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.

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.

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.

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.

"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.

Change in physical activity, food choices and hemoglobin A1c among American Indians and Alaska Natives with type 2 diabetes

•

At baseline, physically active participants with higher healthy food scores had lower HbA1c levels than non-active participants.

•

Over the three-year period, women who increased physical activity and/or healthy food consumption had slightly decreased HbA1c.

•

Changes in physical activity and HbA1c differed by gender.

The prevalence of diabetes among American Indian and Alaska Native (AI/AN) adults is the highest of all United States racial/ethnic groups. Health behaviors, including regular physical activity and healthy food choices, are important components in the management of diabetes. We estimated the cross-sectional association between physical activity and healthy food scores, separately, and combined (PAHF) with hemoglobin A1c (HbA1c) over three years of the Special Diabetes Program for Indians-Healthy Heart demonstration project (SDPI-HH) intervention. The relationship between physical activity and food choices was also examined. Among 3,039 SDPI-HH participants at baseline, those reporting being physically active and having high healthy food scores had statistically significant lower HbA1c (mean = 7.67 ± 2.01) compared to inactive participants with low healthy food scores (7.90 ± 1.92). Among the 1,150 SDPI-HH participants who attended the three-year follow-up visit, participants who increased physical activity, consumption of healthy foods, or both had a larger decrease in HbA1c (β = -0.29, P = 0.03) over the study period compared to participants with no improvement in physical activity or increase in consuming healthy foods. This association was statistically significant among women (β = -0.35, P = 0.04) but not among men (β = -0.08, P = 0.70). Our findings indicated that an increase in healthier behaviors, including physical activity and healthy food choices, was associated with a small improvement in HbA1c in the subset of women who participated in the SDPI-HH through the three-year follow up. Although the decrease in HbA1c was small, physical activity and healthy food choices are important behaviors to incorporate into everyday life among AI/AN adults, particularly those with diabetes.

Maintaining the Partnership Between a Tribal Breast and Cervical Cancer Program and a University-Based Cancer Prevention Center During COVID-19 Lock-Down Restrictions-A Case Study

To inform women of the Navajo Nation of safety measures implemented to minimize COVID-19 virus exposure during screening and treatment procedures at Navajo Nation based health care facilities, the Navajo Nation Breast and Cervical Cancer Prevention Program (NNBCCPP) and the University-based Partnership for Native American Cancer Prevention Program (NACP) collaborated to develop a podcast to describe the continued availability of services. During the COVID-19 pandemic, women of all ages and ethnicities in the US needing breast and cervical cancer prevention screenings and treatment, have been hesitant to seek services given the advice to avoid crowded spaces and maintain physical distancing. Epidemiological trends indicate that proactive, intensive strategies are needed in Native American communities for early detection and treatment to support early cancer diagnosis and improve cancer survival. The NNBCCPP and Northern Arizona University (NAU) through the National Institute of Health's National Cancer Institute funded NACP had a nascent partnership prior to the onset of COVID-19 pandemic. This partnership relied on face-to-face interaction to allow for informal social interaction, facilitate clear communication and support continued trust building. To adhere to federal, state and tribal recommendations to minimize gatherings and to stay in-place to minimize the spread of the virus, the Navajo Nation and NAU restricted, and in most cases would not approve employee travel for partnership meetings. The plans to develop a podcast necessitated bringing additional members into the collaboration who were unfamiliar to the original partners and due to travel restrictions, required all interactions to be remote. This expanded group met virtually to develop a script, record and edit the podcast. More importantly, group members had to build and maintain trust over months of communicating via a teleconference video platform. This collaborative addressed challenges related to unstable Internet connections and periodic stay-at-home policies; thus, these emerging partners had to modify social and professional communication to respect and accommodate the stress and uncertain circumstances created by the pandemic on the citizens and employees of Navajo Nation. This case study describes strategies used to maintain and respect all members of the partnership.

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.

