Strategic Directions in Preventive Intervention Research to Advance Health Equity.

As commissioned by the Society for Prevention Research, this paper describes and illustrates strategic approaches for reducing health inequities and advancing health equity when adopting an equity-focused approach for applying prevention science evidence-based theory, methodologies, and practices. We introduce an ecosystemic framework as a guide for analyzing, designing, and planning innovative equity-focused evidence-based preventive interventions designed to attain intended health equity outcomes. To advance this process, we introduce a health equity statement for conducting integrative analyses of ecosystemic framework pathways, by describing the role of social determinants, mechanisms, and interventions as factors directly linked to specific health equity outcomes. As background, we present health equity constructs, theories, and research evidence which can inform the design and development of equity-focused intervention approaches. We also describe multi-level interventions that when coordinated can produce synergistic intervention effects across macro, meso, and micro ecological levels. Under this approach, we encourage prevention and implementation scientists to apply and extend these strategic directions in future research to increase our evidence-based knowledge and theory building. A general goal is to apply prevention science knowledge to design, widely disseminate, and implement culturally grounded interventions that incrementally attain specific HE outcomes and an intended HE goal. We conclude with recommendations for conducting equity-focused prevention science research, interventions, and training.

Measuring the effects of the COVID-19 pandemic on Diné and White Mountain Apache school personnel, families, and students: protocol for a prospective longitudinal cohort study.

BACKGROUND: This paper describes the protocol for a longitudinal cohort study, "Project SafeSchools" (PSS), which focuses on measuring the effects of COVID-19 and the return to in-person learning on Diné (Navajo) and White Mountain Apache (Apache) youth, parents, and educators. The early surges of the COVID-19 pandemic led to the closure of most reservation and border town schools serving Diné and Apache communities. This study aims to: (1) understand the barriers and facilitators to school re-opening and in-person school attendance from the perspective of multiple stakeholders in Diné and Apache communities; and (2) evaluate the educational, social, emotional, physical, and mental health impacts of returning to in-person learning for caregivers and youth ages 4-16 who reside or work on the Diné Nation and the White Mountain Apache Tribal lands. METHODS: We aim to recruit up to N = 200 primary caregivers of Diné and Apache youth ages 4-16 and up to N = 120 school personnel. In addition, up to n = 120 of these primary caregivers and their children, ages 11-16, will be selected to participate in qualitative interviews to learn more about the effects of the pandemic on their health and wellbeing. Data from caregiver and school personnel participants will be collected in three waves via self-report surveys that measure COVID-19 related behaviors and attitudes, mental health, educational attitudes, and cultural practices and beliefs for both themselves and their child (caregiver participants only). We hypothesize that an individual's engagement with a variety of cultural activities during school closures and as school re-opened will have a protective effect on adult and youth mental health as they return to in-person learning. DISCUSSION: The results of this study will inform the development or implementation of preventative interventions that may help Diné and Apache youth and their families recover from the negative impact of the COVID-19 pandemic, and positively impact their health and wellness.

Development of "CULTURE FORWARD: A strengths and culture-based tool to protect our native youth from suicide".

OBJECTIVE: Indigenous knowledge and practices promote American Indian/Alaska Native (AI/AN; Native) communities' health and well-being. Historical losses and continued oppression have resulted in disproportionately higher AI/AN youth suicide rates. This article describes the development of a new national resource guide titled "CULTURE FORWARD" for tribal leaders and stakeholders to support youth suicide prevention efforts through cultural strengths. METHOD: The CULTURE FORWARD guide was developed over 6 months through a community-engaged process. We conducted nine roundtables and eight interviews with a wide variety of community members, leaders, and providers representing 36 diverse tribal communities and geographic regions. Participants discussed AI/AN youth risk and protective factors, successful community efforts to prevent suicide, and content and dissemination ideas. A comprehensive literature review complemented qualitative findings. A diverse and representative National Advisory Editorial Board guided content and design throughout development. RESULTS: Qualitative data were analyzed iteratively and thematically. Across all listening sessions, culture was identified as a key protective factor against AI/AN youth suicide. Five themes related to cultural strengths informed guide chapters. Each chapter includes an introduction; how that theme helps prevent Native youth suicide; a review of academic literature, community stories and programs; action steps; and additional resources. CONCLUSIONS: CULTURE FORWARD honors and empowers communities by weaving strands of knowledge, stories, and practical resources highlighting Native communities' strengths to protect against Native youth suicide. The guide is free online and print copies are being distributed nationally. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Diné (Navajo) female perspectives on mother-daughter communication and cultural assets around the transition to womanhood: a cross-sectional survey.

