Institutes of Health Intervention Research to Improve Native American Health (IRINAH) consortioum, investigators who conduct health promotion and disease prevention research among American Indians, Alaska Natives, and Native Hawaiians. The promising practices profiled include new strategies in (a) community partnerships, engagement, and capacity building; (b) integration of indigenous and academic perspectives; (c) alignment of interventions with indigenous cultural values and practices; and (d) implementation and evaluation of multilevel interventions responsive to complex cultural contexts. The IRINAH projects illustrate the evolution of an intervention science responsive to the needs, realities, and promise of indigenous communities, with application to health research among other culturally distinct health inequity groups.

Perceived descriptive norms for alcohol use among tribal college students: Relation to self-reported alcohol use, consequences, and risk for alcohol use disorder.

This research addressed gaps in the literature by testing relationships between perceived descriptive alcohol use norms and individual's own alcohol use and consequences among tribal college and university (TCU) students. Survey data were collected from 3239 tribal college students in 22 TCUs across the United States in 2015 and 2016, of whom 3174 provided usable data on the variables of interest for the current manuscript. Results indicated students misperceived the descriptive norms for alcohol use at their TCU, on average estimating students at their college drank more frequently, more per occasion, and more total drinks per week relative to the observed averages on these outcomes. Participants' own drinking was significantly related to their perceived norms, with higher perceived norms related to more drinking. In addition, higher perceived norms were associated with greater alcohol-related negative consequences and lower likelihood of being a non-drinker. These findings extend research with students at majority-serving colleges and universities, indicating normative misperceptions exist and have similar relationships to alcohol use and consequences among TCU students nationwide. These findings support adaptation of normative feedback interventions for use with TCU students to emphasize healthy alcohol norms and correct misperceptions that support the stereotype that all students drink to excess.

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.

Beyond the Belmont Principles: A Community-Based Approach to Developing an Indigenous Ethics Model and Curriculum for Training Health Researchers Working with American Indian and Alaska Native Communities.

Individuals responsible for carrying out research within their diverse communities experience a critical need for research ethics training materials that align with community values. To improve the capacity to meet local human subject protections, we created the research Ethics Training for Health in Indigenous Communities (rETHICS), a training curriculum aligned within American Indian and Alaska Native (AI/AN) context, culture, and community-level ethical values and principles. Beginning with the Belmont Report and the Common Rule that defines research with human subjects (46 CFR 45), the authors convened three different expert panels (N = 37) to identify Indigenous research values and principles common across tribal communities. The resulting culturally grounded curriculum was then tested with 48 AI/AN individuals, 39 who also had recorded debriefing interviews. Using a thematic analysis, we coded the qualitative feedback from the expert panel discussions and the participant debriefings to assess content validity. Participants identified five foundational constructs needed to ensure cultural-grounding of the AI/AN-specific research training curriculum. These included ensuring that the module was: (a) framed within an AI/AN historical context; (b) reflected Indigenous moral values; (c) specifically linked AI/AN cultural considerations to ethical procedures; (d) contributed to a growing Indigenous ethics; and (e) provided Indigenous-based ethics tools for decision making. Using community-based consultation and feedback from participants led to a culturally grounded training curriculum that teaches research ethical principles and procedures for conducting research with AI/ANs. The curriculum is available for free and the community-based process used can be adapted for other cultural groups.

Influence of developmental social role transitions on young adult substance use.

Young adulthood (ages 18-25) is a developmental period characterized by numerous transitions in social roles. This period is also associated with increased risk of substance use and negative-consequences. Changes in developmental social role status can be related to changes in substance use. In this review, we discuss key developmental transitions and social roles associated with young adult substance use, including changes in educational status, employment, intimate partner relationships, friendships, and living status. We include important differences in substance use among groups defined by race, ethnicity, and sexual orientation. We conclude with implications for developmentally tailored prevention/intervention approaches targeting social role transitions associated with at-risk substance use.

CULTURAL ADAPTATIONS OF EVIDENCE-BASED HOME-VISITATION MODELS IN TRIBAL COMMUNITIES.

The Tribal Maternal, Infant, and Early Childhood Home Visiting (Tribal MIECHV) Program provides federal grants to tribes, tribal consortia, tribal organizations, and urban Indian organizations to implement evidence-based home-visiting services for American Indian and Alaska Native (AI/AN) families. To date, only one evidence-based home-visiting program has been developed for use in AI/AN communities. The purpose of this article is to describe the steps that four Tribal MIECHV Programs took to assess community needs, select a home-visiting model, and culturally adapt the model for use in AI/AN communities. In these four unique Tribal MIECHV Program settings, each program employed a rigorous needs-assessment process and developed cultural modifications in accordance with community strengths and needs. Adaptations occurred in consultation with model developers, with consideration of the conceptual rationale for the program, while grounding new content in indigenous cultures. Research is needed to improve measurement of home-visiting outcomes in tribal and urban AI/AN settings, develop culturally grounded home-visiting interventions, and assess the effectiveness of home visiting in AI/AN communities.

Exploring pathways to trust: a tribal perspective on data sharing.

The data-sharing policies of the National Institutes of Health aim to maximize public benefit derived from genetic studies by increasing research efficiency and use of a pooled data resource for future studies. Although broad access to data may lead to benefits for populations underrepresented in genetic studies, such as indigenous groups, tribes have ownership interest in their data. The Northwest-Alaska Pharmacogenetic Research Network, a partnership involving tribal organizations and universities conducting basic and translational pharmacogenetic research, convened a meeting to discuss the collection, management, and secondary use of research data, and of the processes surrounding access to data stored in federal repositories. This article reports the tribal perspectives that emerged from the dialogue and discusses the implications of tribal government sovereign status on research agreements and data-sharing negotiations. There is strong tribal support for efficient research processes that expedite the benefits from collaborative research, but there is also a need for data-sharing procedures that take into account tribal sovereignty and appropriate oversight of research--such as tribally based research review processes and review of draft manuscripts. We also note specific ways in which accountability could be encouraged by the National Institutes of Health as part of the research process.

Capacity building from the inside out: development and evaluation of a CITI ethics certification training module for American Indian and Alaska Native community researchers.

Current human subject research training modules fail to capture ethically relevant cultural aspects of research involving American Indian and Alaska Native (AI/AN) community members. Applying a Community Engaged Research (CEnR) approach, we adapted the Collaborative IRB Training Initiative training module "assessing risk and benefits." In a two-arm randomized controlled trial, followed by debriefing interviews, we evaluated module acceptability and understandability (test scores) among 40 reservation-based community members. Participants who took the adapted module, compared to those who took the standard module, reported higher scores on relevance of the material overall satisfaction, module quiz scores, and a trend toward higher self-efficacy. Implications of the efficacy of this approach for enhancing ethics training and community participation in research within AI/AN and other cultural populations within and outside the United States are discussed.