Engaging Native American High School Students in Public Health Career Preparation Through the Indigenous Summer Enhancement Program

Native American¹ populations are systematically marginalized in the healthcare and public health workforce. One effective approach to reduce health disparities and improve health care delivery among Indigenous populations is to train more Native American health professionals who integrate academic and cultural knowledge to understand and influence health behaviors and perspectives. Diné College partnered with Northern Arizona University to develop the Navajo Native American Research Center for Health (NARCH) Partnership, funded by the National Institutes of Health. The high school component of the Navajo NARCH Partnership created the Indigenous Summer Enhancement Program (ISEP), a 1-week summer training program providing exposure to health careers and mentorship in pursuing public health careers for Native American high school students. ISEP utilizes the Diné Educational Philosophy (DEP), a Navajo conceptual framework to serve as the foundation of the program. In 2020–2021, due to COVID-19 restrictions, the DEP model had to be incorporated in the Navajo NARCH high school virtual program activities. ISEP used 2018 and 2019 past program evaluation data to inform the virtual programming. Students' perception of the program was collected using an online Qualtrics evaluation questionnaire. Students stated appreciation for program staff, fellow students, peer mentors and culturally relevant learning experiences in both virtual and in-person environments. Recommendations included: expanding the length of ISEP and continuing the hands-on activities and Public Health Leadership series.

NACP: Partnership for Native American Cancer Prevention

Cancer trends over a two-decade period show a greater reduction in cancer mortality rates for non-Hispanic Whites than for Native Americans. The Partnership for Native American Cancer Prevention (NACP) was established to address cancer health disparities that impact Native Americans. The partners are Northern Arizona University, the University of Arizona Cancer Center, Arizona's tribal communities and the National Cancer Institute. The activities include outreach, research and cancer education. Overall, NACP seeks to expand capacity for culturally-sensitive and community-relevant research on cancer, and to continue developing respectful collaborations that will empower sovereign Native American communities to define, implement, and achieve their goals for cancer health equity.

Development of a Culturally Anchored Qualitative Approach to Conduct and Analyze Focus Group Narratives Collected in Diné (Navajo) Communities to Understand the Impacts of the Gold King Mine Spill of 2015

The Gold King Mine Spill (Spill) occurred in August 2015 upstream from Silverton, Colorado and released three million gallons of contaminated water into the Animas River, a tributary to the San Juan River that flows across the Navajo Nation. Using principles of community-engaged research, the Gold King Mine Spill Diné Exposure Project co-developed a culturally anchored approach to conduct focus groups and analyze narratives collected in three Diné (Navajo) communities along the San Juan River within 9 months of the Spill. Focus group questions were designed to document the socio-cultural impacts of the Spill. This paper: (1) outlines the partnerships and approvals; (2) describes focus group design, training, data collection and analysis; and (3) reflects on the use of a culturally anchored approach in Indigenous, specifically Diné-centered research. Diné social and cultural etiquette and concepts of relationality were used to adapt standard (non-Indigenous) qualitative methods. Findings describe community perceptions of short-term impacts of the disaster, as well as past and present injustices, communication related to the Spill, and concerns of persistent threats to Diné lifeways. The culturally anchored approach was critical in fostering trust with Diné participants and aligned with the candor of the discussions.

Impacts to Diné activities with the San Juan River after the Gold King Mine Spill

BACKGROUND

On August 5th, 2015, 3 million gallons of acid mine drainage was accidentally discharged from the Gold King Mine near Silverton, Colorado into Cement Creek which is a tributary to the Animas and San Juan Rivers. The government-initiated risk assessment only assessed a recreational scenario (i.e. hiker drinking from the river), failing to recognize the deep connection of the Diné (Navajo) with the San Juan River.

METHODS

Utilizing a mixed-methods approach we determined the impacts of the 2015 Gold King Mine Spill (GKMS or Spill) on Diné activities. We developed a questionnaire to collect pre- and post-GKMS Diné activity frequency and duration. Navajo Nation Community Health Representatives administered the questionnaire to 63 Diné adults and 27 children living in three Navajo communities along the River.

RESULTS

Through analysis of the focus group transcripts we identified 43 unique activities between the Diné and San Juan River. There were significant reductions in the total number, frequency, and duration of livelihood, dietary, recreational, cultural/spiritual and arts and craft activities. On average, Diné activities with the San Juan River following the GKMS decreased by 56.2%.

SIGNIFICANCE

The significant reduction in activities following the GKMS may lead to long-term trauma, impacting the ability of the Diné to pass down teachings to their children affecting future generations to come. The 43 distinct activities between the Diné and the San Juan River highlight the importance for scientists and disaster responders to consider cultural and spiritual impacts when responding to environmental disasters and conducting risk assessments among Indigenous communities.

