Using concept mapping to identify opportunities for HPV vaccination efforts: Perspectives from the Midwest and West Coast.

Human papillomavirus (HPV) infection significantly contributes to the burden of cancer in the United States, despite the existence of a highly effective vaccine. While numerous interventions to address vaccination uptake exist, vaccination rates remain low. We conducted a concept mapping exercise to solicit perspectives on barriers and facilitators to HPV vaccination from state-level stakeholders in five states in the Midwest and West Coast of the U.S. We identified 10 clusters of barriers and facilitators based on participants' statements. For rural areas specifically, clusters rated as most important included education and provider influence; those rated as most feasible were education and coordinated/consistent messaging. Our results suggest that a combination of important (but potentially more difficult to implement) strategies, combined with those rated as most feasible (but potentially less impactful) may be beneficial. Our findings highlight similarities across diverse states, suggesting that states can learn from each other and work together to improve HPV vaccination rates. Using concept mapping proved to be an efficient way to collect information from diverse, stakeholders in different locations, and is a methodology that could be used for program planning in areas beyond HPV vaccination.

Medical Students' Perceptions of American Indian-Focused Educational Experiences.

INTRODUCTION: American Indians are burdened with a myriad of health disparities. As South Dakota's largest minority population, increasing medical students' experiences with the healthcare of American Indians can play a significant role in helping to alleviate American Indians' health disparities as these future physicians will be better able to predict, detect, and treat the health care needs of this population. METHODS: Survey data from 103 medical students at the University of South Dakota Sanford School of Medicine (SSOM) was collected and analyzed. Demographic information and perceived levels of being informed about American Indians and populations on reservations were collected. Furthermore, medical students' insights on how the SSOM can improve its students' educational experiences with American Indian populations were also collected. RESULTS: Compared to their perceived knowledge of American Indians prior to beginning medical school (26.2 percent), responding medical students believe they became more informed regarding American Indians (61.2 percent) as they progressed through medical school. Fifty-one of the 64 students (80 percent) who answered the open-ended question noted that their medical training would benefit from increased opportunities (including required) with American Indian people, culture, and reservation-based communities. CONCLUSION: There is a desire amongst medical students to increase and require more cultural information and clinical experiences with American Indian people and populations on reservations. Future research is needed to obtain medical student feedback on the newly implemented curriculum and elective opportunities.

Influences on HPV vaccination across levels of the social ecological model: perspectives from state level stakeholders.

Nationally, human papillomavirus (HPV) vaccination rates fall short of the Healthy People 2020 goal of 80% completion. Although strategies to increase these rates exist, low rates persist. We used concept mapping with state-level stakeholders to better understand barriers and facilitators to HPV vaccination. Concept mapping is a participatory research process in which respondents brainstorm ideas to a prompt and then sort ideas into piles. We present results of the brainstorming phase. We recruited participants identified by researchers' professional connections (n = 134) via e-mail invitations from five states (Iowa, South Dakota, Minnesota, Oregon, and Washington) working in adolescent health, sexual health, cancer prevention and control, or immunization. Using Concept Systems' online software we solicited participants' beliefs about what factors have the greatest influence on HPV vaccination rates in their states. From the original sample 58.2% (n = 78) of participants completed the brainstorming activity and generated 372 statements, our team removed duplicates and edited statements for clarity, which resulted in 172 statements. We coded statements using the Social Ecological Model (SEM) to understand at what level factors affecting HPV vaccination are occurring. There were 53 statements at the individual level, 22 at the interpersonal level, 21 in community, 51 in organizational, and 25 in policy. Our results suggest that a tiered approach, utilizing multi-level interventions instead of focusing on only one level may have the most benefit. Moreover, the policy-level influences identified by participants may be difficult to modify, thus efforts should focus on implementing evidence-based interventions to have the most meaningful impact.

The Collaborative Research Center for American Indian Health's Partnership River of Life: Special Issue Introduction.

In 2012, the National Institutes of Health funded the Collaborative Research Center for American Indian Health (CRCAIH) to work toward two broad goals: 1) to build tribal research infrastructure, and 2) to increase research on social determinants of health in American Indian communities. As the introduction to this special issue of American Indian and Alaska Native Mental Health Research, we highlight results from the Partnership River of Life evaluation tool in order to provide broader context for the other manuscripts presented here. Insights were gained during the Partnership River of Life group discussion and evaluation process of combining the groups' rivers to create one representation of the CRCAIH partnership. Detailed results underscore insights for similar transdisciplinary groups.

A Transdisciplinary Approach is Essential to Community-based Research with American Indian Populations.

