Utilizing Digital Storytelling to Develop a Public Health Professions Pathway for Native American High School Students.

Digital storytelling is a decentering methodology in health promotion that positions the storyteller as an expert to create a narrative of their lived experiences. This article describes using a two-phase digital storytelling process within the Diné (Navajo) Educational Philosophy framework to guide the development of a culturally grounded curriculum plan that actively engages Diné youth in exploring health professions pathways in their community. The first phase consisted of developing a high school digital storytelling team by training three Diné youth attending high school on the Navajo Nation located in southwest United States, in digital storytelling. In the second phase, the high school digital storytelling team worked collaboratively with seven Diné students enrolled at the local tribal college to develop digital stories about navigating from high school to college. Data from seven completed digital stories were analyzed with assistance from a community advisory board to identify asset-based themes that contributed to positively transitioning from high school to a tribal college. The results revealed several strategies for successful transitions from high school to a public health college major. The culturally relevant strategies and stories were incorporated into a school-based health professions pathway curriculum plan for Diné youth.

Diné-centered Research Reframes the Gold King Mine Spill: Understanding Social and Spiritual Impacts Across Space and Time.

This paper explores how Indigenous-led research reframes the impacts and response to environmental disasters in the context of acid mine spills in rural communities of the Southwest United States. The collaborative research project addressing the Gold King Mine Spill (GKMS) designed qualitative methodologies that center Indigenous worldviews and contribute to broader understandings of environmental justice. The research team, led by Diné scholars and community leaders, gathered qualitative responses from 123 adult participants in twelve focus groups from three rural communities on the Navajo Nation. The project incorporated fluent Diné speakers and cultural consultants to lead focus groups in a manner consistent with cultural worldviews. The analysis of the focus group data resulted in original findings that reframe previous understandings of environmental harm by broadening the boundaries to include: 1) social relations across time; 2) social relations across space; 3) spiritual relations; and 4) restoring balance. The findings allow for greater insight into the colonial context of disaster on rural and Indigenous lands and confronts colonial-rooted disasters through Indigenous-informed political action.

A multisectoral approach to advance health equity in rural northern Arizona: county-level leaders' perspectives on health equity.

BACKGROUND: Multisectoral and public-private partnerships are critical in building the necessary infrastructure, policy, and political will to ameliorate health inequity. A focus on health equity by researchers, practitioners, and decision-makers prioritizes action to address the systematic, avoidable, and unjust differences in health status across population groups sustained over time and generations that are beyond the control of individuals. Health equity requires a collective process in shaping the health and wellbeing of the communities in which we live, learn, work, play, and grow. This paper explores multisectoral leaders' understanding of the social, environmental, and economic conditions that produce and sustain health inequity in northern Arizona, a geographically expansive, largely rural, and culturally diverse region. METHODS: Data are drawn from the Southwest Health Equity Research Collaborative's Regional Health Equity Survey (RHES). The RHES is a community-engaged, cross-sectional online survey comprised of 31 close-ended and 17 open-ended questions. Created to assess cross-sectoral regional and collective capacity to address health inequity and inform multisectoral action for improving community health, the RHES targeted leaders representing five rural northern Arizona counties and 13 sectors. Select open-ended questions were analyzed using an a priori coding scheme and emergent coding with thematic analysis. RESULTS: Although leaders were provided the definition and asked to describe the root causes of inequities, the majority of leaders described social determinants of health (SDoH). When leaders described root causes of health inequity, they articulated systemic factors affecting their communities, describing discrimination and unequal allocation of power and resources. Most leaders described the SDoH by discussing compounding factors of poverty, transportation, housing, and rurality among others, that together exacerbate inequity. Leaders also identified specific strategies to address SDoH and advance health equity in their communities, ranging from providing direct services to activating partnerships across organizations and sectors in advocacy for policy change. CONCLUSION: Our findings indicate that community leaders in the northern Arizona region acknowledge the importance of multisectoral collaborations in improving health equity for the populations that they serve. However, a common understanding of health equity remains to be widely established, which is essential for conducting effective multisectoral work to advance health equity.