Psychological distress prevalence and associated stressors and supports among urban-displaced Congolese adults in Kenya

BACKGROUND

There is limited understanding of the prevalence of psychological distress and associated stressors and supports among displaced adults in low- and middle-income first asylum countries.

METHOD

This article reports the findings of a cross-sectional study. We recruited 245 Congolese adults (18-80 years) residing in Nairobi, Kenya using snowball sampling. Data were collected using an interviewer-administered questionnaire consisting of sociodemographic characteristics, the Self-Reporting Questionnaire (SRQ-20), and a locally developed stressors and supports survey. We used multivariable logistic regression to examine associations among sociodemographic, stressor, and support variables and the likelihood of experiencing psychological distress.

RESULTS

More than half of the participants (52.8%) reported symptoms indicative of psychological distress. Factors associated with increased psychological distress included perceiving to have a useful role in one's family or community, AOR = 1.85; 95% CI [1.1.17, 3.11], p = .012, feeling confused or not knowing what to do, AOR = 2.13; 95% CI [1.20, 4.6], p = .014, and feeling afraid to leave home for medical/health care to help with an illness, AOR = 1.57; 95% CI [1.17, 2.15], p < .01. Additionally, ethnic Banyamulenge Congolese adults without legal refugee status had an increased likelihood of experiencing psychological distress, AOR = .07; 95% CI [0, .74], p = .035.

CONCLUSION

Future research is warranted to understand how to implement targeted mental health and psychosocial support (MHPSS) to improve urban-displaced adults' sense of safety and belonging. Our findings suggest that legal refugee status is an important structural determinant of mental health, which should be considered in MHPSS practice and policy. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Community Engagement Practices at Research Centers in U.S. Minority Institutions: Priority Populations and Innovative Approaches to Advancing Health Disparities Research

This paper details U.S. Research Centers in Minority Institutions (RCMI) Community Engagement Cores (CECs): (1) unique and cross-cutting components, focus areas, specific aims, and target populations; and (2) approaches utilized to build or sustain trust towards community participation in research. A mixed-method data collection approach was employed for this cross-sectional study of current or previously funded RCMIs. A total of 18 of the 25 institutions spanning 13 U.S. states and territories participated. CEC specific aims were to support community engaged research (94%); to translate and disseminate research findings (88%); to develop partnerships (82%); and to build capacity around community research (71%). Four open-ended questions, qualitative analysis, and comparison of the categories led to the emergence of two supporting themes: (1) establishing trust between the community-academic collaborators and within the community and (2) building collaborative relationships. An overarching theme, building community together through trust and meaningful collaborations, emerged from the supporting themes and subthemes. The RCMI institutions and their CECs serve as models to circumvent the historical and current challenges to research in communities disproportionately affected by health disparities. Lessons learned from these cores may help other institutions who want to build community trust in and capacities for research that addresses community-related health concerns.

Adapting Summer Education Programs for Navajo Students: Resilient Teamwork

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

Resilience and Stress among Hopi Female Caregivers

Resilience and stress are important factors in the caregiving experience, but research has yet to examine their association among American Indian (AI) caregivers. This study examines resilience and stress in a group of Hopi female caregivers. Data came from the Hopi Adult Caregiver Survey (2017), which conducted interviews with 44 Hopi women who were providing care without remuneration to an adult family member. Measures included the abbreviated Connor-Davidson Resilience Scale (CD-RISC-10), the Perceived Stress Scale (PSS-10), and questions about caregiver characteristics, care recipient characteristics, social support/ community support, and cultural factors. Stress and resilience were looked at above the median (higher stress or higher resilience) and below the median (lower stress or lower resilience). Caregivers who reported relatively lower resilience were more likely to report that they lived separately from their care recipients and that all Hopis are expected to be caregivers. Caregivers who reported relatively higher stress reported a higher total number of caregiver difficulties, a poorer self-perception of their own health, use of a traditional healer in the past 5 years, and that females are expected to be caregivers. A regression analysis adjusting for age, education, and employment status indicated that higher resilience among the caregivers was significantly associated with lower stress. In light of these findings, programs working with AI caregivers may wish to explore whether supporting the resilience of these caregivers is a means towards limiting their stress.

