Increasing culturally responsive care and mental health equity with indigenous community mental health workers

Fatal Firearm Violence Among American Indians and Alaska Natives

There is a dearth of population-based studies regarding firearm-related deaths and years of potential life lost among American Indians and Alaska Natives (AI/AN). Using the Centers for Disease Control and Prevention's (CDC) We Based Injury Statistics Query and Reporting System (WISQARS) data for the three most recent years (2018-2020), we analyzed the demographic characteristics of AI/ANs who succumbed to firearm violence. AI/ANs averaged almost 500 firearm-related deaths per year. The majority of these deaths were observed among individuals 20-39 years of age (53%), males (84.4%), and in the West (55.3%). A plurality of these firearm-related deaths were suicides (48.9%) followed by homicides (43.5%). During the 3-year study period, the age-adjusted firearm death rate increased almost 5 times the growth of the AI/AN population. Also, a staggering 67,050 years of potential life were lost before the age of 80 years (YPLL80) during this period. Firearm suicides were responsible for the largest proportion of YPLL80s (48.5%). Traditional legal interventions [e.g., child access prevention (CAP) laws and extreme risk protection orders (ERPO)], if expanded to more states could potentially help reduce AI/AN firearm mortality. None of the 10 states with the highest firearm mortality of AI/AN have ERPOs and 8 of the 10 do not have CAP laws. Also, a renewed focus on cultural continuity and indigenous protective factors is essential to ameliorate the level of firearm violence in AI/ANs.

Examining global Indigenous community wellness worker models: a rapid review

BACKGROUND

There is a growing interest in employing community wellness worker models in Indigenous populations to address inequities in healthcare access and outcomes, concerns about shortage in health and mental health human resources, and escalating burden of chronic and complex diseases driving significant increase in health services demand and costs. A thorough review of Indigenous community wellness worker models has yet to be conducted. This rapid review sought to outline the characteristics of a community wellness worker model in Indigenous contexts across the globe, detailing factors shaping implementation challenges and success.

METHODS

A rapid review of the international peer-reviewed and grey literature of OVID Medline, Global Index Medicus, Google, and Google Scholar was conducted from January to June 2022 for Indigenous community wellness/mental health worker models and comparative models. Articles were screened and assessed for eligibility. From eligible articles, data pertaining to study design and sample; description of the program, service, or intervention; model development and implementation; terminology used to describe workers; training features; job roles; funding considerations; facilitators and barriers to success; key findings; outcomes measured; and models or frameworks utilized were extracted. Data were synthesized by descriptive and pattern coding.

RESULTS

Twenty academic and eight grey literature articles were examined. Our findings resulted in four overarching and interconnected themes: (1) worker roles and responsibilities; (2) worker training, education, and experience; (3) decolonized approaches; and (4) structural supports.

CONCLUSION

Community wellness worker models present a promising means to begin to address the disproportionately elevated demand for mental wellness support in Indigenous communities worldwide. This model of care acts as a critical link between Indigenous communities and mainstream health and social service providers and workers fulfill distinctive roles in delivering heightened mental wellness supports to community members by leveraging strong ties to community and knowledge of Indigenous culture. They employ innovative structural solutions to bolster their efficacy and cultivate positive outcomes for service delivery and mental wellness. Barriers to the success of community wellness worker models endure, including power imbalances, lack of role clarity, lack of recognition, mental wellness needs of workers and Indigenous communities, and more.

Enhancing COVID-19 Vaccine Uptake among Tribal Communities: A Case Study on Program Implementation Experiences from Jharkhand and Chhattisgarh States, India

Tribal populations in India have health care challenges marked by limited access due to geographical distance, historical isolation, cultural differences, and low social stratification, and that result in weaker health indicators compared to the general population. During the pandemic, Tribal districts consistently reported lower COVID-19 vaccination coverage than non-Tribal districts. We assessed the MOMENTUM Routine Immunization Transformation and Equity (the project) strategy, which aimed to increase access to and uptake of COVID-19 vaccines among Tribal populations in Chhattisgarh and Jharkhand using the reach, effectiveness, adoption, implementation, and maintenance framework. We designed a qualitative explanatory case study and conducted 90 focus group discussions and in-depth interviews with Tribal populations, community-based nongovernmental organizations that worked with district health authorities to implement the interventions, and other stakeholders such as government and community groups. The active involvement of community leaders, targeted counseling, community gatherings, and door-to-door visits appeared to increase vaccine awareness and assuage concerns about its safety and efficacy. Key adaptations such as conducting evening vaccine awareness activities, holding vaccine sessions at flexible times and sites, and modifying messaging for booster doses appeared to encourage vaccine uptake among Tribal populations. While we used project resources to mitigate financial and supply constraints where they arose, sustaining long-term uptake of project interventions appears dependent on continued funding and ongoing political support.

Youth Suicide Prevention Programming among the Mississippi Band of Choctaw Indians: Effects of the Lifelines Student Curriculum

Suicide continues to be a leading cause of mortality for young people. Given persistent intersecting forms of disadvantage, Native American adolescents are especially vulnerable to mental health adversities and other suicide risk factors. The Mississippi Band of Choctaw Indians (MBCI) implemented the Choctaw Youth Resilience Initiative (CYRI), a five-year SAMHSA-funded project that began in 2019. This study uses Choctaw student pre-test/post-test survey data to examine the effectiveness of the Hazelden Lifelines Suicide Prevention Training curriculum for youth. A lagged post-test design was used, whereby post-surveys were administered at least one month after program completion. Several intriguing results were observed. First, the lagged post-test model was subject to some pre-to-post attrition, although such attrition was comparable to a standard pre/post design. Second, analyses of completed surveys using means indicated various beneficial effects associated with the Lifelines curriculum implementation. The greatest benefit of the program was a significant change in student perceptions concerning school readiness in response to a suicidal event. Some opportunities for program improvement were also observed. Our study sheds new light on suicide prevention training programs that can be adapted according to Native American youth culture. Program implementation and evaluation implications are discussed in light of these findings.