Practicing Tribal Sovereignty Through a Tribal Health Policy: Implementation of the Healthy Diné Nation Act on the Navajo Nation.

INTRODUCTION: The Navajo Nation is a large sovereign tribal nation. After several years of grassroots efforts and overcoming an initial presidential veto, the Navajo Nation passed the Healthy Diné Nation Act (HDNA) in 2014 to promote healthy behaviors in Navajo communities. This was the first such policy in the US and in any sovereign tribal nation worldwide. PURPOSE AND OBJECTIVES: The objective of this study was to describe the process, implementation, and evaluation of the HDNA passage and its 2020 reauthorization and the potential for using existing and tribal-specific data to inform tribal policy making. INTERVENTION APPROACH: The HDNA included a 2% tax on unhealthy foods sold on the Navajo Nation and waived a 6% sales tax on healthy foods. HDNA-generated funds were allocated to 110 local communities for wellness projects. No funds were allocated for enforcement or compliance. EVALUATION METHODS: We assessed HDNA tax revenue and tax-funded wellness projects in 110 chapters over time, by region and community size. The food store environment was assessed for fidelity of HDNA implementation, price changes since pretax levels, and shopper behaviors. HDNA revenue was cross-matched with baseline nutrition behaviors and health status through a Navajo-specific Behavioral Risk Factor Surveillance System survey. RESULTS: HDNA revenue decreased modestly annually, and 99% of revenue was disbursed to local chapters, mostly for the built recreational environment, education, equipment, and social events. Stores implemented the 2% tax accurately, and the food store environment improved modestly. Regions with high tax revenue also had high rates of diabetes, but not other chronic conditions. The HDNA was reauthorized in 2020. IMPLICATIONS FOR PUBLIC HEALTH: Sovereign tribal nations can drive their own health policy. Program evaluation can use existing data sources, tailored data collection efforts, and tribal-specific surveys to gain insight into feasibility, implementation, and impact.

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.

Characteristics of American Indian Female Caregivers on a Southwest American Indian Reservation.

American Indian (AI) caregivers have been excluded from national survey efforts. Drawing from a 2012 survey administered on the Hopi Reservation in northern Arizona, 20% of adults are caregivers. More information is needed to guide program development tailored to Hopi needs. In a University-Community collaboration, a 58 question survey was administered to self-identified caregivers of a family member about amount and type of care provided, difficulties, caregiver health, and desired support services. Characteristics of caregivers and their experiences were described. Forty-four (44) female Hopi caregivers were interviewed from June-October 2017, mean age of 59 years (± 12.6) with mean 5.5 year (± 4.4) history of providing care. Over 84% provided care to either a parent or grandparent. Most caregivers provided transportation (93.2%), housework (93.2%), and medical related care (72.7%). Caregivers stated they had difficulties with not having enough time for family and or friends (88.6%), financial burdens (75.0%), and not having enough time for themselves (61.4%). The most frequently identified difficulty was stress (45.5%). Caregivers would like additional services, with 76.7% asking for training. Over 77% would not consider placing their relative in an assisted living facility. Compared to national data, Hopi female caregivers are older, provide more care hours/week, more caregiving duties, and for a longer number of years. Stress is the most reported difficulty, although lower than national levels. As caregivers are resistant to placing the recipient in assisted living, educational efforts should focus on training caregivers to assist the care recipient and decreasing caregiver stress.

Food choices and distress in reservation-based American Indians and Alaska Natives with type 2 diabetes.