Voices of Community Partners: Perspectives Gained from Conversations of Community-Based Participatory Research Experiences

Community-based participatory research (CBPR) has been documented as an effective approach to research with underserved communities, particularly with racial and ethnic minority groups. However, much of the literature promoting the use of CBPR with underserved communities is written from the perspective of the researchers and not from the perspective of the community partner. The purpose of this article is to capture lessons learned from the community partners’ insight gained through their experiences with CBPR. A multi-investigator consensus method was used to qualitatively code the transcripts of a CBPR story-telling video series. Seven major themes were identified: (1) expectations for engaging in research, (2) cultural humility, (3) respecting the partnership, (4) open communication, (5) genuine commitment, (6) valuing strengths and recognizing capacities, and (7) collaborating to yield meaningful results. The themes drawn from the community partner’s voice align with the tenets of CBPR advanced in the academic literature. More opportunities to include the community voice when promoting CBPR should be undertaken to help introduce the concepts to potential community partners who may be research cautious.

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.

Development of Guidelines to Improve the Effectiveness of Community Advisory Boards in Health Research

BACKGROUND

Community advisory boards (CABs) are a common community engagement strategy. Tools for developing CABs that are accessible to academic-community partnerships are limited. This article describes the process and partnership with the Hopi Tribe to develop CAB guidelines as a tool for research funded by the Center for Indigenous Environmental Health Research (CIEHR) and nonaffiliated projects.

METHODS

The CAB guidelines consist of three sections: formation, operation, and sustainability and evaluation. Each section includes best practices and interactive worksheets. The CAB guidelines were piloted with the Hopi Tribe to determine feasibility and relevance.

RESULTS

The CAB guidelines were well-received by the tribal CAB. Some of the worksheets were difficult to complete because they did not represent their perspectives or introduced potential tension in CAB interactions. Revisions were made accordingly.

CONCLUSIONS

Future evaluation and broad dissemination of the CAB guidelines will promote the use and effectiveness of CABs in health research.

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: β=0·078, P=0·0007; males: β=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.

Resilience in American Indian and Alaska Native Public Health: An Underexplored Framework

OBJECTIVE

To conduct a systematic literature review to assess the conceptualization, application, and measurement of resilience in American Indian and Alaska Native (AIAN) health promotion.

DATA SOURCES

We searched 9 literature databases to document how resilience is discussed, fostered, and evaluated in studies of AIAN health promotion in the United States.

STUDY INCLUSION AND EXCLUSION CRITERIA

The article had to (1) be in English; (2) peer reviewed, published from January 1, 1980, to July 31, 2015; (3) identify the target population as predominantly AIANs in the United States; (4) describe a nonclinical intervention or original research that identified resilience as an outcome or resource; and (5) discuss resilience as related to cultural, social, and/or collective strengths.

DATA EXTRACTION

Sixty full texts were retrieved and assessed for inclusion by 3 reviewers. Data were extracted by 2 reviewers and verified for relevance to inclusion criteria by the third reviewer.

DATA SYNTHESIS

Attributes of resilience that appeared repeatedly in the literature were identified. Findings were categorized across the lifespan (age group of participants), divided by attributes, and further defined by specific domains within each attribute.

RESULTS

Nine articles (8 studies) met the criteria. Currently, resilience research in AIAN populations is limited to the identification of attributes and pilot interventions focused on individual resilience. Resilience models are not used to guide health promotion programming; collective resilience is not explored.

CONCLUSION

Attributes of AIAN resilience should be considered in the development of health interventions. Attention to collective resilience is recommended to leverage existing assets in AIAN communities.

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.

Network Analysis as a Tool for Assessing and Building Community Capacity for Provision of Chronic Disease Services

A network analysis was conducted in spring 2000 by the Southwest Center for Health Promotion in the U.S. Mexico border community of Douglas, Arizona. The purpose of the analysis was to assess the level of collaboration among the 23 public and not-for-profit agencies that provided health and human services for a broad range of chronic disease prevention, screening, and treatment services. Data were also collected on levels of trust and anticipated outcomes (benefits and draw-backs) of collaboration. The article presents the findings of the network analysis, focusing on its usefulness as a tool for evaluating efforts at building community capacity through enhanced interagency collaboration.