Expanding the Question-Persuade-Refer (QPR) Evidence Base: Youth Suicide Prevention among the Mississippi Band of Choctaw Indians

Youth suicide risks have been on the rise or persistently elevated for decades, and Native American communities are especially vulnerable. This study provides a promising framework for suicide prevention among underserved populations in the U.S., especially Native American communities in states lacking strong suicide prevention supports. Our investigation reports the evaluation results of the Question-Persuade-Refer (QPR) gatekeeper training program, a key component of the SAMHSA-funded Choctaw Youth Resilience Initiative (CYRI) implemented by the Mississippi Band of Choctaw Indians (MBCI). QPR trains adult gatekeepers to identify youth at risk of suicide and refer them to certified mental health service providers. Standardized QPR pre-test and post-test training surveys were administered at in-person trainings delivered to youth-serving MBCI organization leaders and staff. Statistical analyses of all survey items indicate that QPR gatekeeper trainings significantly enhanced the knowledge of prevention practices and risk identification skills for the MBCI trainees. The robust evidence of positive changes revealed in this study suggests that QPR can be an effective suicide prevention program for underserved minority communities, especially Native American populations in rural states where suicide is a persistent and leading cause of mortality.

The Role of Social Networks on Depression and Anxiety Among a Sample of Urban American Indian/Alaska Native Emerging Adults

PURPOSE

Mental health inequalities continue to persist among American Indian/Alaska Native (AI/AN) people. However, few studies have examined the association of social networks and depression and anxiety among urban emerging AI/AN adults.

METHODS

This study analyzes the association of social network characteristics with depression and anxiety among a sample of urban AI/AN emerging adults. A second set of regression models tested the same associations but controlling for respondent sexual and gender minority (SGM) status. Data were from a sample of 150 AI/AN emerging adults residing in urban areas from 20 different states (86% female; mean age 21.8; 48.0% SGM) who participated in a randomized controlled trial analyzing the effects of culturally grounded interventions on alcohol and other drug use and cultural connectedness.

RESULTS

Participants with a higher proportion of network members who were around the same age reported significantly less anxiety. Those who had a higher proportion of network members who they sometimes/often argue/fight with were more likely to report greater depression and anxiety. Participants with higher proportions of social network members who have ever lived on a reservation/Rancheria/tribal land/tribal village reported significantly less depression. However, participants with higher proportions of social network members who lived 50 miles away or more reported significantly more depression. Controlling for SGM status, results were largely similar.

DISCUSSION

Results highlight the role of social connections on the mental well-being of urban AI/AN emerging adults.

Development and Feasibility Pilot Study of Indigenous Recovery Planning: A Community-Engaged Approach to Addressing Substance Use in a Native Community

Although Native (American Indian and Alaska Native [AI/AN]) populations have high rates of abstinence from alcohol, health problems associated with substance use remain a pressing concern in many AI/AN communities. As part of a longstanding community-based participatory research (CBPR) project involving five years of relationship building and three preliminary studies, our team of academic and community co-researchers developed a culturally grounded intervention to facilitate recovery from substance use disorders among tribal members from a rural AI reservation. Our Indigenous Recovery Planning (IRP) intervention consists of six weekly sessions and aims to provide inroads to existing resources in the community, affirm and enhance Native identity, address culturally relevant risk factors, and build upon strengths. Results from a feasibility pilot study (N = 15) suggest that IRP is feasible to implement and acceptable to the community. Although there was insufficient statistical power to conduct hypothesis testing, there were changes between pretest and posttest scores in the expected directions. Future directions and limitations of this research are discussed.

"'We'd Just Patch Ourselves up': Preference for Holistic Approaches to Healthcare and Traditional Medicine among Members of a State-Recognized Tribe"

Background:Health disparities between Native Americans and white Americans persist due to a variety of factors, including colonization, poverty, and racism. Racist interpersonal interactions between nurses and other healthcare providers and tribal members may also contribute to reluctance among Native Americans to engage with Western healthcare systems. Purpose: The purpose of this study was to better understand the healthcare experiences of members of a state-recognized Gulf Coast tribe. Methods: In partnership with a community advisory board, 31 semistructured interviews were conducted, transcribed, and analyzed utilizing a qualitative description approach. Results: All participants mentioned their preferences, views about, or experiences of using natural or traditional medicine approaches (referenced 65 times). Emergent themes include (a) preference for and use of traditional medicine; (b) resistance to western healthcare systems; (c) preference for holistic approaches to health; and (d) negative provider interpersonal interactions contributing to reluctance in seeking care. Conclusion: These findings suggest that integrating a holistic conceptualization of health and traditional medicine practices into Western healthcare settings would benefit Native Americans.

An Updated Narrative Review on the Role of Alcohol Among Indigenous Communities

Purpose of Review

The role of alcohol varies considerably among Indigenous Peoples and is the backdrop of persistent stereotypes despite decades of research. This paper provides an updated narrative review on the alcohol literature among Indigenous communities, highlighting recent studies published since 2017.

Recent Findings

We examined published literature involving alcohol use rates, including abstinence; risk and protective factors; treatment; and recovery, as well as future directions for alcohol prevention and intervention efforts with Indigenous communities.

Summary

Evidence-based alcohol use prevention, intervention, and recovery strategies with Indigenous communities are outlined. Recommendations are provided for researchers, health providers, and public policy advocates to address and better understand alcohol use, treatment, prevention, and recovery among Indigenous Peoples. Specific recommendations include using community-based participatory research strategies and harm reduction approaches to prevent and treat alcohol use problems with Indigenous communities. Future research is needed to elucidate mechanisms of resilience and recovery from Alcohol Use Disorder and possible shifts in perceptions of alcohol use for Indigenous Peoples.

