Implementation beyond the clinic: Community-driven utilization of research evidence from PC CARES, a suicide prevention program.

While implementation and dissemination of research is a rapidly growing area, critical questions remain about how, why, and under what conditions everyday people integrate and utilize research evidence. This mixed-methods study investigates how participants of Promoting Community Conversations About Research to End Suicide (PC CARES) make sense of and use research evidence about suicide prevention in their own lives. PC CARES is a health intervention addressing the need for culturally responsive suicide prevention practices in rural Alaska through a series of community Learning Circles. We analyzed PC CARES transcripts and surveys for 376 participants aged 15+ across 10 Northwest Alaska Native villages. Quantitative analysis showed significant correlations between five utilization of research evidence (URE) factors and participants' intent to use research evidence from PC CARES Learning Circles. Key qualitative themes from Learning Circle transcripts expanded upon these URE constructs and included navigating discordant information, centering relationships, and Indigenous worldviews as key to interpreting research evidence. We integrate and organize our findings to inform two domains from the Consolidated Framework for Research Implementation: (1) intervention characteristics and (2) characteristics of individuals, with emphasis on findings most relevant for community settings where self-determined, evidence-informed action is especially important for addressing health inequities.

Decoloniality as a Framework for Indigenous Youth Suicide Prevention Pedagogy: Promoting Community Conversations About Research to End Suicide.

Indigenous youth suicide remains a substantial health disparity in circumpolar communities, despite prevention efforts through primary health care, public health campaigns, school systems, and social services. Innovations in prevention practice move away from expert-driven approaches to emphasize local control through processes that utilize research evidence, but privilege self- determined action based on local and personal contexts, meanings, and frameworks for action. "Promoting Community Conversations About Research to End Suicide" is a community health intervention that draws on networks of Indigenous health educators in rural Alaska, who host learning circles in which research evidence is used to spark conversations and empower community members to consider individual and collective action to support vulnerable people and create health-promoting conditions that reduce suicide risk. The first of nine learning circles focuses on narratives of local people who link the contemporary youth suicide epidemic to 20th century American colonialism, and situates prevention within this context. We describe the theoretical framework and feasibility and acceptability outcomes for this learning circle, and elucidate how the educational model engages community members in decolonial approaches to suicide prevention education and practice, thus serving as a bridge between Western and Indigenous traditions to generate collective knowledge and catalyze community healing.

Siamit: A Novel Academic-Tribal Health Partnership in Northwest Alaska.

PROBLEM: American Indians and Alaska Natives hold a state-conferred right to health, yet significant health and health care disparities persist. Academic medical centers are resource-rich institutions committed to public service, yet few are engaged in responsive, equitable, and lasting tribal health partnerships to address these challenges. APPROACH: Maniilaq Association, a rural and remote tribal health organization in Northwest Alaska, partnered with Massachusetts General Hospital and Harvard Medical School to address health care needs through physician staffing, training, and quality improvement initiatives. This partnership, called Siamit, falls under tribal governance, focuses on supporting community health leaders, addresses challenges shaped by extreme geographic remoteness, and advances the mission of academic medicine in the context of tribal health priorities. OUTCOMES: Throughout the 2019-2020 academic year, Siamit augmented local physician staffing, mentored health professions trainees, provided continuing medical education courses, implemented quality improvement initiatives, and provided clinical care and operational support during the COVID-19 pandemic. Siamit began with a small budget and limited human resources, demonstrating that relatively small investments in academic-tribal health partnerships can support meaningful and positive outcomes. NEXT STEPS: During the 2020-2021 academic year, the authors plan to expand Siamit's efforts with a broader social medicine curriculum, additional attending staff, more frequent trainee rotations, an increasingly robust mentorship network for Indigenous health professions trainees, and further study of the impact of these efforts. Such partnerships may be replicable in other settings and represent a significant opportunity to advance community health priorities, strengthen tribal health systems, support the next generation of Indigenous health leaders, and carry out the academic medicine mission of teaching, research, and service.

Arctic Suicide, Social Medicine, and the Purview of Care in Global Mental Health.

Youth suicide is a significant health disparity in circumpolar indigenous communities, with devastating impacts at individual, family, and community levels. This study draws on structured interviews and ethnographic work with health professionals in the Alaskan Arctic to examine the meanings assigned to Alaska Native youth suicide, as well as the health systems that shape clinicians' practices of care. By defining suicide as psychogenic on the one hand, and as an index of social suffering on the other, its solutions are brought into focus and circumscribed in particular and patterned ways. We contrast psychiatric and social explanatory models, bureaucratic and relational forms of care, and biomedical and biosocial models for care delivery. Within the broader context of global mental health, this study suggests steps for linking caregiving to the health and social equity agenda of social medicine and for operationalizing commitments to health as a human right.

Covid-19 Requires a Social Medicine Response.