OBJECTIVE: To examine the association between food choice and distress in a large national sample of American Indians/Alaska Natives (AI/AN) with type 2 diabetes. DESIGN: Participants completed a sociodemographic survey, an FFQ and the Kessler-6 Distress Scale. Foods were identified as 'healthy' or 'unhealthy' using a classification grounded in the health education provided by the programme case managers; healthy and unhealthy food scores were calculated using reported intake frequencies. Pearson's correlation coefficients for distress and food scores were calculated for all participants and by gender. Multiple linear regression models stratified by gender assessed the association between distress and food scores, controlling for sociodemographics and duration of type 2 diabetes. SETTING: Rural AI reservations and AN villages. SUBJECTS: AI/AN (n 2484) with type 2 diabetes. RESULTS: Both males (34·9 %) and females (65·1 %) had higher healthy food scores than unhealthy scores. In bivariate analysis, distress level had a significant negative correlation with healthy food scores among female participants, but the association was not significant among males. Significant positive correlations between distress and unhealthy food scores were found in both genders. In the final multivariate models, healthy food scores were not significantly related to distress; however, unhealthy food scores showed significant positive relationships with distress for both genders (females: ß=0·078, P=0·0007; males: ß=0·139, P<0·0001). CONCLUSIONS: Health professionals working with AI/AN diagnosed with type 2 diabetes should offer food choice strategies during difficult times and recognize that males may be more likely than females to select unhealthy foods when distressed.

Identifying Protective Factors to Promote Health in American Indian and Alaska Native Adolescents: A Literature Review.

Exposure to protective factors, conditions that protect against the occurrence of an undesirable outcome or promote the occurrence of a desirable outcome within an adolescent's environment, can foster healthy adolescent behaviors and reduce adult morbidity and mortality. Yet, little is known about the nature and effect of protective factors on the positive social and health outcomes among American Indian and Alaska Native (AIAN) adolescents. We conducted a review of the literature to identify the protective factors associated with positive health outcomes among AIAN adolescents. We consulted Elsevier Science Direct, ERIC EBSCOhost, PubMed, and the Web of Science databases. A total of 3421 articles were encountered. Excluded publications were those that did not focus on AIAN adolescents (n = 3341), did not identify protective factors (n = 56), were not original research studies (n = 8), or were not written in the English language. We identified nine categories of protective factors positively associated with health and social outcomes, including: current and/or future aspirations, personal wellness, positive self-image, self-efficacy, non-familial connectedness, family connectedness, positive opportunities, positive social norms, and cultural connectedness. Such factors positively influenced adolescent alcohol, tobacco, and substance use; delinquent and violent behavior; emotional health including depression, suicide attempt; resilience; and academic success. Protective factors spanned multiple domains of the socio-ecological model. Strengths-based health promotion efforts that leverage local, innate protective factors and work with AIANs to create environments rich in protective factors are key to improving the health and wellbeing of AIAN adolescents.

Caregiving on the Hopi Reservation: Findings from the 2012 Hopi Survey of Cancer and Chronic Disease.

A family caregiver provides unpaid assistance to a family member/friend with a chronic disease, illness or disability. The caregiving process can affect a caregiver's quality of life by reducing time for themselves, for other family members and for work. The 2000 Behavioral Risk Factor Surveillance Survey estimates that 16 % of adult American Indians (AIs) are caregivers. A 2012 survey collected knowledge and personal experience data from a random sample of Hopi men and women (248 men and 252 women). Self-identified caregivers answered questions on time spent caregiving, caregiver difficulties and services requested. Approximately 20 % of the 500 Hopi participants self-identified as caregivers (N = 98), with 56 % female. Caregivers in contrast to non-caregivers had a lower percentage of ever having a mammogram (86, 89 %), a higher percentage of ever having had a Pap smear test (89.1, 85.6 %), a prostate specific antigen test (35, 30.6 %) and ever having had a colonoscopy (51.2, 44 %). Almost 21 % of caregivers reported difficulty with stress and 49 % reported it as their greatest caregiver difficulty. More males (28.6 %) identified financial burden as the greatest difficulty than females (p = 0.01). Training on patient care was the service that caregivers would like to receive most (18.2 %). The percentage of Hopi's providing caregiving was similar to national averages, although among men, was somewhat higher than national data (44 vs. 34 %). Stress was identified as a difficulty, similar to national studies.

Flexible Roles for American Indian Elders in Community-Based Participatory Research.

