Funded Projects

Grant Number: 1R01CA192967
Project Title: Enhancing Prevention Pathways Towards Tribal Colorectal Health
PI Name: Shiraz I. Mishra, MBBS, PhD
PI Contact Info: 505-925-6085, smishra@salud.unm.edu
PD Name: Erica Breslau, PhD, MPH 
Institute: University of New Mexico
RFA/PA: PAR-14-260
Project Start: 4/01/2016
Project End: 6/30/2023

Abstract
American Indians/Alaska Natives (AI/ANs) experience significant health inequities and disparities in colorectal cancer (CRC) related incidence, mortality, stage at diagnosis, and survival. Recent reductions in CRC incidence and mortality rates and improvements in stage at diagnosis and survival rates in the general U.S. population have been attributed to routine screening with prompt removal of polyps, early detection, and timely and appropriate treatment. AI/ANs are significantly less likely than non-Hispanic Whites to receive timely and risk- and age-appropriate cancer screenings, including recommended CRC screening. The short-term goal is to test the efficacy of serially implemented interventions designed to enhance annual CRC screening using the fecal immunochemical test (FIT). Serial implementation refers to offering routine screening, irrespective of response to an earlier invitation, in concordance with national guidelines which recommend annual FIT testing between ages 50-75. The FIT is most appropriate because, based on consensus guidelines, it is an approved, high sensitivity fecal occult blood test that is offered annually and is available in Indian Health Service and tribal health facilities where resources to provide screening colonoscopy are limited. We will follow all positive FIT results with timely and appropriate diagnostic and treatment services. We address screening disparities through the testing of interventions designed to enhance annual CRC screening using the FIT among average- risk, on-reservation AIs aged 50-75 in the rural Southwest. The interventions are theory-informed, evidence- based, and graded in their intensity. The high intensity intervention will include navigated outreach, a mailed FIT kit, educational material, and follow-up reminders (Study Group 1). The medium intensity intervention will include a mailed FIT kit, educational material, and follow-up reminders (Study Group 2). The reference group (Study Group 3) will receive usual care (screening recommendation and a FIT kit at a clinic visit). We will use rigorous research methods to: (a) determine the efficacy of interventions to enhance annual CRC screening through completion of the FIT kit; (b) understand contextually relevant factors important for behavior change; (c) identify the most cost-effective strategies to enhance routine CRC screening; and (d) develop plans to inform sustainability and scalability. This is a collaborative effort between the University of New Mexico, the Albuquerque Area Indian Health Board (100% Indian-owned and operated), and six Pueblo Tribes in the rural Southwest. The research team has an extensive and successful history of conducting community based participatory cancer prevention research in collaboration with AI communities. Moreover, the research team recognizes the value of integrating a co-learning process and engaging in trust-based mutually beneficial research. Findings from this research could lead to an immediate increase in CRC screening and ultimately reduce the CRC disease burden among AIs experiencing cancer disparities and health inequities.

Grant Number: 1R01CA164533-01A1
Project Title: Community Intervention to Reduce Tobacco Use among Pregnant Alaska Native Women
PI Name: Christi A. Patten, PhD
PI Contact Info: 507-266-2577, patten.christi@mayo.edu
PD Name: Stephanie R Land, PhD
Institute: Mayo Clinic Rochester
RFA/PA: PAR-11-346
Project Start: 7/1/2013
Project End: 4/30/2018