BACKGROUND: The inclusion of protective factors ("assets") are increasingly supported in developing culturally grounded interventions for American Indian (AI) populations. This study sought to explore AI women's cultural assets, perspectives, and teachings to inform the development of a culturally grounded, intergenerational intervention to prevent substance abuse and teenage pregnancy among AI females. METHODS: Adult self-identified AI women (N = 201) who reside on the Navajo Nation completed a cross-sectional survey between May and October 2018. The 21-question survey explored health communication around the transition to womanhood, cultural assets, perceptions of mother-daughter reproductive health communication, and intervention health topics. Univariate descriptive analyses, chi squared, and fisher's exact tests were conducted. RESULTS: Respondents ranged in age from 18 to 82 years, with a mean age of 44 ± 15.5 years. Women self-identified as mothers (95; 48%), aunts (59; 30%), older sisters (55; 28%), grandmothers (37; 19%), and/or all of the aforementioned (50; 25%). 66% (N = 95) of women admired their mother/grandmother most during puberty; 29% (N = 58) of women were 10-11 years old when someone first spoke to them about menarche; and 86% (N=172) felt their culture was a source of strength. 70% (N = 139) would have liked to learn more about reproductive health when they were a teenager; 67% (N = 134) felt Diné mothers are able to provide reproductive health education; 51% (N = 101) reported having a rite of passage event, with younger women desiring an event significantly more than older women. Responses also indicate a disruption of cultural practices due to government assimilation policies, as well as the support of male relatives during puberty. CONCLUSIONS: Results informed intervention content and delivery, including target age group, expanded caregiver eligibility criteria, lesson delivery structure and format, and protective cultural teachings. Other implications include the development of a complementary fatherhood and/or family-based intervention to prevent Native girls' substance use and teen pregnancy.

Wakȟáŋyeza (Little Holy One) - an intergenerational intervention for Native American parents and children: a protocol for a randomized controlled trial with embedded single-case experimental design.

BACKGROUND: Trauma within Native American communities compromises parents' parenting capacity; thus, increasing childrens' risk for substance use and suicide over the lifespan. The objective of this manuscript is to describe the Wakȟáŋyeza (Little Holy One) intervention and evaluation protocol, that is designed to break cycles of intergenerational trauma, suicide, and substance use among Fort Peck Assiniboine and Sioux parents and their children. METHODS: A randomized controlled trial with an embedded single-case experimental design will be used to determine effectiveness of the modular prevention intervention on parent-child outcomes and the added impact of unique cultural lesson-components. Participants include 1) Fort Peck Assiniboine and Sioux parents who have had adverse childhood experiences, and 2) their children (3-5 years). Parent-child dyads are randomized (1:1) to Little Holy One or a control group that consists of 12 lessons taught by Indigenous community health workers. Lessons were developed from elements of 1) the Common Elements Treatment Approach and Family Spirit, both evidence-based interventions, and 2) newly created cultural (intervention) and nutrition (control group only) lessons. Primary outcomes are parent (primary caregiver) trauma symptoms and stress. Secondary outcomes include: Parent depression symptoms, parenting practices, parental control, family routines, substance use, historical loss, communal mastery, tribal identity, historical trauma. Child outcomes include, externalizing and internalizing behavior and school attendance. Primary analysis will follow an intent-to-treat approach, and secondary analysis will include examination of change trajectories to determine impact of cultural lessons and exploration of overall effect moderation by age and gender of child and type of caregiver (e.g., parent, grandparent). DISCUSSION: Many Native American parents have endured adverse childhood experiences and traumas that can negatively impact capacity for positive parenting. Study results will provide insights about the potential of a culturally-based intervention to reduce parental distress - an upstream approach to reducing risk for childrens' later substance misuse and suicidality. Intervention design features, including use of community health workers, cultural grounding, and administration in Head Start settings lend potential for feasibility, acceptability, sustainability, and scalability. TRIAL REGISTRATION: ClinicalTrials.gov: NCT04201184 . Registered 11 December 2019.