Covid-19 is an inherently social disease, with exposure, illness, care, and outcomes stratified along familiar social, economic, and racial lines. However, interventions from public health and clinical medicine have focused primarily on the scale-up of technical and biomedical solutions that fail to address the social contexts driving its distribution and burden. Fused with a moment of reckoning with racial injustice and economic inequality in the U.S. and across the world, these disparities charge policy leaders to develop, study, and share a response grounded in social medicine. As a yardstick for formulating, evaluating, and implementing health policy and care delivery, social medicine recommends at least three things: integrating health, social, and economic responses; bringing care to the points of greatest need; and focusing on broad equity-driven reforms in the pandemic's wake. With these tools, Covid-19 presents us with an opportunity to address the inequities that the disease highlights, exploits, and may otherwise entrench.

Social Medicine in Practice: Realizing the American Indian and Alaska Native Right to Health.

American Indians and Alaska Natives have long held a state-conferred right to health, yet Indigenous communities across the United States continue to experience significant health and health care disparities. In this paper we posit two contributing factors: socialization for scarcity in tribal health care, and a slowness among health workers and allied health and social scientists to make explicit and convincing linkages between social determinants of health and human rights. We then summarize one attempt to align tribal health care delivery in the Alaskan Arctic with a rights-based approach, highlighting both the role of social and structural determinants as causes of health disparities and the role of social and structural interventions in local efforts to chart a future of equal health for our home.

Beyond two worlds: Identity narratives and the aspirational futures of Alaska Native youth.

Indigenous communities across the Alaskan Arctic have experienced profound revisions of livelihood, culture, and autonomy over the past century of colonization, creating radical discontinuities between the lives of young people and those of their parents and Elders. The disrupted processes of identity development, access to livelihoods, and cross-generational mentorship associated with colonialism have created complex challenges for youth as they envision and enact viable paths forward in the context of a rapidly changing Arctic home. In this study, we consider the meanings associated with different constructions of culture and selfhood, and the ways in which these identity narratives position Inupiaq Alaskan Native youth in relation to their personal and collective futures. Through an intergenerational and participatory inquiry process, this study explores how representations of shared heritage, present-day struggles, resilience, and hope can expand possibilities for youth and thus impact individual and community health.

Promoting Community Conversations About Research to End Suicide: learning and behavioural outcomes of a training-of-trainers model to facilitate grassroots community health education to address Indigenous youth suicide prevention.

Alaska Native (AN) youth suicide remains a substantial and recalcitrant health disparity, especially in rural/remote communities. Promoting Community Conversations About Research to End Suicide (PC CARES) is a community health intervention that responds to the need for culturally responsive and evidence-supported prevention practice, using a grassroots approach to spark multilevel and community-based efforts for suicide prevention. This paper describes theoretical and practical considerations of the approach, and assesses the feasibility and preliminary learning and behavioural outcomes of the training-of-trainers model. It details the training of a first cohort of intervention facilitators in Northwest Alaska (NWA). Thirty-two people from 11 NWA village communities completed the PC CARES facilitator training, preparing them to implement the intervention in their home communities. Facilitator pre-post surveys focused on readiness to facilitate, a group quiz assessed participants' understanding of relevant research evidence, and practice facilitation exercises demonstrated competency. Curriculum fidelity and accuracy scores were calculated using audio recordings from learning circles conducted by facilitators in their home communities. Facilitator reflections describe the successes of the model and identify several areas for improvement. As of March 2017, 20 of the 32 trained facilitators in 10 of the 11 participating villages have hosted 54 LCs, with a total of 309 unique community members. Coding of these LCs by 2 independent raters indicate acceptable levels of fidelity and accurate dissemination of research evidence by facilitators. Facilitator reflections were positive overall, suggesting PC CARES is feasible, acceptable and potentially impactful as a way to translate research to practice in under-resourced, rural AN communities. PC CARES represents a practical community education and mobilisation approach to Indigenous youth suicide prevention that displays preliminary success in learning and behavioural outcomes of local facilitators.

Preliminary Evaluation of a School-Based Youth Leadership and Prevention Program in Rural Alaska Native Communities.

Youth Leaders Program (YLP) is a health intervention implemented in a rural Alaskan school district, which utilizes natural helpers and peer leaders to increase protective factors such as school engagement and personal/cultural identities, and to reduce risks associated with drug/alcohol abuse, violence, and bullying. Through these means, the program aims to ultimately decrease the disproportionately high rates of indigenous youth suicide in the region. This paper describes process and outcome evaluation findings from the program during the 2013-2014 school year. Data collected include a survey for program participants done at the beginning and end of the study year (n = 61, complete pairs); pre- and post-intervention school data (attendance, GPA, and disciplinary actions) (n = 86); an all-school survey asking students at the participating schools about their experience with YLP and participating youth (n = 764); interviews with program advisors (n = 11) and school principals (n = 2); and focus groups with participating students at all eleven participating schools at the end of the year. Outcomes included increased school attendance (mean attendance increased from 146 to 155 days) and improved academic performance (mean GPA of 8th, 9th, and 10th graders increased from 3.01 to 3.14) of program participants; positive peer reviews of participating student interventions in cases of bullying, depression, and suicidality; and a reported increase in the sense of agency, responsibility, and confidence among participating youth. The YLP appears to improve school climate and increase school and other protective factors for participating students. Recommendations for program implementation in the future and implications for school health will be discussed.