Social determinants of health and their effects on health outcomes create a complex system, with interaction between social, economic, physical, and biological factors necessitating research take a holistic approach. Transdisciplinary research, one of the three core values of the Collaborative Research Center for American Indian Health, seeks to go beyond methods of knowledge production occurring solely within disciplinary boundaries, because real-world societal problems do not adhere to such restrictions. Community involvement is an essential component for successful research partnerships with American Indian and Alaska Native (AI/AN) communities. We posit that transdisciplinary approaches, which considers community-level expertise as an equitable component on the research team, show great potential for advancing research in AI/AN communities.

Not a One-Size-Fits-All Approach: Building Tribal Infrastructure for Research Through CRCAIH.

The Collaborative Research Center for American Indian Health (CRCAIH) was created to foster tribal partnerships in the Minnesota, North Dakota, and South Dakota regions to increase capacity for tribal research. Since 2013, through community engagement and technical assistance from CRCAIH's cores and divisions, seven tribal partners have expanded research infrastructure and recognize the benefits of an established tribal research office. This manuscript showcases the unique approaches individual CRCAIH tribal partners have taken to build tribal research infrastructure. The unique experiences of the CRCAIH tribal partnership holds valuable lessons for other tribes interested in increasing research capacity through research review, regulation, and data management.

Using Social Network Analysis to Visualize Networks in American Indian Health Research.

The Collaborative Research Center for American Indian Health (CRCAIH) is a transdisciplinary, collaborative center focused on building American Indian tribal research infrastructure. Funded by the National Institute of Minority Health and Health Disparities in 2012, it was created as a platform to join tribal communities and researchers in South Dakota, North Dakota, and Minnesota to develop research infrastructure and stimulate research in American Indian health. The CRCAIH infrastructure has created a large network of transdisciplinary research partnerships. To understand the initial development of the CRCAIH network and understand the broader impact it has had on American Indian and Alaska Native health research, CRCAIH undertook a network analysis based on publications by collaborators working with and within CRCAIH. The network analysis showed how far the CRCAIH network went in a short period of time to create a platform for networking to build collaborations and further stimulate research with American Indian communities.

Cultivating Native American scientists: an application of an Indigenous model to an undergraduate research experience.

With growing evidence demonstrating the impact of undergraduate research experiences on educational persistence, efforts are currently being made to expand these opportunities within universities and research institutions throughout the United States. Recruiting underrepresented students into these programs has become an increasingly popular method of promoting diversity in science. Given the low matriculation into postsecondary education and completion rates among Native Americans, there is a great need for Native American undergraduate research internships. Although research has shown that Western education models tend to be less effective with Native populations, the implementation of indigenous epistemologies and pedagogies within higher education, including research experiences, is rare. This study explores the applicability of a cognitive apprenticeship merged with an indigenous approach, the Circle of Courage, to build a scientific learning environment and enhance the academic and professional development of Native students engaged in an undergraduate research experience in the health sciences. Data were drawn from focus groups with 20 students who participated in this program in 2012-2014. Questions explored the extent to which relational bonds between students and mentors were cultivated as well as the impact of this experience on the development of research skills, intellectual growth, academic and professional self-determination, and the attachment of meaning to their research experiences. Data were analyzed via deductive content analysis, allowing for an assessment of how the theoretical constructs inherent to this model (belonging, mastery, independence, and generosity) impacted students. Findings suggest that engaging Native students in research experiences that prioritize the needs of belonging, mastery, independence, and generosity can be a successful means of fostering a positive learning environment, in which students felt like significant members of a research team, developed a greater understanding and appreciation for the role of science in education and its various applications to socially relevant health issues, made more informed decisions about a career in research and the health sciences, and worked toward improving the health and well-being of others while also inspiring hope among their people back home. This study represents an extension of the application of the Circle of Courage to an undergraduate research experience and provides evidence of its ability to be used as a framework for cultivating Native scientists.

My Journey: Development and Practice-Based Evidence of a Culturally Attuned Teen Pregnancy Prevention Program for Native Youth.

A clear need exists for teen pregnancy prevention programs that are responsive to the specific needs and cultural contexts of Native American communities. Recent data indicates that the birth rate for Native teens is nearly two and a half times the rate for White teens (32.9 versus 13.2). To address this disparity, we conducted formative research with Northern Plains Native American community members, resulting in My Journey, a culturally attuned curriculum for 6⁻8th graders. My Journey is grounded in traditional values and teachings to promote self-efficacy in sexual health decision-making and engagement in prosocial behaviors. We conducted a pilot study with 6⁻8th grade students (n = 45), aged 11⁻14 years (22 females, 23 males). Pilot study findings confirm program feasibility and acceptability. The process evaluation revealed that teachers liked the curriculum, particularly its adaptability of cultural components and ease of student engagement. The outcome evaluation demonstrated that My Journey provided an avenue for NA youth to increase their sex refusal self-efficacy. Application of the culture cube framework revealed My Journey has made a meaningful practice-based evidence contribution as a community-defined, culturally integrated curriculum that is effective. Future directions include broader implementation of My Journey, including adaption for additional populations.

