Community Health Representatives as Trusted Sources for Increasing Representation of American Indian Communities in Clinical Research.

Indigenous and American Indian Alaskan Native (AI/AN) community members are systematically underrepresented in clinical trial research. This paper focuses on exploratory steps to partner with Native Nations of Arizona to engage Community Health Representatives (CHR) as a trusted source for building COVID-19 clinical trial research, including vaccine trials awareness. CHRs are frontline public health workers who apply a unique understanding of the experience, language, and culture of the population served. This workforce has entered the spotlight as essential to the prevention and control of COVID-19. METHODS: Three Tribal CHR programs were engaged to develop and refine culturally centered educational materials and a pre-post survey using a consensus-based decision-making approach. CHRs used these materials in brief education sessions during regular client home visits and community events. RESULTS: At 30 days post CHR intervention, participants (N = 165) demonstrated significantly increased awareness about and ability to enroll in COVID-19 treatment and vaccine trials. Participants also described a significant increase in trust in researchers, decreased perceived barriers related to cost for participation in a clinical trial, and improved belief that participation in a COVID-19 clinical trial for treatment was considered a benefit to American Indian and Alaskan Native people. CONCLUSION: CHRs as trusted sources of information, coupled with culturally centered education materials designed by CHRs for CHR clients, demonstrated a promising approach to improved awareness of clinical trial research generally and COVID-19 trials specifically among Indigenous and American Indian community members of Arizona.

Diné (Navajo) Traditional Knowledge Holders' Perspective of COVID-19.

From the start of the COVID-19 pandemic on the Navajo Nation, Diné (Navajo) traditional knowledge holders (TKHs), such as medicine men and women and traditional practitioners, contributed their services and healing practices. Although TKHs are not always fully acknowledged in the western health care system, they have an established role to protect and promote the health of Diné people. To date, their roles in mitigating the COVID-19 pandemic have not been fully explored. The purpose of this research was to understand the social and cultural contexts of the COVID-19 pandemic and vaccines based on the roles and perspectives of Diné TKHs. A multi-investigator consensus analysis was conducted by six American Indian researchers using interviews with TKHs collected between December 2021-January 2022. The Hózhó Resilience Model was used as a framework to analyze the data using four parent themes: COVID-19, harmony and relationships, spirituality, and respect for self and discipline. These parent themes were further organized into promoters and/or barriers for 12 sub-themes that emerged from the data, such as traditional knowledge, Diné identity, and vaccine. Overall, the analysis showed key factors that could be applied in pandemic planning and public health mitigation efforts based on the cultural perspective of TKHs.

Community based participatory research approaches to combat oral health inequities among American Indian and Alaska Native populations.

American Indian and Alaska Native (AI/AN) communities have experienced a history of systemic racism and still face significant oral health disparities. These disparities extend to the youngest community members in the form of early childhood caries (ECC). Although behavior and biology contribute to ECC, the conditions where people live, grow, and work, and the systems and political and economic forces that shape individual health outcomes, are thought to greatly impact ECC among AI/AN populations. To address ECC in AI/AN communities, we used a community based participatory approach that incorporated social determinants of health. We found that implementing culturally-tailored, culturally-centered, and AI/AN-created materials for ECC interventions is viewed favorably by community members and tribal leaders. Because of the complexity of ECC in AI/AN communities we adopted a bundled approach of best practices to reduce ECC including: (1) incorporating locally, contextually, and culturally relevant strategies to present recommended ECC prevention approaches; (2) employing AI/AN community members as educators; (3) utilizing motivational interviewing with expectant mothers; and (4) providing fluoride varnish. Our work underscores the importance of developing trusting partnerships with each other and with our communities, drawing upon the insights of community advisory board members, and eliciting formative assessment data from tribal members to gain a more holistic understanding of our participants' lived experience to design relevant intervention materials. Incorporating local knowledge and situating Western oral health prevention approaches within culturally aligned frameworks can enhance partnerships and create sustainable materials for community work.

Diné teachings and public health students informing peers and relatives about vaccine education: Providing Diné (Navajo)-centered COVID-19 education materials using student health messengers.