Racism, early psychosis, and institutional contact: A qualitative study of Indigenous experiences

BACKGROUND

There is evidence of Indigenous and ethnic minority inequities in the incidence and outcomes of early psychosis. Racism has been implicated as having an important role.

AIM

To use Indigenous experiences to develop a more detailed understanding of how racism operates to impact early psychosis outcomes.

METHODS

Critical Race Theory informed the methodology used. Twenty-three Indigenous participants participated in four family focus group interviews and thirteen individual interviews, comprising of 9 Māori youth with early psychosis, 10 family members and 4 Māori mental health professionals. An analysis of the data was undertaken using deductive structural coding to identify descriptions of racism, followed by inductive descriptive and pattern coding.

RESULTS

Participant experiences revealed how racism operates as a socio-cultural phenomenon that interacts with institutional policy and culture across systems pertaining to social responsiveness, risk discourse, and mental health service structures. This is described across three major themes: 1) selective responses based on racial stereotypes, 2) race related risk assessment bias and 3) institutional racism in the mental health workforce. The impacts of racism were reported as inaction in the face of social need, increased use of coercive practices and an under resourced Indigenous mental health workforce.

CONCLUSION

The study illustrated the inter-related nature of interpersonal, institutional and structural racism with examples of interpersonal racism in the form of negative stereotypes interacting with organizational, socio-cultural and political priorities. These findings indicate that organizational cultures may differentially impact Indigenous and minority people and that social responsiveness, risk discourse and the distribution of workforce expenditure are important targets for anti-racism efforts.

Feasibility, acceptability and effectiveness of a culturally informed intervention to decrease stress and promote well-being in reservation-based Native American Head Start teachers

BACKGROUND

While benefiting from strong cultural ties to family, land and culture Native Americans residing on reservations experience psychological distress at rates 2.5 times that of the general population. Treatment utilization for psychological health in reservation-based communities is low with access to culturally appropriate care lacking. Evidence suggests that for mental health treatment, Native Americans prefer culturally informed care that respects Native perspectives on health and well-being.

METHODS

To decrease stress and promote well-being in tribal Head Start teachers we adapted and implemented a culturally focused intervention within a community-based participatory research framework using mixed methods. Feasibility and acceptability of the adapted 5-session curriculum was tested in a single arm intervention study with a sample of 18 teachers on the Fort Peck Reservation. Participants completed surveys at baseline and upon completion of the intervention. Within session observations and two post-intervention focus groups (n = 8, n = 10) were conducted to elaborate and explain the quantitative results eliciting participant experience of intervention effectiveness and feasibility, acceptably and appropriateness. Implementation outcomes were assessed quantitatively using the Acceptability of Intervention, Intervention Appropriateness, and Feasibility of Intervention measures.

RESULTS

Quantitively, attendance rate overall was 93% with no dropouts. Pretest/posttest surveys were analyzed using t-tests and Hedges g to measure effect size. Contrary to our hypothesis, self-perceived stress showed a small positive effect size, indicating that participants were more stressed post intervention. However, depression decreased, with tribal identity and resilience showing positive effect sizes. Content analysis for the qualitative data collected within session observations and post intervention focus groups revealed how lifetime traumas were affecting participants, providing some explanation for the increase in stress. Teachers reported that the sessions helped their psychological health and well-being, supporting feasibility of future interventions. Acceptability scored highest with a mean (SD) of 4.25 (.84) out of 5, appropriateness 4.18 (.86) and feasibility 4.06 (.96) supporting intervention to be acceptable, appropriate, and feasible.

CONCLUSION

Utilizing a culturally based intervention to buffer stress and support the well-being of reservation-based teachers showed promise in helping them recognize their cultural strengths, stress, and need for ongoing support. Implementation outcomes show that intervention scale-out is feasible.

New Collaborative Research on Suicide Prevention, Practice, and Policy With American Indian and Alaska Native Communities Holds Promise for All Peoples

Youth suicide is increasing in the United States, with deaths among younger people of color driving this upward trend. For more than four decades, American Indian and Alaska Native (AIAN) communities have suffered disproportionate rates of youth suicide and years of productive life lost compared to other U.S. Races. The National Institute of Mental Health (NIMH) recently funded three regional Collaborative Hubs to carry out suicide prevention research, practice, and policy development with AIAN communities in Alaska and rural and urban areas of the Southwestern United States. The Hub partnerships are supporting a diverse array of tribally-driven studies, approaches, and policies with immediate value for increasing empirically driven public health strategies to address youth suicide. We discuss unique features of the cross-Hub work, including: (a) long-standing Community-Based Participatory Research processes that led to the Hubs' innovative designs and novel approaches to suicide prevention and evaluation, (b) comprehensive ecological theoretical approaches that contextualize individual risk and protective factors in multilevel social contexts; (c) unique task-shifting and systems of care approaches to increase reach and impact on youth suicide in low-resource settings; and (d) prioritization of strengths-based approaches. The work of the Collaborative Hubs for AIAN youth suicide prevention is generating specific and substantive implications for practice, policy, and research presented in this article at a time when youth suicide prevention is a dire national priority. Approaches also have relevance for historically marginalized communities worldwide.