Feasibility, Acceptability, and Preliminary Impact of Asdzáán Be'eená: An Intergenerational, Strength-Based, and Culturally Grounded Program to Improve the Health of Navajo Families.

Native American youth endure a complex interplay of factors that portend greater risk-taking behaviors and contribute to marked health disparities experienced in adolescence. The Asdzáán Be'eená ("Female Pathways" in Navajo) program was developed as a primary prevention program to prevent substance use and teen pregnancy among Navajo girls. The Asdzáán Be'eená program consists of 11 lessons delivered to dyads of girls ages 8 to 11 years and their female caregivers. Feasibility, acceptability, and preliminary impact on risk and protective factors were assessed through a pre-/post study design. Data were collected from girls and their female caregivers at baseline, immediate, and 3 months postprogram completion. Forty-seven dyads enrolled in the study, and 36 completed the 3-month evaluation. At 3 months postprogram, girls reported significant increases in self-esteem, self-efficacy, parent-child relationship, social support, cultural, and sexual health knowledge. Caregivers reported increased family engagement in Navajo culture and parent-child communication and improved child functioning (fewer internalizing and externalizing behaviors). Findings suggest Asdzáán Be'eená has potential to break the cycle of substance use and teen pregnancy in Native communities by improving protective and reducing risk factors associated with these adverse health outcomes. Additional rigorous efficacy trials are necessary to establish program effectiveness.

Suicide and the opioid overdose crisis among American Indian and Alaska Natives: a storm on two fronts demanding swift action.

The opioid crisis in the United States has received national attention and critical resources in the past decade. However, what has been overlooked is the effect the opioid crisis may be having on a three-decade suicide crisis among American Indian and Alaska Native (AIAN) communities that already have too few resources to address behavioral and mental health issues. This paper describes recent epidemiological trends associated with both opioid overdose and suicide at a national level for AIANs and the rest of the United States. We used data reported by the Centers for Disease Control and Prevention to report historical trends of opioid overdose and suicide for AIAN and non-AIAN populations. We found alarming and potentially correlated trends of opioid use and suicidality among AIAN populations. We highlight both current and future research that will be essential to understanding and addressing the unique intersection between opioid and suicide risk and protective factors to inform dual prevention and intervention efforts among AIAN populations with potential relevance to public health response among other at-risk populations.

A Qualitative Evaluation of a Community Based, Culturally Relevant Intervention to Promote Healthy Food Access in American Indian Communities.

In response to a need for healthy, affordable food, Johns Hopkins Center for American Indian Health and three rural indigenous communities launched the "Feast for the Future," (FFF) to promote access to healthy foods and the transfer of traditional food-based knowledge from farmers/elders to youth. To assess program impact, 43 in-depth interviews were conducted with participating farmers, elders, and Community Advisory Board members. Interviews were recorded, transcribed, and analyzed in Atlas.ti. Common themes from qualitative analyses included: FFF programs support farming/gardening revitalization and cultural connectedness/identity; FFF has supported positive behavior change among interviewees and their families; There is a need to revitalize traditional food systems; Farming/gardening is central to cultural identity; and Responsibility for food choices. The interviews revealed that the community-based program is perceived by key stakeholders as reaffirming cultural identity and promoting healthy eating. As a CAB member shared.

Utilizing broad-based partnerships to design a precision approach to implementing evidence-based home visiting.