Introduction/background: On 9 April 2021, the Centers for Disease Control and Prevention (CDC) reported that only 19. 9% of United States (US) adults were fully vaccinated against COVID-19. In that same week, the Navajo Nation (NN) reported that 37.4% of residents were fully vaccinated, making the NN a leader in the uptake of COVID-19 vaccines. Despite high vaccination rates, vaccine hesitancy exists within the NN. The Diné (Navajo) Teachings and Public Health Students Informing Peers and Relatives about Vaccine Education (RAVE) intervention was designed to utilize trusted health messengers as an effective means to address adults' vaccine concerns and hesitancy. Methods: The research team used COVID-19 vaccine materials developed in a previous collaboration with non-Navajo tribal communities and publicly available materials. Diné Traditional Knowledge Holders (TKHs) were interviewed to develop and incorporate Diné-specific information on individual and collective health behaviors into the RAVE materials. These drafted health education materials were presented to NN community health representatives (CHRs) and Diné public health students using a consensus panel approach. NN residents who participated in the intervention completed a 16-element retrospective pretest. Results: The adaptation and tailoring process of materials yielded 4 health education materials. The students recruited 46 adults for health education sessions. These participants then completed the retrospective pretest. Changes in the 16 elements were in the desired direction, although only six were significant: four related to attitudes and two concerned with vaccination intention. Participants were more likely to consider vaccination and to try to get vaccinated after the education session. Discussion: Trusted messengers and culturally centered materials have been identified as effective means of health behavior education with Native American audiences. RAVE applied these intervention elements by (1) training Diné College public health students to leverage their cultural knowledge and social relationships (cultural and social capital) to recruit vaccine-hesitant adults and provide education; (2) building on previous understanding of Native American communities' vaccine concerns; and (3) integrating Diné perspectives on individual and collective health into the adaptation of materials designed for general audiences; this knowledge was gained from interviews with TKHs.

Building Trust and Awareness to Increase AZ Native Nation Participation in COVID-19 Vaccines.

The goal of this study was to establish effective, culturally appropriate strategies to enhance participation of American Indian/Alaska Native (AI/AN) communities in prevention and treatment of COVID-19, including vaccine uptake. Thirteen Community Health Representatives (CHRs) from three Arizona Native nations tailored education materials to each community. CHRs delivered the intervention to over 160 community members and administered a pre-posttest to assess trusted sources of information, knowledge, and self-efficacy and intention regarding COVID-19 vaccines. Based on pre-posttest results, doctors/healthcare providers and CHRs were the most trusted health messengers for COVID-19 information; contacts on social media, the state and federal governments, and mainstream news were among the least trusted. Almost two-thirds of respondents felt the education session was relevant to their community and culture, and more than half reported using the education materials to talk to a family member or friend about getting vaccinated. About 67% trusted the COVID-19 information provided and 74% trusted the CHR providing the information. Culturally and locally relevant COVID-19 vaccine information was welcomed and used by community members to advocate for vaccination. The materials and education provided by CHRs were viewed as helpful and emphasized the trust and influence CHRs have in their communities.

Adapting Summer Education Programs for Navajo Students: Resilient Teamwork.

In May 2020, the Navajo Native American Research Center for Health Partnership (Navajo NARCH) was scheduled to launch two summer programs: a 10 weeks-long Summer Research Enhancement Program (SREP) for undergraduate students to learn and practice health research methods and participate in a practicum experience, and a week-long Indigenous Summer Enhancement Program (ISEP) for high school students that introduces a range of health professions and develops leadership qualities. Students accepted into the programs are predominantly Navajo and live within Navajo Nation (NN) during the summer. Due to NN restrictions and CDC guidelines for physically distancing in response to the coronavirus (COVID-19) pandemic, the Navajo NARCH team organized to offer both programs entirely online via Zoom™. This paper explores the instructional teams' adaptation process to maintain a commitment to preserve the programs' supportive environment for exploring and developing strong multicultural approaches in public health and health research. In preparation for online instruction, the team developed and offered workshops for staff and instructors to address anticipated challenges. The team identified the following challenges: technological difficulties, social disconnectedness, consistent student engagement, and facilitation of a practicum research experience. Results showed that program adaptations were successful as the team applied collaborative and holistic approaches, and established social connections remotely with students to offer meaningful research and practicum experiences.

Intertribal Collaboration and Health: A Literature Review.

In the United States, American Indians and Alaska Natives (AIAN) are rebuilding their nations through assertion of sovereignty, standards of governance, cultural frameworks, strategic orientation, and effective leadership. The approach emphasizes tribal self-determination in managing nation affairs and reducing reliance on state and federal assistance. Through nation-building, tribal nations can improve their citizens' health and well-being while empowering local capacity and cultural pride. Intertribal collaboration can be an effective strategy to leverage resources and create a coalition for support and knowledge exchange; however, the research documenting practices, and outcomes of tribal health management that uses intertribal collaboration is limited. This systematic review investigates health-focused collaborations among the tribal nations in North America. Peer-reviewed articles that included at least two federally recognized tribes, described AIAN driven initiatives, implemented a health management plan, collaborated between Indigenous leaders, and goals of social, behavioural, mental, and physical health outcomes were examined. This search was limited to articles published between January 1, 1970 to November 30, 2019. The PRISMA systematic review process was used. Twenty-seven articles were screened, and three articles were eligible for thematic review. The articles highlighted the importance of utilizing an Indigenous framework to facilitate program management and collaboration, recognition of cultural differences, and sovereignty rights. Characteristics that contributed to the establishment and strengthening of intertribal collaboration were: (1) adapt new proposals, (2) respectful recognition of sovereignty, and (3) transparent and honest communication. The small sample size indicated most Indigenous health programs are not "AIAN-driven", limiting the foundation for building evidence-based frameworks.