Racism, early psychosis and institutional contact: a qualitative study of Indigenous experiences

There is evidence of Indigenous and ethnic minority inequities in the incidence and outcomes of early psychosis. racism has an important role. This study aimed to use Indigenous experiences to develop a more detailed understanding of how racism operates to impact early psychosis. Critical Race Theory informed the methods used. Twenty-three Indigenous participants participated in 4 family focus group interviews and 13 individual interviews, comprising of 9 youth, 10 family members and 4 mental health professionals. An analysis of the data was undertaken using deductive structural coding to identify descriptions of racism, followed by inductive descriptive and pattern coding. Participant experiences revealed how racism operates as a socio-cultural phenomenon that interacts with institutional policy and culture across systems. This is described across three themes: (1) selective responses based on racial stereotypes, (2) race related risk assessment bias and (3) institutional racism in the mental health workforce. The impacts of racism were reported as inaction in the face of social need, increased coercion and an under resourced Indigenous workforce. These findings indicate that organizational cultures may differentially impact Indigenous and minority people and that social responsiveness, risk discourse and the distribution of workforce expenditure are important targets for anti-racism efforts.

An Integrative Review of Barriers and Facilitators Associated With Mental Health Help Seeking Among Indigenous Populations

OBJECTIVE

Indigenous populations, compared with majority populations, have a reduced likelihood of receiving professional help for mental health, contributing to health disparities. To increase use of and access to mental health services for Indigenous people, specific factors that affect service use need to be examined. An integrative review was undertaken of the barriers to and facilitators of help seeking and service use for Indigenous populations in Canada, the United States, Australia, and the Pacific Islands.

METHODS

Five databases-PsycINFO, PubMed, Web of Science, Social Services Abstracts, and Bibliography of Native North Americans-and gray literature were searched to identify original studies with data specific to Indigenous people. A qualitative analysis of common themes among the studies was conducted, along with a quality appraisal of included articles. Of the 1,010 records identified, the final synthesis included 41 articles.

RESULTS

Six main themes emerged: informal supports, which were often used as a first choice for help seeking compared with formal services; structural obstacles and supports; stigma and shame; self-reliance and uncertainty about services; cultural factors and mistrust of mainstream services; and the need for outreach and information regarding mental illness and services.

CONCLUSIONS

Policy implications include needed structural changes to decrease mistrust of mainstream systems and services and increased funding and resource availability. Along with technology-facilitated treatment, programs for Indigenous people, families, and communities that enhance education and foster positive relationships can serve as a first step toward Indigenous people becoming comfortable with the idea of talking about mental health and with seeking treatment.

The Pre-implementation Process of Adapting a Culturally Informed Stress Reduction Intervention for Native American Head Start Teachers

Head Start is a federally funded program for children (3-5 years) from low-income families. In the Fort Peck Native American Reservation, tribal Head Start teachers have reported high stress in supporting children experiencing adverse childhood experiences. Thus, we adapted the Little Holy One intervention (ClinicalTrials.gov: NCT04201184) for the teachers' context and culture to enhance psychological health and well-being. Within a participatory framework, the eight-step ADAPT-ITT methodology was used to guide the adaptation process: assessment; decision; adaptation; production; topical experts; integration; training; and testing. For Step 1, we purposive sampled 27 teachers, ancillary staff, and parents to understand teachers' stress, support mechanisms, and interest in an intervention via focus groups (n = 9) and individual interviews (n = 18). Qualitative data underscored teachers' experiences of stress, depression, and need for support (Step 1). Iterative feedback from a tribal advisory board and Little Holy One designers rendered selection of five lessons (Step 2, 5), which were adapted for the teachers via theater testing (Step 3, 4). Community capacity assessment revealed their ability to implement the intervention (Step 6). Testing of this adapted intervention in a feasibility trial (steps 7, 8) will be reported in a future publication. A rigorous systematic process within a participatory framework allowed intervention adaption based on community input. Leveraging "culture as treatment" may be useful for enhancing psychological health outcomes for Native Americans who historically underutilize existing psychological services.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43477-022-00070-3.

Supporting Indigenous Child Suicide Prevention Within Classrooms in Canada: Implications for School Psychologists and Educators

Indigenous young people in Canada are disproportionately overrepresented in suicide rates and alarmingly, young children are accounted for in these disparities. Since children spend much of their day at school, schools are a vital context for suicide prevention, identification, and intervention. However, research indicates that educators often report that they feel unprepared to address mental health challenges within the classroom. Indigenous communities are developing community driven responses to suicide that are culturally relevant and strengths based. It is critical that these models are considered when developing such suicide prevention within schools as they diverge from medicalized focused approaches and attend to broader social dimensions. It is imperative that educators and the education system are properly equipped with the training and resources to provide suicide prevention within schools and communities servicing Indigenous children. School psychologists can play an important role in providing this prevention leadership. Through interviews with educators, we learned about the types of supports that are needed within schools to address Indigenous child suicide, and in what ways school psychologists could enhance prevention efforts. Using a reflexive approach to thematic analysis, we identified four main themes related to support needed. Findings are discussed in conversation with the current state of child specific suicide and suicide prevention literature. Applied implications for suicide prevention within schools for Indigenous children, as well as future research and community-based recommendations are considered.

Content Analysis of Preferred Recovery Pathways Among Urban American Indians and Alaska Natives Experiencing Alcohol Use Disorders

Approximately three fourths of the American Indian and Alaska Native (AI/AN) population lives in urban areas, and urban AI/ANs are disproportionately affected by alcohol-related morbidity and mortality. Although no studies have documented alcohol use disorder (AUD) treatment outcomes specific to urban AI/ANs, studies in other Native communities highlight concerns about the cultural acceptability of directive, abstinence-based approaches, such as cognitive behavioral therapy and 12-step programs. Understanding this population’s desired recovery pathways in their own words may help providers create more culturally appropriate, patient-centered, and effective approaches. Participants ( N = 31) were urban AI/ANs who screened positive for AUD using the AUDIT-C. They participated in semi-structured interviews eliciting their experiences in AUD treatment to date and suggestions for redesigning AUD treatment in their own vision. Conventional content analysis was used to create a thematic description. Findings indicated that intrinsic motivation and not extrinsic pressure (e.g., mandated treatment) was associated with positive treatment engagement and outcomes. Participants appreciated feeling safe and supported in AUD treatment, but also felt AUD treatment could be institutional and oppressive. Participants preferred compassionate counselors with lived experience who could provide insights into recovery; they largely did not appreciate a “tough love” approach or power struggles with counselors. Native-led treatment centers providing access to cultural practices were preferred. Moving forward, participants suggested AUD treatment providers should help patients meet basic needs, prioritize patient-driven versus provider-driven goal-setting, support patients’ reconnection with meaningful activities, facilitate access to a supportive community network, and recognize cultural activities as important recovery pathways.