The aim of this paper is to describe a participatory process for adapting an implementation strategy, using a precision approach, for an evidence-based home visiting program, Family Spirit. Family Spirit serves Native American and low-income communities nationwide. To redesign Family Spirit's implementation strategy, we used workshops (n = 5) with key stakeholders and conducted an online survey with implementers (n = 81) to identify hypothesized active ingredients and "pivot points" to guide when to tailor the program and for whom. Active ingredients identified included the relationship between the home visitor and clients, lessons ensuring child safety and healthy development, parent-child communication, and goal setting. Pivot points included whether the client is a first-time mother who has substance abuse history, has a baby at risk for childhood obesity, and/or has sexual or reproductive health concerns. These results are informing the adaptation of Family Spirit' implementation strategy making it more responsive to diverse families while balancing fidelity to the previously proven standard model.

Unintentional injury deaths among American Indian residents of the Fort Apache Indian Reservation, 2006-2012.

This study aims to describe the epidemiology of unintentional injury deaths among American Indian residents of the Fort Apache Indian Reservation between 2006 and 2012. Unintentional injury death data were obtained from the Arizona Department of Health Services and death rates were calculated per 100 000 people per year and age adjusted using data obtained from Indian Health Service and the age distribution of the 2010 US Census. Rate ratios were calculated using the comparison data obtained through CDC's Web-based Injury Statistics Query and Reporting System. The overall unintentional injury mortality rate among American Indians residing on the Fort Apache Indian Reservation between 2006 and 2012 was 107.0 per 100 000. When stratified by age, White Mountain Apache Tribe (WMAT) mortality rates for all unintentional injuries exceed the US all races rate except for ages 10-14 for which there were no deaths due to unintentional injury during this period. The leading causes of unintentional injury deaths were MVCs and poisonings. Unintentional injuries are a significant public health problem in the American Indian and Alaska Native communities. Tribal-specific analyses are critical to inform targeted prevention and priority setting.

Employing a sequential multiple assignment randomized trial (SMART) to evaluate the impact of brief risk and protective factor prevention interventions for American Indian Youth Suicide.

BACKGROUND: This study is built on a long-standing research partnership between the Johns Hopkins Center for American Indian Health and the White Mountain Apache Tribe to identify effective interventions to prevent suicide and promote resilience among American Indian (AI) youth. The work is founded on a tribally-mandated, community-based suicide surveillance system with case management by local community mental health specialists (CMHSs) who strive to connect at-risk youth to treatment and brief, adjunctive interventions piloted in past research. METHODS: Our primary aim is to evaluate which brief interventions, alone or in combination, have the greater effect on suicide ideation (primary outcome) and resilience (secondary outcome) among AI youth ages 10-24 ascertained for suicide-related behaviors by the tribal surveillance system. We are using a Sequential Multiple Assignment Randomized Trial with stratified assignment based on age and suicidal-behavior type, and randomizing N = 304 youth. Brief interventions are delivered by AI CMHSs, or by Elders with CMHS support, and include: 1) New Hope, an evidence-based intervention to reduce immediate suicide risk through safety planning, emotion regulation skills, and facilitated care connections; and 2) Elders' Resilience, a culturally-grounded intervention to promote resilience through connectedness, self-esteem and cultural identity/values. The control condition is Optimized Case Management, which all study participants receive. We hypothesize that youth who receive: a) New Hope vs. Optimized Case Management will have significant reductions in suicide ideation; b) Elders' Resilience vs. Optimized Case Management will have significant gains in resilience; c) New Hope followed by Elders' Resilience will have the largest improvements on suicide ideation and resilience; and d) Optimized Case Management will have the weakest effects of all groups. Our secondary aim will examine mediators and moderators of treatment effectiveness and sequencing. DISCUSSION: Due to heterogeneity of suicide risk/protective factors among AI youth, not all youth require the same types of interventions. Generating evidence for what works, when it works, and for whom is paramount to AI youth suicide prevention efforts, where rates are currently high and resources are limited. Employing Native paraprofessionals is a means of task-shifting psychoeducation, culturally competent patient support and continuity of care. TRIAL REGISTRATION: Clinical Trials NCT03543865, June 1, 2018.

"Let our Apache Heritage and Culture Live on Forever and Teach the Young Ones": Development of The Elders' Resilience Curriculum, an Upstream Suicide Prevention Approach for American Indian Youth.