Promising Strategies for Obesity Prevention and Treatment Within American Indian Communities

In the United States, obesity prevention and treatment programs are dominated by individual-focused strategies. Yet epidemic proportions of obesity and high failure and dropout rates of conventional efforts prompt consideration of alternate approaches. A nonsystematic review of American Indian (AI) health promotion programs highlights a group-focused approach using three primary and two supportive strategies. These strategies are outlined as: (a) build and reinforce social cohesion and collective efficacy, (b) use the motivating force of friendly competition, and (c) aspire to change local norms and policies through assuring high visibility of alternate behaviors and engaging formal and informal leaders. Although evidence to demonstrate the impact of these efforts is limited and not currently available to public health audiences, AI communities' sustained acceptance and continued involvement in the programs suggest that these strategies are worthy of review and consideration by public health practitioners addressing obesity on a national level.

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.

American Indian Elders' resilience: Sources of strength for building a healthy future for youth

This study examined American Indian (AI) elders' resilience to support an intervention to build resilience among AI urban youth. A literature review of peer-reviewed articles that address resilience in AI and other Indigenous elders yielded six studies that focused on intergenerational relationships, culture, and self-identity. In addition, a qualitative research project collected narratives with urban AI elders to document perceptions of resilience and resilience strategies. The combined outcomes of the literature search and research project revealed how resilience is exemplified in elders' lives and how resilience strategies are linked to cultural teachings and values, youth activities, and education.

American Indian and Alaska Native resilience along the life course and across generations: A literature review

Examining American Indian and Alaska Native (AI/AN) resilience using the life course framework could inform public health strategies that support favorable health outcomes, despite adversity (e.g., discrimination, historical loss, comorbidity). A systematic review of peer-reviewed literature published from 1970 to 2015 yielded eight articles on AI/AN life course and resilience. A content analysis identified three themes. AI/AN resilience is 1) an ongoing, dynamic process, 2) evident within linked lives and life transitions, and 3) accessed through cultural knowledge and practice. Resilience research could change the paradigm of AI/AN health research to guide asset-based approaches across the life course.

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.

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.

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.

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.

Breast cancer education for Navajo women: a pilot study evaluating a culturally relevant video

This pilot study evaluated a culturally specific video designed to teach Navajo women about breast cancer treatment options. Fourteen Navajo women diagnosed with breast cancer and 26 healthcare providers participated in a mixed-method evaluation that documented their perceptions immediately and 6 months after viewing the video. After initial viewing, women reported reduced anxiety about treatment and interest in support groups. Six months later, women said the video prompted them to seek more information from printed sources and their provider. Younger Navajo women who were 44 to 51 years old were more likely to attend support groups than women who were 55-67 years. Providers corroborated the positive effects of the video. The providers believed the video encouraged patients to seek information about breast cancer and to ask questions about treatment plans and side effects. A culturally relevant video for Navajo women can be an effective teaching tool and can enhance patient-provider communication.

Focus groups in small communities

Qualitative research methods have gained increasing acceptance as valuable tools for gathering information on attitudes, beliefs, and sociocultural factors that influence health behaviors. Conducting focus groups is a commonly used qualitative method. Existing guidelines for conducting focus groups do not address the challenges presented by the social familiarity of small communities and do not highlight the advantages of using the technique as part of a community-based participatory research (CBPR) effort. In small communities, researchers must consider characteristics of the facilitator and recorder, recruitment strategies, the importance of stressing confidentiality even when discussing seemingly nonsensitive topics, and the effect of disseminating results. Addressing these elements as part of a CBPR approach is advantageous because community partners know the ways in which the community talks about an issue and understand the subtle social impact of asking, answering, and interpreting locally specific questions.

Systematic review of physical activity interventions implemented with American Indian and Alaska Native populations in the United States and Canada

OBJECTIVE

To describe physical activity (PA) interventions implemented in American Indian/Alaska Native (AI/AN) populations in the United States and Canada.

DATA SOURCES

MEDLINE, PubMed, ERIC, and Sociological Abstracts were used to identify peer-reviewed journal articles. Dissertation abstracts, Web sites, and conference proceedings were searched to identify descriptions within the gray literature from 1986 to 2006.