Downward National Trends in Mental Health Treatment Offered in Spanish: State Differences by Proportion of Hispanic Residents

OBJECTIVE

This study aimed to determine how the prevalence of mental health treatment facilities that offer services in Spanish has changed over time in the United States.

METHODS

Data from the National Mental Health Services Survey conducted in 2014 (N=13,015 facilities) and 2019 (N=12,345 facilities) were used to measure changes in the proportions of facilities that offered treatment in Spanish overall and by year, state, and proportion of Hispanic residents. Descriptive statistics were used to illustrate state-level changes in services offered in Spanish.

RESULTS

Between 2014 and 2019, the national Hispanic population increased by 4.5%, or 5.2 million people. During the same period, the proportion of facilities that offered treatment in Spanish declined by 17.8%, or a loss of 1,163 Spanish-speaking mental health facilities. Overall, 44 states saw a decline in the availability of services in Spanish, despite growth in Hispanic populations across all states. Among states with the fastest Hispanic population growth, several also experienced the greatest reduction in Spanish-language services.

CONCLUSIONS

The findings indicate that availability of Spanish-language mental health services decreased in most U.S. states during 2014–2019. Promoting mental health service delivery in Spanish is critical for reducing barriers to treatment and ensuring health equity across populations.

Development and Cultural Adaptation of Psychological First Aid for COVID-19 Frontline Workers in American Indian/Alaska Native Communities

The coronavirus disease 19 (COVID-19) pandemic is broadly affecting the mental health and well-being of people around the world, and disproportionately affecting some groups with already pre-existing health inequities. Two groups at greater risk of physical and/or mental health detriments from COVID-19 and more profoundly impacted by the pandemic include frontline workers and American Indian/Alaska Native (AI/AN) communities. To provide support and prevent long-term mental health problems, we culturally adapted a psychological first aid guide specifically for COVID-19 frontline workers serving AI/AN communities. We engaged a diverse, collaborative work group to steer the adaptation content and process. We also held two focus group discussions with frontline workers in AI/AN communities to incorporate their perspectives into the adapted guide. Results from the group discussions and the collaborative work group were compiled, analyzed to extract themes and suggestions, and integrated into the adapted content of the guide. Main adaptations included updating language (i.e., to be more culturally appropriate, less prescriptive, and less text heavy), framing the guide from a harm-reduction lens, incorporating cultural activities, values, and teachings common across diverse AI/AN communities (e.g., importance of being a good relative), and validating feelings and experiences of frontline workers. The resulting adapted guide includes four modules and is available as a free online training. Our adaptation process may serve as a guiding framework for future adaptations of similar resources for specific groups. The adapted guide may stand as an enduring resource to support mental well-being, the prevention of mental health problems, and reduction of health inequities during the pandemic and beyond.

Preventing Suicidal Behavior Among American Indian and Alaska Native Adolescents and Young Adults

From 2009 to 2018, overall suicide rates in the United States increased by 20.3% and increased by 43.5% among non-Hispanic American Indian and Alaska Native (AI/AN) communities. Combining years 2009 through 2018, suicide rates per 100 000 population among non-Hispanic AI/AN adolescents and young adults aged 15 to 34 years were 2 to 4 times higher than those of adolescents and young adults of other races and ethnicities. An estimated 14% to 27% of non-Hispanic AI/AN adolescents attempted suicide during that time. The elevated rates of suicidal behavior among non-Hispanic AI/AN adolescents and young adults reflect inequities in the conditions that create health. In this topical review, we describe school-based educational efforts that are driven by local AI/AN communities, such as the American Indian Life Skills curriculum, that teach stress and coping skills and show promise in reducing suicidal ideation attempts and fatalities among AI/AN adolescents. Using a social-determinants-of-health lens, we review the availability and quality of employment as an important influencer of suicidal behavior, as well as the role of the workplace as an environment for suicide prevention in AI/AN communities. Working with tribal, state, local, and federal colleagues, the public health community can implement programs known to be effective and create additional comprehensive strategies to reduce inequities and ultimately reduce suicide rates.

An update on ACEs domain frequencies across race/ethnicity and sex in a nationally representative sample

BACKGROUND

Adverse childhood experiences (ACEs) research has yielded important information regarding ACEs prevalence and impacts; however, few studies have included American Indian/Alaska Native (AI/AN) populations.

OBJECTIVE

We aimed to update and expand the ACEs literature by using recent data (2009-2018; over 50% from 2015 to 2017); using a large, nationally representative sample (total N = 166,606) and AI/AN sub-sample (N = 3369); and including additional covariates (i.e., sex, age, income, education) to provide a comprehensive understanding of ACEs across diverse populations.

PARTICIPANTS AND SETTING

Data were from the CDC's BRFSS, a standardized scale used in most ACEs literature, to improve generalizability of study findings, which may contribute to investigating future ACEs trends.

METHODS

Descriptive statistics and negative binomial regression analyses were conducted to examine the frequency of ACEs and the eight ACEs domains across racial/ethnic and sex groups.