Abstract
Developing effective tobacco cessation interventions during pregnancy for American Indian and Alaska Native people is a national priority and will contribute to the U.S. public health objective of reducing tobacco- related health disparities. In the southwest region of Alaska where the proposed project will take place, 79% of Alaska Native women smoke cigarettes or use smokeless tobacco (ST) during pregnancy. In addition, pregnancy appears to be a high risk period for initiation of tobacco use, primarily ST, among women reporting no use of tobacco 3 months before pregnancy. Our pilot study suggested that an individual-based intervention delivered at the first prenatal visit had low reach to pregnant women and poor tobacco abstinence rates. Intervention efforts targeting the entire community, not only pregnant women, to address social norms about tobacco use may be more effective. Thus, we propose to evaluate the efficacy of a novel, multi-component, theory-based intervention for reducing tobacco use during pregnancy, incorporating both individually targeted and community level components delivered by female elders "Native Sisters." The intervention builds on effective community and individual-based approaches for tobacco cessation and lay health advisor approaches for cancer prevention among Native American women. As part of the intervention, a social marketing campaign including digital stories and other small media will be developed with community feedback. Individually targeted components will be six 30-40 minute telephone or home-based peer counseling sessions with pregnant women. This R01 project is submitted in response to PAR-11-346. It will be conducted in two phases. All aspects of the project will be guided by a community advisory committee. In Phase I, we will develop the social marketing components by obtaining qualitative feedback from pregnant women, family members and elders on message content and delivery channels. In Phase II, we will evaluate the intervention using a group- randomized design with village as the unit of assignment. Sixteen villages will be randomly assigned to receive the intervention or control condition (usual care), with > 20 women enrolled from each village. Enrollment will occur at the time of a positive pregnancy test which is the earliest point of prenatal care, enhancing the intervention's potential reach. Both tobacco users and non-users will be eligible because many start to use during pregnancy. Assessments will be completed by enrolled women through 6 months postpartum. We will evaluate the efficacy of the intervention compared with the control condition on the biochemically confirmed 7-day point prevalence tobacco use rate at week 36 gestation and at 6 months postpartum. We will also examine the effect of the intervention on proposed social cognitive-theory based mediators of change including perceived self-efficacy for non-tobacco use and anti-tobacco norms. Our long term objective is to determine effective interventions for Alaska Native women that will ultimately reduce the risk of tobacco-related maternal, fetal, and infant adverse health outcomes.

Grant Number: 1R01CA174481-01
Project Title: Web-based Smoking Cessation Program for Tribal College Students
PI Name: Won Choi, PhD, MPH
PI Contact Info: 913-588-4742, wchoi@kumc.edu
PD Name: Stephanie R Land, PhD
Institute: University Of Kansas Medical Center
RFA/PA: PAR-11-346
Project Start: 4/1/2013
Project End: 3/31/2018

Abstract
American Indian tribal college students have the highest smoking rates of any racial/ethnic group in the young adult population and also are disproportionately burdened by smoking-related morbidity and mortality. There are very few effective culturally-tailored smoking cessation programs for AI smokers. Our research group has worked with the American Indian community for the past 8 years to develop a culturally-tailored smoking cessation program (All Nations Breath of Life - ANBL), for AI adult smokers. All Nations Breath of Life was developed using the community-based participatory research approach and is an in-person group based program that incorporates cultural issues throughout the program. We have produced 30% cessation rates at 6-month follow-up with adult American Indian smokers from tribes and nations in the Midwest. Due to limited studies with the tribal college population, we have already conducted a cross-sectional internet-based survey to collect information on their smoking behaviors as well as other health behaviors. This research experience and strong collaboration with the AI community leaves us well poised to adapt the ANBL program for the tribal college smoking population. However, this current program needs substantial modifications to meet the unique needs of the tribal college student population. It recognizes the sacred role of tobacco among many American Indians and how culture affects smoking cessation among AIs, while still addressing recreational smoking. However, preliminary data from our recent studies indicate that the internet may be more favorable and appropriate delivery method for reaching this younger and more mobile tribal college population due to the web interactivity, immediacy of feedback, and wide reach and accessibility. This current proposal reflects a natural progression to addressing the significant problem of smoking among tribal college students using our successful methods. In this study, we will adapt and test a culturally tailored internet-based smoking cessation (I-ANBL) program based on ANBL, which was developed through CBPR methods. For the current proposal, we will conduct an individual randomized controlled trial (N=242) to test the effectiveness of an internet-based, culturally tailored smoking cessation program (I-ANBL) in a tribal college student population. Data will be collected at baseline, 3 months and 6 months using salivary cotinine, as well as comprehensive set of environmental and psychosocial measures. We hypothesize that AI tribal college students randomized to the culturally-tailored smoking cessation internet arm (I-ANBL) will have significantly higher continuous abstinence rates at 6 months than those receiving the heart healthy diet intervention (I-FV), focusing on increasing fruit and vegetable consumption. We will also examine the costs of delivering the tailored intervention program and potential mediators and moderators of the intervention-cessation relationship. Such a high-reach, low-cost strategy for promoting smoking cessation in this at-risk and underserved population could have great potential for adoption on a larger scale and thus help reduce existing health disparities.