Community-based participatory research builds partnerships between communities and academic researchers to engage in research design, decision making, data collection, and dissemination of health promotion initiatives. Community-based participatory projects often have formal agreements or defined roles for community and academic partners. Our project (November 2012-November 2014) was designed to document life narratives of urban American Indian elders as a foundation for developing a resilience-based health promotion curriculum for urban American Indian adolescents aged 12 to 18. We used a flexible method for engaging community partners that honored the individual strengths of elders, encouraged them to describe how they wanted to contribute to the project, and provided multiple ways for elders to engage with university partners. We invited elders to participate in one or more of the following roles: as members of consensus panels to develop interview questions, as members of a community advisory board, or as participants in individual qualitative interviews. The flexibility of roles gave elders the opportunity to serve as advisors, co-developers, interviewees, or reviewers during 2 years of curriculum development. Engaging American Indian elders in the research process acknowledged the multiple layers of expertise they had as traditional leaders in the community while promoting trust in and ownership of the project. This flexible technique can be used by other communities that may not be comfortable with structured processes of engagement.

A Brief Evaluation of a Project to Engage American Indian Young People as Agents of Change in Health Promotion Through Radio Programming, Arizona, 2009-2013.

Young people can be valuable motivational resources for health promotion. A project implemented from 2009 through 2013 in a small American Indian community in northwest Arizona recruited American Indian young people aged 10 to 21 as agents of change for health promotion through radio programming. Thirty-seven participants were recruited and trained in broadcasting and creative writing techniques; they produced and aired 3 radio dramas. In post-project evaluation, participants were confident they could influence community behaviors but thought that training techniques were too similar to those used in school activities and thus reduced their drive to engage. Effective engagement of young people requires creativity to enhance recruitment, retention, and impact.

Service learning: a vehicle for building health equity and eliminating health disparities.

Service learning (SL) is a form of community-centered experiential education that places emerging health professionals in community-generated service projects and provides structured opportunities for reflection on the broader social, economic, and political contexts of health. We describe the elements and impact of five distinct week-long intensive SL courses focused on the context of urban, rural, border, and indigenous health contexts. Students involved in these SL courses demonstrated a commitment to community-engaged scholarship and practice in both their student and professional lives. SL is directly in line with the core public health value of social justice and serves as a venue to strengthen community-campus partnerships in addressing health disparities through sustained collaboration and action in vulnerable communities.

Demographic characteristics and food choices of participants in the Special Diabetes Program for American Indians Diabetes Prevention Demonstration Project.

OBJECTIVE: American Indians and Alaska Natives (AI/ANs) suffer a disproportionate burden of diabetes. Identifying food choices of AI/ANs at risk of type 2 diabetes, living in both rural and urban settings, is critical to the development of culturally relevant, evidence-based education strategies designed to reduce morbidity and mortality in this population. DESIGN: At baseline, 3135 AI/AN adults participating in the Special Diabetes Program for American Indians Diabetes Prevention Demonstration Project (SDPI-DP) completed a socio-demographic survey and a 27-item food frequency questionnaire (FFQ). The primary dietary behavior goal of SDPI-DP education sessions and lifestyle coaching is changes in food choices, i.e., increased fruits, vegetables and whole grains, decreased high sugar beverages, red meat, and processed foods. Subsequently, program assessment focuses on changes in food types. Foods were delineated using a 'healthy' and 'unhealthy' classification as defined by the educators advising participants. Urban and rural differences were examined using χ(2) tests and two sample t-tests. Multiple linear regressions and linear mixed models were used to assess the association between socio-demographic factors and food choice. RESULTS: Retired participants, those living in urban areas and with high income and education selected healthy foods most frequently. Young males, those with low income and education consumed unhealthy foods most frequently. Selection of unhealthy foods did not differ by urban and rural setting. CONCLUSIONS: The ubiquitous nature of unhealthy food choices makes them hard to avoid. Food choice differences by gender, age, income, and setting suggest that nutrition education should more effectively target and meets the needs of young AI/AN males.

Documenting Cancer Information Seeking Behavior and Risk Perception in the Hualapai Indian Community to Inform a Community Health Program.