RESULTS

AI/ANs had the highest ACEs compared to all racial/ethnic groups. Females had higher mean ACEs compared to males of the same racial/ethnic group; significant differences were identified between non-Hispanic White (NHW) females and NHW males, and between Hispanic females and Hispanic males. Across all 10 stratified subgroups, AI/AN females had the highest average ACEs followed by AI/AN males. Emotional abuse was the most reported ACEs domain across all individuals, and family incarceration was the lowest. AI/AN females and males had the highest ACEs frequencies in family substance use, witnessing intimate partner violence, and sexual and emotional abuse.

CONCLUSIONS

Findings have important implications for public health intervention and prevention efforts that may mitigate the impact of ACEs across racial/ethnic groups, particularly for AI/AN populations.

Medical Mistrust in Perinatal Mental Health

Despite the advancement of telemedicine and recent innovations in treatment, minoritized women continue to bear a disproportionate burden of pregnancy-related psychiatric conditions and complications, which the pandemic has further exacerbated. Research demonstrates that medical mistrust and systemic racism play central roles in the underutilization of services by racially and ethnically diverse women during pregnancy and postpartum. To effectively address these disparities, it is imperative to understand the drivers of medical mistrust in perinatal health care systems. This Perspectives article describes the historical context of medical mistrust in psychiatric and obstetric health systems and offers solutions to mitigate mistrust and the impact of systemic racism on perinatal care.

Impact on community members of a culturally appropriate adaptation of a social and emotional well-being intervention in an aboriginal community

Purpose

Indigenous Australians report mental health problems at a much higher rate than non-Indigenous Australians. However, rather than more services, it has been proposed that there should be a positive, socially based approach to improving mental health in Indigenous communities. The population-wide Western Australian Act-Belong-Commit mental health promotion campaign appeared to be consistent with such an approach. Hence, after consultation with Indigenous community members, a culturally adapted version of the campaign was developed and launched in a largely Indigenous remote Australian community. A survey of Indigenous community members was conducted two years later to assess campaign impact. The aim of this paper is to report on the impact on community members of this cultural adaptation.

Design/methodology/approach

Intercept interviews were conducted with Indigenous community members (n = 31) to assess respondents’ awareness of the campaign elements and activities, understanding of campaign messages and whether respondents had undertaken activities to improve their own or their family’s social and emotional well-being as a result of the campaign.

Findings

There was universal awareness of the adapted campaign in this sample, with 81% reporting doing something for their own social and emotional well-being, 74% reporting doing something for the social and emotional well-being of their family or friends and 48% reporting doing something for community well-being, as a result of campaign exposure.

Originality/value

The cultural adaptation of the Act-Belong-Commit campaign in the Australian Roebourne community is the first reported Indigenous adaptation of a population-wide mental health promotion campaign.

Examining the role of Indigenous primary healthcare across the globe in supporting populations during public health crises

When health systems are overwhelmed during a public health crisis regular care is often delayed and deaths result from lapses in routine care. Indigenous primary healthcare (PHC) can include a range of programmes that incorporate treatment and management, prevention and health promotion, as well as addressing the social determinants of health (SDoH) and a focus on redressing health inequities. We examined how Indigenous PHC mobilises and innovates during a public health crisis to address patient needs and the broader SDoH. A rapid review methodology conducted from January 2021 - March 2021 was purposefully chosen given the urgency with COVID-19, to understand the role of Indigenous PHC during a public health crisis. Our review identified five main themes that highlight the role of Indigenous PHC during a public health crisis: (1) development of culturally appropriate communication and education materials about vaccinations, infection prevention, and safety; (2) Indigenous-led approaches for the prevention of infection and promotion of health; (3) strengthening intergovernmental and interagency collaboration; (4) maintaining care continuity; and (5) addressing the SDoH. The findings highlight important considerations for mobilising Indigenous PHC services to meet the needs of Indigenous patients during a public health crisis such as the COVID-19 pandemic.

Exploring Mental Health Presentations in Remote Aboriginal Community Controlled Health Services in the Kimberley Region of Western Australia Using an Audit and File Reviews

The study aims to explore the role of mental health care in remote Aboriginal health services in the Kimberley region of Western Australia and provide a more nuanced understanding of the patients presenting for care, their needs, and the clinical response. Little is currently known about primary health care presentations for mental health, suicide, and self-harm for remote dwelling Aboriginal residents of the Kimberley region, despite high rates of psychological distress, self-harm, and suicide across the area. This study was progressed through a retrospective, cross-sectional audit of the electronic medical records system used by three remote clinics to explore the interactions recorded by the clinics about a patient's mental health. In addition, an in-depth file review was conducted on a stratified purposive sample of 30 patients identified through the audit. Mental ill-health and psychological distress were found to be prominent within clinical presentations. Psychosocial factors were frequently identified in relation to a patient's mental health presentation. Optimizing patients' recovery and wellness through service improvements, including an enhanced mental health model of care, is an important next step.

Beliefs about causal factors for suicide in rural Alaska Native communities and recommendations for prevention

Rural Indigenous communities in Alaska suffer staggeringly high rates of suicide. In close-knit Alaska Native villages, each suicide leaves a trail of affected family and community members in its wake. This research aimed to understand community perceptions of what causes suicide in rural Alaska Native villages and generate recommendations for prevention strategies. In-depth interviews were conducted with 25 Alaska Native university students who moved from rural villages to an urban area to attend college. All had been profoundly affected by others' suicides and shared their beliefs about causal factors and recommendations for prevention efforts. Perceived causes included resistance to seeking help or discussing personal problems, loss of culture, traumatic experiences, geographical and social isolation, lack of opportunity, substance abuse, and exposure to others' suicides. Participants believed that suicide is preventable and recommended multi-level approaches to address suicide disparities. They provided recommendations for potentially effective and culturally appropriate prevention strategies, including increasing cultural and social connections, educating community members about mental health, and increasing accessibility of counseling services/reducing barriers to mental health services utilization.