STUDY INCLUSION AND EXCLUSION CRITERIA

The target population had to be described as AI/ AN, aboriginal, native Hawaiian, and/or native U.S. Samoan. PA interventions among indigenous populations of Latin America were not included.

DATA EXTRACTION

Descriptions of 64 different AI/AN PA interventions (28 peer-reviewed journal articles and 36 in the gray literature) were identified.

DATA SYNTHESIS

Data were synthesized by geographic region, intervention strategy, target audience, activities, and sustainability.

RESULTS

Most interventions were conducted in the southwest United States (35.4%), in reservation communities (72%), and among participants 18 years and younger (57.8%). Forty-one percent of the 27 interventions with evaluation components reported significant changes in health, behavior, or knowledge.

CONCLUSIONS

Effective AI/AN PA interventions demonstrated impact on individual health and community resources. Program sustainability was linked to locally trained personnel, local leadership, and stable funding. Culturally acceptable and scientifically sound evaluation methods that can be implemented by local personnel are needed to assess the health and social impact of many long-running AI/AN PA interventions.

Community-based participatory research: conducting a formative assessment of factors that influence youth wellness in the Hualapai community

OBJECTIVES

Using a community-based participatory research approach, a tribe-university team conducted a formative assessment of local factors that influence youth wellness to guide the design of a culturally and locally relevant health promotion program.

METHODS

Open-ended interviews with key informants, a school self-assessment using the Centers for Disease Control's School Health Index, and a locally generated environmental inventory provided data that were triangulated to yield a composite of influential factors and perceived need within the community.

RESULTS

Family involvement and personal goal setting were identified as key to youth wellness. Supportive programs were described as having consistent adult leadership, structured activities, and a positive local and regional image. Availability of illicit drugs and alcohol, poor teacher attitude, and lack of adult involvement were significant negative factors that impact youth behavior.

CONCLUSIONS

Local/native (emic) and university/nonnative (etic) perspectives and abilities can be combined to yield a culturally relevant formative assessment that is useful to public health planning. In this collaborative effort, standard means of data collection and analysis were modified in some cases to enhance and build upon the knowledge and skills of community researchers.

Family cohesion and conflict in an American Indian community

OBJECTIVE

To assess the feasibility of using a portion of the Family Environment Scale (FES) with American Indian families and to describe the mean family profile exhibited by one Native community.

METHODS

The cohesion, expressiveness, conflict and active-recreational orientation subscales of the FES were administered to 130 adults, representing 65 families.

RESULTS

Mean responses reveal a pattern of average levels of cohesion and expressiveness, concurrent with high levels of family conflict.

CONCLUSIONS

Outcomes illustrate the feasibility and utility of this scale in assessing and guiding health promotion services within Native communities. Results suggest Native families have a distinctive family profile.

The school health index as an impetus for change

BACKGROUND

The increase in childhood obesity and prevalence of chronic disease risk factors demonstrate the importance of creating healthy school environments. As part of the Border Health Strategic Initiative, the School Health Index was implemented in public schools in two counties along the Arizona, United States-Sonora, Mexico border. Developed in 2000 by the Centers for Disease Control and Prevention, the School Health Index offers a guide to assist schools in evaluating and improving opportunities for physical activity and good nutrition for their students.

CONTEXT

Between 2000 and 2003, a total of 13 schools from five school districts in two counties participated in the School Health Index project despite academic pressures and limited resources.

METHODS

The Border Health Strategic Initiative supported the hiring and training of an external coordinator in each county who was not part of the school system but who was an employee in an established community-based organization. The coordinators worked with the schools to implement the School Health Index, to develop action plans, and to monitor progress toward these goals.

CONSEQUENCES

The School Health Index process and school team participation varied from school to school. Individual plans were different but all focused on reducing in-school access to unhealthy foods, identified as high-fat and/or of low nutritional value. Ideas for acting on this focus ranged from changing the content of school lunches to discontinuing the use of nonnutritious foods as classroom rewards. All plans included recommendations that could be implemented immediately as well as those that would require planning and perhaps the formation and assistance of a subcommittee (e.g., for developing or adopting a district-wide health curriculum).