Cancer incidence among American Indians (AIs) is low, yet their 5-year relative survival rate is the second lowest of all U.S. populations. Culturally relevant cancer prevention education is key to achieve health equity. This collaborative project of the Hualapai Tribe and University of Arizona modified the National Cancer Institute's 2003 Health Information National Trends Survey (HINTS) to yield a more culturally relevant cancer information survey to document the health seeking behaviors and perceptions of cancer risks and preventability of AI adults residing in the Hualapai Indian community. A team of health care providers, educators and cancer survivors (six native and three non-natives) completed the adaptation. Four trained native surveyors administered the survey using a random household survey design. The Hualapai HINTS was well accepted (<5% refusal rate) and was completed by 205 adults (20.5% of all adult residents). Respondents reported a preference for and a trust in verbal cancer information and communication with health care professionals (77.1% preference; 57.4% trust) and at workshops (75.2% preference; 45.5% trust). Respondents were aware of some health behaviors associated with a reduced cancer risk, e.g., avoid tobacco use and need for screening. Respondents were less well informed about the role of diet and exercise. These findings were used to inform local cancer prevention education efforts and to develop a series of monthly workshops that engaged local health professionals to reinforce and discuss pathways of the primary role of lifestyle related factors, specifically diet and exercise in reducing cancer risk.

Changes in Food Choices of Participants in the Special Diabetes Program for Indians-Diabetes Prevention Demonstration Project, 2006-2010.

INTRODUCTION: American Indians/Alaska Natives (AI/ANs) have a disproportionately high rate of type 2 diabetes. Changing food choices plays a key role in preventing diabetes. This study documented changes in the food choices of AI/ANs with diagnosed prediabetes who participated in a diabetes prevention program. METHODS: The Special Diabetes Program for Indians-Diabetes Prevention Demonstration Project implemented the evidence-based Diabetes Prevention Program (DPP) lifestyle intervention in 36 health care programs nationwide, engaging 80 AI/AN communities. At baseline, at 30 days post-curriculum, and at the first annual assessment, participants completed a sociodemographic survey and 27-item food frequency questionnaire and underwent a medical examination assessing fasting blood glucose (FBG), blood pressure, body mass index (BMI), low-density lipoprotein [LDL], high-density lipoprotein [HDL], and triglycerides. Multiple linear regressions were used to assess the relationship between temporal changes in food choice and other diabetes risk factors. RESULTS: From January 2006 to July 2010, baseline, post-curriculum, and first annual assessments were completed by 3,135 (100%), 2,046 (65%), and 1,480 (47%) participants, respectively. An increase in healthy food choices was associated initially with reduced bodyweight, BMI, FBG, and LDL and increased physical activity. At first annual assessment, the associations persisted between healthy food choices and bodyweight, BMI, and physical activity. CONCLUSION: AI/AN adults from various tribal and urban communities participating in this preventive intervention made sustained changes in food choices and had reductions in diabetes risk factors. The outcomes demonstrate the feasibility and effectiveness of translating the DPP lifestyle intervention to community-based settings.

Using a participatory research approach in a school-based physical activity intervention to prevent diabetes in the Hualapai Indian community, Arizona, 2002-2006.

INTRODUCTION: In the United States, type 2 diabetes has reached epidemic proportions among indigenous people. Community-based participatory research offers American Indian communities and university partners an opportunity to integrate skills in community action and systematic inquiry to develop locally acceptable primary prevention interventions to combat diabetes risk factors. The Hualapai Tribe and the University of Arizona designed, implemented, and assessed a school-based physical activity intervention to reduce diabetes risk factors among youth. METHODS: During a 2-year period, trained community members led in-school physical activity classes 2 times per week among students in grades 3 through 8. Body mass index (BMI), fitness measures, and fasting blood glucose level were measured on 6 occasions. Descriptive statistics and t tests were used to assess change in outcome measures. RESULTS: Of the more than 100 youth who took part in the physical activity classes for 2 years, 71 youth (38 male, 33 female) participated in 3 or more data collection sessions. Over time, the percentage of youth with a high fasting blood glucose level of more than 125 mg/dL decreased concurrently with significant improvements in fitness measures. However, BMI increased in both male and female participants. The high number of youth who missed more than 3 data collection sessions was attributed to poor school attendance and tardiness. CONCLUSION: Classes led by lay physical activity leaders can affect diabetes risk factors in youth. Incongruous health and fitness outcomes suggest that one indicator does not adequately define the risk profile; BMI alone may not be sufficient as a measure of diabetes risk in youth.