The White Mountain Apache Tribe have developed an innovative curriculum that connects youth through Elders to their heritage, traditions, and culture, which has been proven to be a protective factor for native Americans. The development process took 4½ years and included community stakeholder buy-in, Elders' Council group formation, extensive formative work to identify content, iterative feedback between curriculum writers and Elders, and Elder training prior to implementation. Members of the Elders' Council have been visiting the local schools to teach youth about the Apache culture, language, and way of life since February 2014 reaching over 1000 youth. This approach demonstrates a promising upstream suicide prevention strategy. We discuss the process of development, implementation, and lessons learned, as this curriculum has potential for adaptation by other Indigenous communities.

Research with American Indian and Alaska Native populations: Measurement matters.

Research is an important tool in addressing myriad American Indian and Alaska Native (AIAN) health disparities; however, tensions exist between common empirical measurement approaches that facilitate cross-cultural comparisons and measurement specificity that may be more valid locally and/or culturally appropriate. The tremendous diversity of AIAN communities, small population sizes of distinct AIAN cultural groups, and varying cultural contexts and worldviews should influence measurement decisions in health research. We provide a framework for guiding measurement in collaboration with AIAN communities using examples from substance abuse research for illustration. Our goal is to build upon ongoing efforts to advance measurement validity for AIAN research by engaging community-researcher partnerships and critical thinking in the selection, adaptation, creation, and implementation of measures.

Engaging Native American Caregivers in Youth-Focused Diabetes Prevention and Management.

Native American youth aged 10 to 19 years are disproportionately affected by type 2 diabetes. Intergenerational programs may improve health in tribal communities. We evaluated Together on Diabetes, a diabetes prevention and management program, among 257 participating Native American youths with or at risk for type 2 diabetes and their adult caregivers. Feasibility, acceptability, and demographic data were collected from 226 adult caregivers. Data on physical measurements (weight, height, waist circumference) were collected from 37 of the caregivers. Results indicated that engaging adult caregivers was feasible, acceptable, and effective. Furthermore, a subset of adult caregivers reduced their body mass index (weight in kilograms divided by height in m2) significantly from the start to the end of the program, a 12 month period (P = .02). Findings suggest the feasibility of engaging adult caregivers in youth diabetes prevention programs.

ADDRESSING SUBSTANCE-USE PROBLEMS IN TRIBAL HOME VISITING.

Given the high rates for substance use among women and men of childbearing age, perinatal and early childhood home-visiting programs serving tribal communities must consider how they will address substance-use problems among the families they support. In this study, we explored the approaches to identifying and addressing family-based substance-use problems that were implemented by nine home-visiting programs serving American Indian/Alaska Native (AI/AN) communities that are funded through the federal Tribal Maternal, Infant, and Early Childhood Home Visiting Program (Tribal MIECHV). These programs demonstrated a high awareness of substance-use problems and took concrete action to address them above and beyond that included in the home-visiting model they used. All nine programs reported that they provided substance-use preventive services and screened for substance-use problems. While all programs referred to substance-use treatment programs when needed, in six programs the home visitor provided substance-use services. Through Tribal MIECHV, the intense need for substance-use education, assessment, service delivery, and referral in many AI/AN communities is pushing the home-visiting field forward to address this increasingly critical issue for low-income families across the United States and the world.

MEASUREMENT ISSUES IN HOME-VISITING RESEARCH WITHIN TRIBAL COMMUNITIES: CHALLENGES AND STRATEGIES.

In this article, Tribal Maternal, Infant, and Early Childhood Home Visiting (MIECHV) grantees share strategies they have developed and adopted to address the most common barriers to effective measurement (and thus to effective evaluation) encountered in the course of implementation and evaluation of their home-visiting programs. We identify key challenges in measuring outcomes in Tribal MIECHV Programs and provide practical examples of various strategies used to address these challenges within diverse American Indian and Alaska Native cultural and contextual settings. Notably, high-quality community engagement is a consistent thread throughout these strategies and fundamental to successful measurement in these communities. These strategies and practices reflect the experiences and innovative solutions of practitioners working on the ground to deliver and evaluate intervention programs to tribal communities. They may serve as models for getting high-quality data to inform intervention while working within the constraints and requirements of program funding. The utility of these practical solutions extends beyond the Tribal MIECHV grantees and offers the potential to inform a broad array of intervention evaluation efforts in tribal and other community contexts.