INTERPRETATION

After working with the School Health Index, most schools made at least one immediate change in their school environments. The external coordinator was essential to keeping the School Health Index results and action plans on the agendas of school administrators, especially during periods of staff turnover. Staff turnover, lack of time, and limited resources resulted in few schools achieving longer-term policy changes.

Developing and adapting a family-based diabetes program at the U.S.-Mexico border

CONTEXT

The prevalence of diabetes among Hispanics is more than twice that of non-Hispanic whites in communities along the U.S.-Mexico border. The University of Arizona and two community health agencies on the Arizona border, Campesinos Sin Fronteras and Mariposa Community Health Center, collaborated to design, pilot and assess the feasibility of a lay health-outreach worker- (promotora-) delivered diabetes education program for families. La Diabetes y La Unión Familiar was developed to build family support for patients with diabetes and to teach primary prevention behaviors to family members.

METHOD

Community and university partners designed a culturally appropriate program addressing family food choices and physical activity, behavior change, communication, and support behaviors. The program offers educational content and activities that can be presented in home visits or multifamily group sessions. Community partners led the implementation, and university partners guided the evaluation.

CONSEQUENCES

Seventy-two families (249 total participants) including children and grandchildren participated. Preintervention and postintervention questionnaires completed by adults (n = 116) indicate a significant increase in knowledge of eight diabetes risk factors (P values for eight factors range from < 001 to .006) and a significant increase in family efficacy to change food (P < .001) and activity behaviors (P < .001). Interviews with participants highlight the program's positive psychosocial impact.

INTERPRETATION

Community and university collaboration involved building upon the promotoras' expertise in engaging the community and the university's expertise in program design and evaluation. A promotora-delivered family-based diabetes prevention program that emphasizes family support, communication, and health behaviors is feasible and can yield change in family knowledge, attitude, and behavior relative to diabetes risk factors.

Building community capacity around chronic disease services through a collaborative interorganizational network

This article presents the findings of a study examining the evolution of a network of health and human service organizations operating in a rural community on the Southwest border. The aim of the network was to build the capacity of the community to provide chronic disease education, prevention, and treatment services by developing collaborative relationships among a broad range of organizations. The impetus for the effort was based on receipt of a Turning Point grant. The findings, based on two waves of data collected 1 year apart, demonstrate how network structure and attitudes toward collaboration evolve as a community attempts to build capacity to address its health needs.

A lifestyle intervention improves plasma insulin levels among Native American high school youth

BACKGROUND

Worldwide, type 2 diabetes prevalence is increasing, with Native American populations particularly at risk. The Zuni Pueblo, with a history of wellness activities, volunteered to test the feasibility and efficacy of a high school-based diabetes prevention intervention.

METHODS

This school-based intervention used a multiple cross-sectional design to evaluate outcome measures at 0, 1.5, and 3 years against an Anglo comparison group. The Zuni high school diabetes prevention program included an educational component targeting decreased consumption of sugared beverages, knowledge of diabetes risk factors, and a youth-oriented fitness center. Main outcome measures were plasma glucose and insulin measured fasting and 30 min after a 75-g glucose challenge.

RESULTS

Plasma glucose levels were normal at baseline for Zuni (n = 72) and Anglo (n = 37) youth and did not significantly change throughout the study. At baseline, fasting and 30-min plasma insulin levels were significantly elevated for Zuni youth; they showed significant steady declines for both males and females throughout the study (P = 0.06 to P = 0.000 for trends using quantile regression). By Year 3, values for Zuni males (n = 29) equaled Anglo comparison values, while Zuni female (n = 26) values had declined but were still higher than Anglo comparison values.

CONCLUSIONS

Among at-risk youth, an environmentally based lifestyle intervention may significantly suppress markers of type 2 diabetes risk.

Building community capacity in public health: the role of action-oriented partnerships

Public health practice increasingly is concerned with the capacity and performance of communities to identify, implement, strengthen, and sustain collective efforts to improve health. The authors developed ways to assist local Turning Point partnerships to improve their community public health system as a secondary outcome of their work on the expressed needs of the community. Using focus groups, meeting minutes, attendance records, and meeting observation, the authors fed information back to the partnerships on systems change. A public health systems improvement plan supportive of local partnerships' work on specific health issues was funded and the collaborative research agenda was further refined.