"If you're down, you know, get up, be proud of yourself, go forward": Exploring Urban Southwest American Indian Individual Resilience.

The diverse American Indian and Alaska Native (AI/AN) population suffers health inequities perpetuated by colonialism and post-colonialism. The urban AI/AN population is steadily increasing in part because of federal policies relocating AI/AN away from tribal lands. However, studies of AI/AN urban communities are rare, and efforts to understand and ameliorate health inequities in AI/AN communities typically emphasize deficits rather than capacities. Resilience is an important resource in this context but mainstream, rather than community-derived definitions of resilience, predominate. The present study used multi-investigator consensus analysis in a qualitative study to identify urban American Indian (AI) derived concepts and construct a definition of resilience. The study included 25 AI adults in four focus groups in three urban locales in the southwestern United States. Four resilience themes emerged: 1) AIs built strength through toughness and wisdom; 2) the value of traditional 'lifeways' (i.e., elements of traditional culture that help people navigate their journey through life); 3) the importance of giving and receiving help; and 4) the interconnectedness of Native lifeways, family relationships, and tribal and urban communities. Themes overlap with extant resilience conceptualizations but also provide unique insights into structure and function of urban AI resilience in the Southwest United States.

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 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.

Understanding Resilience and Mental Well-Being in Southwest Indigenous Nations and the Impact of COVID-19: Protocol for a Multimethods Study.

BACKGROUND: Despite experiencing many adversities, American Indian and Alaska Native populations have demonstrated tremendous resilience during the COVID-19 pandemic, drawing upon Indigenous determinants of health (IDOH) and Indigenous Nation Building. OBJECTIVE: Our multidisciplinary team undertook this study to achieve two aims: (1) to determine the role of IDOH in tribal government policy and action that supports Indigenous mental health and well-being and, in turn, resilience during the COVID-19 crisis and (2) to document the impact of IDOH on Indigenous mental health, well-being, and resilience of 4 community groups, specifically first responders, educators, traditional knowledge holders and practitioners, and members of the substance use recovery community, working in or near 3 Native nations in Arizona. METHODS: To guide this study, we developed a conceptual framework based on IDOH, Indigenous Nation Building, and concepts of Indigenous mental well-being and resilience. The research process was guided by the Collective benefit, Authority to control, Responsibility, Ethics (CARE) principles for Indigenous Data Governance to honor tribal and data sovereignty. Data were collected through a multimethods research design, including interviews, talking circles, asset mapping, and coding of executive orders. Special attention was placed on the assets and culturally, socially, and geographically distinct features of each Native nation and the communities within them. Our study was unique in that our research team consisted predominantly of Indigenous scholars and community researchers representing at least 8 tribal communities and nations in the United States. The members of the team, regardless of whether they identified themselves as Indigenous or non-Indigenous, have many collective years of experience working with Indigenous Peoples, which ensures that the approach is culturally respectful and appropriate. RESULTS: The number of participants enrolled in this study was 105 adults, with 92 individuals interviewed and 13 individuals engaged in 4 talking circles. Because of time constraints, the team elected to host talking circles with only 1 nation, with participants ranging from 2 to 6 in each group. Currently, we are in the process of conducting a qualitative analysis of the transcribed narratives from interviews, talking circles, and executive orders. These processes and outcomes will be described in future studies. CONCLUSIONS: This community-engaged study lays the groundwork for future studies addressing Indigenous mental health, well-being, and resilience. Findings from this study will be shared through presentations and publications with larger Indigenous and non-Indigenous audiences, including local recovery groups, treatment centers, and individuals in recovery; K-12 and higher education educators and administrators; directors of first responder agencies; traditional medicine practitioners; and elected community leaders. The findings will also be used to produce well-being and resilience education materials, in-service training sessions, and future recommendations for stakeholder organizations. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/44727.