Grant Number: R01-HL126577
Project Title: The KaHOLO Project: Preventing Cardiovascular Disease in Native Hawaiians
PI Name: Keawe‘aimoku (Joseph) Kaholokula, PhD
PI Contact Info: 808-692-1047, kaholoku@hawaii.edu
PD Name: Charlotte Pratt, PhD
Institute: University of Hawaii at Manoa
RFA/PA: PAR-11-346
Project Start: 4/2015
Project End: 1/31/2021

Abstract
Native Hawaiians (NH) have higher rates of chronic diseases, such as cardiovascular disease (CVD), diabetes, and cancer. Hypertension (HTN), an important modifiable risk factor for CVD, is 70% higher in Native Hawaiians (NH) than in Whites. In fact, NH are 3-4 times more likely to develop CVD conditions, such as stroke and coronary heart disease, and at a younger age. In addition to prescribed medication, improvements in HTN can be achieved through increased physical activity (PA) and self-management education (e.g. stress management, reduces sodium intake, weight-loss, and smoking cessation). Yet, many commonly prescribed PA, such as jogging and use of treadmills, are difficult for NH to initiate and maintain because of socioeconomic barriers and lack of alignment with NH preferred modes of living and cultural values (i.e. familial interdependence, group-based PA, cultural PA). This proposed research uses hula, the traditional dance form of NH and hallmark of NH culture, as the PA basis for a culturally relevant and sustainable CVD prevention program targeting HTN management. Hula training is popular, not only Hawai'i, but across the U.S. through the 784 hālau hula (hula schools) found in most States. Using a community-based participatory research (CBPR) framework, a hula-based CVD health intervention was strongly endorsed by Kumu hula (hula experts and guardians of hula traditions), NH individuals, and communities. Further, hula training was determined to yield metabolic equivalent of energy expenditure as a moderate and vigorous intensity PA. Data from our pilot CBPR randomized control trial (RCT) study found that 60 minutes of hula training twice a week for 12 weeks reduced systolic blood pressure (BP) by 7.5 mmHg (SD=16.5) more than the control group, but the long-term effects were mixed and the study did not assess CVD risk. Interestingly, the pilot intervention also improved social functioning, reduced physical pain, and perceived racial discrimination, suggesting a possible psychosocial and socio-cultural mechanism by which the intervention affects BP. In this application we offer a CBPR guided RCT of 250 NH with physician-diagnosed HTN in Hawai'i and Washington State. We will compare the effects of a 6-month intervention that combines hula training and brief culturally-tailored HTN self-management education delivered by peer educators and Kumu hula to a wait-list control group in reducing systolic BP and CVD risk scores. We will also determine the mediating effects of health behaviors (e.g., smoking), self-regulation, psychosocial (e.g., social support), and socio-cultural factors (e.g., perceived racism) on blood pressure reduction. Our goal is to build on the existing widespread infrastructure of hālau hula and NH organizations to deliver a sustainable, culturally-preferred CVD prevention program.

Grant Number: 1R01HL117729-01
Project Title: Tribal Health and Resilience in Vulnerable Environment (Thrive) Study
PI Name: Valarie J. Jernigan, DrPH, MPH
PI Contact Info: 918-660-3678, valarie-jernigan@ouhsc.edu
PD Name: Barbara L. Wells, PhD
Institute: University Of Oklahoma Hlth Sciences Ctr
RFA/PA: PAR-11-346
Project Start: 8/15/2013
Project End: 5/31/2020