Development of a Pilot Grants Program in Social Determinants of Health in American Indian Health: A Program for Increasing the Representation of Underrepresented Groups in Funded Research.

The problem statement for this manuscript is to describe the literature on grant funding for underrepresented investigators, particularly American Indians, and detail the CRCAIH Pilot Grant Program and its success in developing underrepresented researchers (e.g. American Indian, early stage investigators). Grant funding is increasingly difficult to receive and the demographics of NIH grant awardees have shifted in recent decades to funding investigators that are more experienced. Additionally, racial disparities in awardees exist, particularly among American Indian (AI) researchers. Pilot grant funding mechanisms can be used by early stage investigators to collect preliminary data, which is beneficial for applying for NIH grants. The Collaborative Research Center for American Indian Health (CRCAIH) Pilot Grant Program (PGP) was aimed to increase research on the topic of social determinants of health in AI population health. Since there are no existing procedures for creating a PGP, CRCAIH created a PGP, and the processes are detailed here. Over four years, the CRCAIH PGP funded 15 projects with 47% of PIs or Co-PIs self-reporting as AI. Future directions for the CRCAIH PGP, including a mentoring program to provide more guidance and capacity building to the investigators, are also detailed.

A research experience for American Indian undergraduates: Utilizing an actor-partner interdependence model to examine the student-mentor dyad.

The majority of research examining Undergraduate Research Experiences focuses singularly on student-reported outcomes, often overlooking assessment of the mentor role in student learning and outcomes following these experiences. The goal of the current study was to examine the student-mentor dyad at the beginning and end of a 10-week summer research experience for American Indian undergraduates utilizing a series of actor-partner interdependence models within SEM. Participants included 26 undergraduate interns (50% American Indian; 50% American Indian and White; M age = 24) and 27 mentors (89% White; M age = 47). Findings indicated that in accounting for all potential paths between students and mentors, the partner path between mentor beliefs at the beginning of the program and students' skills related to autonomy (ß =.59, p = .01) and academic resilience (ß =.44, p = .03) at the end of the program were significant. These findings suggest the important impact of mentor beliefs on student outcomes, a relationship that should be adequately assessed and continue to be important focus of undergraduate research experiences. Findings further indicate the important role of mentors for American Indian undergraduates.

Identifying sexual health protective factors among Northern Plains American Indian youth: An ecological approach utilizing multiple perspectives.

This study examined aspects of the sociocultural context in which American Indian (AI) teen pregnancy occurs, focusing specifically on protective factors for Northern Plains AI youth. Principles of community-based participatory research guided the qualitative data collection from 185 community members (focus groups with AI youth, youth parents, and elders; interviews with health care providers and school personnel) from a reservation and an urban community. Results indicated three protective systems impacted the sexual health and behaviors of AI youth: school, family, and enculturation. These findings provide a better understanding of how specific protective factors within these systems may buffer AI youth from involvement in risky sexual behaviors and work to inform culturally relevant prevention and intervention efforts.

Teen Pregnancy Prevention Program Recommendations from Urban and Reservation Northern Plains American Indian Community Members.

Despite declines over the past few decades, the United States has one of the highest rates of teen pregnancy compared to other industrialized nations. American Indian youth have experienced higher rates of teen pregnancy compared to the overall population for decades. Although it's known that community and cultural adaptation enhance program effectiveness, few teen pregnancy prevention programs have published on recommendations for adapting these programs to address the specific needs of Northern Plains American Indian youth. We employed a mixed-methods analysis of 24 focus groups and 20 interviews with a combined total of 185 urban and reservation-based American Indian youth and elders, local health care providers, and local school personnel to detail recommendations for the cultural adaptation, content, and implementation of a teen pregnancy prevention program specific to this population. Gender differences and urban /reservation site differences in the types of recommendations offered and the potential reasons for these differences are discussed.

Understanding gender roles in teen pregnancy prevention among American Indian youth.

OBJECTIVES: To examine the impact of gender norms on American Indian (AI) adolescents' sexual health behavior. METHODS: The project collected qualitative data at a reservation site and an urban site through 24 focus groups and 20 key informant interviews. RESULTS: The reasons that AI youth choose to abstain or engage in sexual intercourse and utilize contraception vary based on gender ideologies defined by the adolescent's environment. These include social expectations from family and peers, defined roles within relationships, and gender empowerment gaps. CONCLUSIONS: Gender ideology plays a large role in decisions about contraception and sexual activity for AI adolescents, and it is vital to include redefinitions of gender norms within AI teen pregnancy prevention program.