Cultural Adaptation of the Mothers and Babies Intervention for Use in Tribal Communities

OBJECTIVE

While one in five women may experience mood and anxiety disorders during pregnancy and postpartum, Indigenous identity increases that risk by 62%, especially among younger Indigenous women. The need for evidence-based perinatal mental health interventions that provide culturally relevant well-being perspectives and practices is critical to improving maternal, child, and community outcomes for Indigenous peoples, and reducing health inequities.

METHODS

Through a collaboration between community maternal and child health professionals, intervention researchers, and a cultural consultant, our workgroup developed cultural adaptations to Mothers and Babies, an evidence-based perinatal depression prevention intervention. Applying a cultural interface model, the workgroup identified existing intervention content for surface adaptations, as well as deep, conceptual adaptations to incorporate traditional teachings into this evidence-based intervention.

RESULTS

This collaboration developed a culturally adapted facilitator manual for intervention providers, including guidance for implementation and further adaptation to represent local tribal culture, and a culturally adapted participant workbook for Indigenous perinatal women that reflects cultural teachings and traditional practices to promote well-being for mother and baby.

IMPLICATIONS

Committing to a culturally respectful process to adapt Mothers and Babies is likely to increase the reach of the intervention into Indigenous communities, reengage communities with cultural practice, improve health outcomes among parents, children, and the next generation's elders, and reduce disparities among Indigenous groups. Replication of this community-engaged process can further the science and understanding of cultural adaptations to evidence-based interventions, while also further reducing health inequities. Future steps include evaluating implementation of the culturally adapted intervention among tribal home visiting organizations.

Sustaining suicide prevention programs in American Indian and Alaska Native communities and Tribal health centers

Background:

Research on sustaining community-based interventions is limited. This is particularly true for suicide prevention programs and in American Indian and Alaska Native (AIAN) settings. Aiming to inform research in this area, this paper sought to identify factors and strategies that are key to sustain suicide prevention efforts in AIAN communities.

Methods:

We used a modified Nominal Group Technique with a purposeful sample of N = 35 suicide prevention research experts, program implementors and AIAN community leaders to develop a list of prioritized factors and sustainability strategies. We then compared this list with the Public Health Program Capacity for Sustainability Framework (PHPCSF) to examine the extent the factors identified aligned with the existing literature.

Results:

Major factors identified included cultural fit of intervention approaches, buy in from local communities, importance of leadership and policy making, and demonstrated program success. Strategies to promote these factors included partnership building, continuous growth of leadership, policy development, and ongoing strategic planning and advocacy. All domains of the PHPCF were representative, but additional factors and strategies were identified that emerged as important in AIAN settings.

Conclusions:

Sustaining effective and culturally informed suicide prevention efforts is of paramount importance to prevent suicide and save lives. Future research will focus on generating empirical evidence of these strategies and their effectiveness at promoting program sustainability in AIAN communities.

Suicide justice: Adopting Indigenous feminist methods in settler suicidology

White settler colonies around the world have long reported disproportionately high rates of Indigenous suicides, a consequence of the continuing violence of imperialism. This article posits a need for interdisciplinary approaches to address this crisis and therefore turns to humanist methods developed in Indigenous and feminist scholarship. I analyze texts from U.S. psychologist Edwin Shneidman to rearticulate their relationship to what I call settler suicidology. I then evoke literary critic Eve K. Sedgwick's reparative reading method to reimagine suicide prevention as suicide justice, reading the novel There There by Tommy Orange (Cheyenne and Arapaho) to advocate for distributive justice as a new approach to Indigenous suicide crises. My term suicide justice names increasing accountability between settler suicide workers and the communities they seek to serve.

Co-Designing Health Service Evaluation Tools That Foreground First Nation Worldviews for Better Mental Health and Wellbeing Outcomes

It is critical that health service evaluation frameworks include Aboriginal people and their cultural worldviews from design to implementation. During a large participatory action research study, Elders, service leaders and Aboriginal and non-Aboriginal researchers co-designed evaluation tools to test the efficacy of a previously co-designed engagement framework. Through a series of co-design workshops, tools were built using innovative collaborative processes that foregrounded Aboriginal worldviews. The workshops resulted in the development of a three-way survey that records the service experiences related to cultural safety from the perspective of Aboriginal clients, their carer/s, and the service staff with whom they work. The surveys centralise the role of relationships in client-service interactions, which strongly reflect their design from an Aboriginal worldview. This paper provides new insights into the reciprocal benefits of engaging community Elders and service leaders to work together to develop new and more meaningful ways of servicing Aboriginal families. Foregrounding relationships in service evaluations reinstates the value of human connection and people-centred engagement in service delivery which are central to rebuilding historically fractured relationships between mainstream services and Aboriginal communities. This benefits not only Aboriginal communities, but also other marginalised populations expanding the remit of mainstream services to be accessed by many.

Vers une décolonisation des ressources de soins et services sociaux : les travailleurs communautaires locaux au Nunavik

OBJECTIVES

According to the World Health Organization, discrepancies in health statistics reflect unequal access to resources. The Truth and Reconciliation Commission of Canada calls for an increase in the number of Indigenous workers within health and social services. The involvement of local community workers is essential to ensure the cultural security of care and the decolonization of services. This article presents the role played by these workers in the expansion of mental health services and social interventions in Nunavik, the contextual considerations that influence their practice and their place within professional teams.

METHODS

A thematic analysis was conducted on semi-structured interviews done in 2016 with 60 Inuit and non-Inuit individuals working in the broad field of health and social services in Nunavik.