Abstract
Food insecurity increases one's risk for obesity, diabetes, hypertension, and cancer (via its links to poor diet and nutrition), conditions highly prevalent among Native Americans in Oklahoma (obesity 42%, diabetes 15%, and hypertension 38%).1 Our pilot study shows that 3 times as many Natives in Oklahoma are food insecure as Whites (21.3% vs. 7.3% respectively).2 Yet few or no studies have assessed individual- and environmental-level correlates of food insecurity among Natives and none have developed interventions or broad-based educational materials within Oklahoma tribal nations.3,4 Aims and Methods: This study, led by a Native American Choctaw Investigator will, Aim #1: Assess correlates (sociodemographics, health behaviors, perceived food environment) and outcomes (dietary intake including vegetables and fruits, BMI, diabetes, and hypertension) of food insecurity in the Chickasaw and Choctaw nations in Oklahoma. A telephone survey will be administered to 500 Native American adults (18+) randomly sampled from tribal registries. Clinical measures will be validated for 200 of those surveyed using tribal clinic electronic healt records. Perceptions of food environments will be compared to objective store measures using GIS data. Aim #2: Design, implement, and evaluate a convenience store intervention to increase the availability and intake of vegetables and fruits among tribal members. Using a cluster-randomized design with 20 matched tribally owned convenience stores (5 cases and 5 controls in each tribe), we will implement evidence-based strategies (increased availability and variety, point of purchase information, reduced prices/coupons) to increase the sales and intake of vegetables and fruits among tribal members. Store-level changes will be measured by pre/post sales records and the Nutrition Environment Measures Survey; individual-level changes by two cross-sectional surveys, administered to 300 convenience store shoppers before and 300 shoppers after the intervention. Tribal members will use video voice,3 an action-oriented participatory media research method to collect qualitative and environmental data (e.g. types of foods/beverages sold and promoted in the convenience stores) to facilitate community planning and channel recommendations to policy makers. Aim #3: Create a multimedia manual, co-developed with tribal members, guiding tribes in food environment changes, and disseminated over a free and open source Website allowing for tribal user- created content. Innovation: Each of the 3 aims builds on our preliminary data and/or best practices, and leverages tribal resources and partnerships to enhance survey participation rates and convenience store "healthy makeovers." Significance and Impact: The knowledge from surveys on food insecurity correlates and health outcomes will inform the design of the convenience store intervention to increase availability of vegetables and fruits. The resulting multimedia manual will guide food environment changes among tribes nationally to address the critically high rates of obesity, diabetes, and hypertension within this population.

Grant number: 5R01HL126578-05
Project Title: Diet Intervention for Hypertension: Adaptation and Dissemination to Native Communities
PI Name: Dedra Buchwald, MD
PI Contact info: 206-708-8622, dedra.buchwald@wsu.edu
PD Name: Larry Fine, MD
Institute: Washington State University
RFA/PA: PAR-11-346
Project Start: 08/15/2015
Project End: 05/31/2020

Abstract
Hypertension, also called high blood pressure (BP), is a major risk factor for cardiovascular disease (CVD). Nearly one-third of all U.S. adults have hypertension, but only half of these cases are successfully controlled by medication or diet. The negative public health consequences are profound. American Indians (AIs) have disproportionate CVD morbidity and mortality, and they have higher burdens of hypertension, diabetes, and smoking than other races. Yet AIs are rarely represented in national studies on hypertension management. Most interventions targeting CVD have focused on reservation-based AIs, even though 71% of AIs live in urban areas. This urban population is an invisible minority, with high rates of disease and disability, and low rates of healthcare usage. Medication alone is suboptimal for controlling BP; a heart-healthy diet is preferable. Dietary Approaches to Stop Hypertension (DASH) is a high-impact lifestyle intervention for primary and secondary prevention of CVD that centers on a low-salt, low-fat diet emphasizing fresh fruits and vegetables. In a randomized trial, the DASH diet lowered systolic BP by 11.5 mm Hg in participants with clinical hypertension. However, the DASH diet never been tested in AIs. We therefore designed an 8-week DASH intervention to improve BP control in hypertensive urban AIs. Our American Indian Five Nuts and Beans Project (AI-5) includes culturally tailored DASH education that emphasizes low sodium intake, traditional Native foods, and maintaining healthy eating habits, plus a $30 weekly credit for home delivery of groceries that meet DASH guidelines. Home delivery is a creative solution to logistical barriers, such as limited access to fresh produce, that often deter residents of poor urban neighborhoods from maintaining a healthy diet. The control condition will receive printed educational materials and a $30 weekly credit for grocery delivery, with no purchasing restrictions. Our randomized trial will test AI-5 i a total of 400 adult AIs with inadequately controlled systolic BP (140-159 mmHg). We will recruit and randomize 200 participants from each of 2 urban clinics: one in Spokane, WA, the other in Oklahoma City, OK. Our primary outcome is systolic BP measured after the 8-week intervention and again 12 weeks later. Secondary outcomes are other modifiable CVD risk factors, risk scores for heart disease and stroke, and dietary habits. We will also conduct an embedded pilot study to inform future research on long-term sustainability and impact. Our Specific Aims are to: 1) evaluate the effect of the AI-5 intervention on BP and secondary outcomes in adult AIs with poorly controlled hypertension, and 2) conduct a pilot study among 100 intervention participants after the intervention concludes by randomizing half to receive 6 weeks of dietician support (pilot intervention) and the other half to receive no further support (pilot control). We will collect BP data at 6 and 9 months post-baseline. This approach will have important public health implications and will inform efforts to export interventions for CVD and hypertension to other urban and rural AI groups. PUBLIC HEALTH RELEVANCE PUBLIC HEALTH RELEVANCE: Reducing intake of salt and fats can prevent cardiovascular disease and further the goals of Healthy People 2020. Sustainable, cost-effective dietary interventions are needed for high-risk populations such as urban American Indians. Our study adapts an existing heart-healthy diet for American Indians with high blood pressure, answering the American Heart Association's call for interventions that address household dietary practices.