DISCOVERING FRUGAL INNOVATIONS THROUGH DELIVERING EARLY CHILDHOOD HOME-VISITING INTERVENTIONS IN LOW-RESOURCE TRIBAL COMMUNITIES.

Early childhood home-visiting has been shown to yield the greatest impact for the lowest income, highest disparity families. Yet, poor communities generally experience fractured systems of care, a paucity of providers, and limited resources to deliver intensive home-visiting models to families who stand to benefit most. This article explores lessons emerging from the recent Tribal Maternal and Infant Early Childhood Home Visiting (MIECHV) legislation supporting delivery of home-visiting interventions in low-income, hard-to-reach American Indian and Alaska Native communities. We draw experience from four diverse tribal communities that participated in the Tribal MIECHV Program and overcame socioeconomic, geographic, and structural challenges that called for both early childhood home-visiting services and increased the difficulty of delivery. Key innovations are described, including unique community engagement, recruitment and retention strategies, expanded case management roles of home visitors to overcome fragmented care systems, contextual demands for employing paraprofessional home visitors, and practical advances toward streamlined evaluation approaches. We draw on the concept of "frugal innovation" to explain how the experience of Tribal MIECHV participation has led to more efficient, effective, and culturally informed early childhood home-visiting service delivery, with lessons for future dissemination to underserved communities in the United States and abroad.

Exploration of Pathways to Binge Drinking Among American Indian Adolescents.

Binge drinking is a serious public health problem among American Indian adolescents, yet few theoretical models specific to this population and type of problematic drinking have been tested. The White Mountain Apache Tribe has begun surveillance of binge drinking and a related line of research to inform tailored prevention efforts. The goal of this paper is to use structural equation modeling to understand the relationships between different individual, family, peer, and cultural factors that predict or protect against binge drinking behavior among Apache adolescents ages 10-19 years old. A cross-sectional case-control study was completed with N = 68 Apache adolescents who required medical attention due to a recent binge event (past 90 days) and N = 55 controls with no lifetime history of binge drinking. The hypothesized model was estimated with Mplus using the WLSMV robust least squares estimator. In the final model, stressful life events were related to family functioning and peer relationships. In turn, family functioning affected peer relationships and adolescent impulsivity, which were both associated with greater risk of binge drinking. The path between peer relationships and having engaged in binge drinking was statistically significant for those expressing lower cultural identity, but not for those reporting higher cultural identity. Findings suggest preventive interventions should emphasize teaching coping skills to manage life stressors and handle impulsivity, strengthening families, and changing peer dynamics with social network-based approaches as well as social skill training. The model highlights the potentially important role of culture in strengthening positive peer relationships to reduce binge drinking risk.

Decreases in Suicide Deaths and Attempts Linked to the White Mountain Apache Suicide Surveillance and Prevention System, 2001-2012.

OBJECTIVES: We evaluated the impact of a comprehensive, multitiered youth suicide prevention program among the White Mountain Apache of Arizona since its implementation in 2006. METHODS: Using data from the tribally mandated Celebrating Life surveillance system, we compared the rates, numbers, and characteristics of suicide deaths and attempts from 2007 to 2012 with those from 2001 to 2006. RESULTS: The overall Apache suicide death rates dropped from 40.0 to 24.7 per 100 000 (38.3% decrease), and the rate among those aged 15 to 24 years dropped from 128.5 to 99.0 per 100 000 (23.0% decrease). The annual number of attempts also dropped from 75 (in 2007) to 35 individuals (in 2012). National rates remained relatively stable during this time, at 10 to 13 per 100 000. CONCLUSIONS: Although national rates remained stable or increased slightly, the overall Apache suicide death rates dropped following the suicide prevention program. The community surveillance system served a critical role in providing a foundation for prevention programming and evaluation.