RESULTS

The integration of local community workers is perceived to bring several benefits, including the improvement of interventions and unique learning opportunities. However, several factors hinder this collaboration, such as clarity of mandates, access to pre-requisite training and diplomas, recognition of local knowledge, and staff turnover. More flexibility and support after hiring would allow for the service structure to be adapted to the complex reality of Nunavik.

CONCLUSION

This article adds to the body of literature highlighting the importance of collaboration with local community workers. The decolonization of services necessarily involves redesigning structures in order to recognize their contribution and to give a place to local knowledge.

Moving Towards Racial Equity in the Child and Youth Mental Health Sector in Ontario, Canada

In the aftermath of high-profile incidents involving Black, Indigenous and People of Color (BIPOC) in North America, there is a growing awareness of the pervasiveness of systemic racism and the role that agencies play in perpetuating racism and racial inequities. In the child and youth mental health sector, the journey to improving racial equity is impeded by a lack of consistent frameworks or guidelines. In this commentary, we explore five domains of organizational practices that are prominent in the literature and support diverse clients, communities and staff, including: (1) organizational leadership and commitment, (2) inter-organizational and multisectoral partnerships, (3) workforce diversity and development, (4) client and community needs and engagement, and (5) continuous improvement. As we highlight these domains, we urge researchers, policy makers, and child and youth mental health service providers to work together to advance racial equity in meaningful ways.

An equivalence analysis of provider education in youth mental health care

OBJECTIVE

To test for equivalence between providers with and without advanced degrees in multiple domains related to delivery of evidence-based treatment.

DATA SOURCE

Provider and client data from an effectiveness trial of Alternatives for Families: A Cognitive Behavioral Therapy (AF-CBT) in a major metropolitan area in the United States.

STUDY DESIGN

We tested for equivalence between providers (N = 182) with and without advanced degrees in treatment-related knowledge, practices, and attitudes; job demands and stress; and training engagement and trainer-rated competence in AF-CBT. We also conducted exploratory analyses to test for equivalence in family clinical outcomes.

DATA COLLECTION

Providers completed measures prior to randomization and at 6-month follow-up, after completion of training and consultation in AF-CBT. Children and caregivers completed assessments at 0, 6, 12, and 18 months.

PRINCIPAL FINDINGS

Providers without advanced degrees were largely non-inferior to those with advanced degrees in treatment-related knowledge, practices, and attitudes, while findings for job demands and stress were mixed. Providers without advanced degrees were non-inferior to providers with advanced degrees in consultation attendance (B = -1.42; confidence interval (CI) = -3.01-0.16; margin of equivalence (Δ) = 2), number of case presentations (B = 0.64; CI = -0.49-1.76; Δ = 2), total training hours (B = -4.57; CI = -10.52-1.37; Δ = 3), and trainer-rated competence in AF-CBT (B = -0.04; CI = -3.04-2.96; Δ = 4), and they were significantly more likely to complete training (odds ratio = 0.66; CI = 0.10-0.96; Δ = 30%). Results for clinical outcomes were largely inconclusive.

CONCLUSIONS

Provider-level outcomes for those with and without advanced degrees were generally comparable. Additional research is needed to examine equivalence in clinical outcomes. Expanding evidence-based treatment training to individuals without advanced degrees may help to reduce workforce shortages and improve reach of evidence-based treatments.

Health Risk Factors in American Indian and Non-Hispanic White Homeless Adults

Objectives: American Indians (AIs) are over-represented among homeless populations, but are understudied regarding their unique risk and resilience factors relative to non-Hispanic white (NHW) adults experiencing homelessness. In the current study, we aimed to address this gap. Methods: We recruited participants (108 AIs and 307 NHWs) from 6 homeless serving agencies in Oklahoma City, OK. Participants completed standard assessments of health, health behaviors, including alcohol and drug use, readiness to change endorsed health behaviors (eg, unsafe sex, fruit and vegetable intake, happiness with weight, physical activity), sleep location and quality, personal victimization, and discrimination. Results: Compared to NHWs, AIs endorsed greater alcohol use problems and were more likely to report having been arrested/booked for disorderly conduct or public drunkenness; however, AIs were less likely to report smoking cigarettes and reported greater readiness to change unsafe/unprotected sexual behaviors. Furthermore, compared to NHWs, AIs reported experiencing greater discrimination and were more likely to report sleeping outside or on the streets, versus in shelters; however, AIs reported fewer days of inadequate sleep. Conclusions: Findings suggest AI-specific risk and resilience factors for homelessness. This information can aid in treatment, service, and housing planning for this under-studied group who experiences some of the greatest health disparities.

Reaching Those at Highest Risk for Suicide: Development of a Model Using Machine Learning Methods for use With Native American Communities

OBJECTIVE

Suicide prevention is a major priority in Native American communities. We used machine learning with community-based suicide surveillance data to better identify those most at risk.

METHOD

This study leverages data from the Celebrating Life program operated by the White Mountain Apache Tribe in Arizona and in partnership with Johns Hopkins University. We examined N = 2,390 individuals with a validated suicide-related event between 2006 and 2017. Predictors included 73 variables (e.g., demographics, educational history, past mental health, and substance use). The outcome was suicide attempt 6, 12, and 24 months after an initial event. We tested four algorithmic approaches using cross-validation.

RESULTS

Area under the curves ranged from AUC = 0.81 (95% CI ± 0.08) for the decision tree classifiers to AUC = 0.87 (95% CI ± 0.04) for the ridge regression, results that were considerably higher than a past suicide attempt (AUC = 0.57; 95% CI ± 0.08). Selecting a cutoff value based on risk concentration plots yielded 0.88 sensitivity, 0.72 specificity, and a positive predictive value of 0.12 for detecting an attempt 24 months postindex event.

CONCLUSION

These models substantially improved our ability to determine who was most at risk in this community. Further work is needed including developing clinical guidance and external validation.

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.