Alternative high school students' physical activity: role of self-efficacy.

OBJECTIVE: To examine physical activity self-efficacy as a mediator of the association between perceived barriers to PA and moderate-to-vigorous physical activity (MVPA) among alternative high school (AHS) students. METHODS: Students (N=145) from 6 AHS completed self-report questionnaires. RESULTS: Mediation analyses revealed partial mediation of PA self-efficacy on relationships between general barriers to PA and MVPA (b = -.39 reduced b = -.33) among females (47.6% of sample). CONCLUSIONS: Interventions with female AHS students should include a component on building PA self-efficacy. However, results suggest the broader environment may have greater impact on MVPA than individual-level psycho-social factors.

Sociocontextual circumstances in daily stress reactivity among caregivers for elder relatives.

Using a daily diary design, we examined whether emotional and physical reactivity in the face of care-related stressors is more intense for caregivers (CGs) living with lower levels of available socioemotional support and higher numbers of extrinsic stressors. Sixty-three CGs reported their experiences based on the past 24 hr (i.e., number of caregiving tasks, care recipient problem behaviors, family disagreements regarding care, depressive symptoms, feelings of burden, physical symptoms) on eight consecutive survey days; they also reported on extrinsic stressors and available socioemotional support. Multilevel analyses indicated significant moderator effects: within-person patterns of reactivity to care-related stressors were especially strong for CGs with lower levels of available socioemotional support and higher numbers of extrinsic stressors. For example, managing additional care recipient problem behaviors on a given day was more strongly associated with increased depressive and physical health symptoms as well as feelings of burden for CGs with relatively high numbers of extrinsic stressors. Implications for intervention are discussed.

Individual, interpersonal, and relationship factors predicting hormonal and condom use consistency among adolescent girls.

INTRODUCTION: Few existing studies have considered influences of adolescents' sexual partners on contraceptive consistency. This study examines the influence of personal characteristics, partner characteristics, and relationship factors on consistency of contraceptive use among an ethnically diverse sample of adolescent girls at high risk for pregnancy and sexually transmitted diseases. METHOD: Data are from 110 sexually active 13- to 17-year-old girls participating in a clinic-based intervention study aimed at reducing sexual risk behaviors. Personal characteristics were assessed at baseline (T1), and partner and relationship characteristics were assessed at 12 months (T2). RESULTS: Multivariate analyses revealed that T2 hormonal contraceptive consistency was predicted by T1 hormonal consistency, girls' desire to use birth control, having the same sexual partner at T1 and T2, perceived partner support for birth control, and communication with partner about sexual risk. T2 condom use consistency was negatively predicted by emergency contraceptive use history and perceived partner support for birth control. DISCUSSION: Findings underscore the importance of nurses addressing both personal and relationship factors in their efforts to promote consistent contraceptive use among sexually active adolescent girls.

Food hiding and weight control behaviors among ethnically diverse, overweight adolescents. Associations with parental food restriction, food monitoring, and dissatisfaction with adolescent body shape.

The present study aims to extend previous research conducted with children by examining associations between parental behaviors (food restriction, food monitoring) and parental perceptions (dissatisfaction with adolescent body shape) with adolescent behaviors (food hiding and weight control behaviors) among an ethnically diverse sample of overweight adolescents. Survey data were collected from overweight adolescents and their parents/guardians (n=116 dyads) at an urban Midwest adolescent health clinic. Adjusting for parent and adolescent demographic characteristics, logistic regression analyses revealed a significant positive association between parental food restriction and adolescent food hiding. No significant associations were found between dissatisfaction with adolescent body shape or parental food monitoring and adolescent food hiding and adolescent weight control behaviors when controlling for demographic factors. Interventions with parents of overweight adolescents should focus on helping parents talk with their adolescents about weight concerns in a non-judgmental way and teaching parents strategies to both create a healthful home food environment and guide and support their adolescents to lose weight in a healthful manner.

Caregiving for elder relatives: which caregivers experience personal benefits/gains?

The present study asks whether the positive, rewarding experiences of caregiving (benefits/gains) emerge merely as a function of caregiver personality, or whether, after personality traits (agreeableness, conscientiousness, extroversion, neuroticism) are taken into account, other interpersonal factors make a difference. Survey data were collected from 63 family caregivers. Bivariate analyses revealed that caregiving benefits/gains were significantly and positively associated with two personality traits (agreeableness, extroversion), family and spouse/partner socio-emotional support, and prior relationship quality. Hierarchical regressions indicated that whereas neither family socio-emotional support nor prior relationship quality significantly predicted variance in caregiving benefits/gains beyond that accounted for by agreeableness and extroversion, spouse/partner socio-emotional support did. Implications for research and practice are discussed.