Grant Number: 1R01HL117736-01A1
Project Title: Technology Innovations for Supporting Health in Alaska Native People
PI Name: Judith J. Prochaska, PhD, MPH
PI Contact Info: 650-724-3608, jpro@stanford.edu
PD Name: Barbara L. Wells, PhD
Institute: Stanford University
RFA/PA: PAR-11-346
Project Start: 4/15/2014
Project End: 3/31/2020

Abstract
the proposed research will evaluate the efficacy of two culturally tailored, technology-mediated disease prevention interventions for supporting change in multiple risk behaviors in rural Alaska Native (AN) men and women. Directly informed by the research team's fieldwork over the past 6 years in rural Alaska, continued community partnership with the tribes, and ethnographic research, the interventions will be tailored to AN health needs and values to target 5 of the American Heart Association's 7 Strategic Impact Goals for 2020. In a randomized controlled 2-group design, the trial will compare two active treatment conditions: Group 1 targets tobacco and physical activity; Group 2 targets control of hypertension and hypercholesterolemia (HTN-HCL) through medication adherence and nutritional changes. Both conditions utilize trans theoretical model-tailored, computerized interventions, delivered via telemedicine by Indigenous-focused counselors located in Anchorage reaching AN people in their rural home villages. Computerized intervention contacts occur at baseline, 3-, 6- and 12-months with final assessment at 18-months. Study design provides an equivalent contact time and technology comparison; facilitates individual-level randomization within communities, as all participants receive highly individualized counseling and intervention materials; and allows for comparison of traditional risk factor (HTN-HCL) versus risk behavior (tobacco/ physical activity) interventions. Participants (N=300) will be daily smokers with at least one additional cardiovascular disease risk factor (e.g., inactivity, overweight, HTN, HCL) or established vascular disease. The trial aims to reach AN people regardless of residential location or intention to change. The primary hypothesis is that Group 1 will achieve significantly greater biochemically- confirmed tobacco abstinence than Group 2 through 18-months follow-up and secondarily will significantly increase their physical activity. Secondary hypotheses are that Group 2 will achieve significantly greater control of HTN and HCL than Group 1 through (i) medication compliance and (ii) dietary change. Tertiary aims will: (a) compare the interventions on overall behavior change; (b) model cost-effectiveness and budgetary impact of each intervention; and (c) examine moderators/mediators of treatment outcome, including the trans-3'-hydroxycotinine to cotinine ratio, a noninvasive measure of nicotine metabolism rate. The proposal combines technology, pharmacology, behavioral science, and health economics for advancing the health of AN people who face significant health disparities with limited access to interventions given their isolated geographics.

Grant number: 5R01HL122150-02
Project Title: Multilevel Program and Policies to Reduce Chronic Disease for American Indians
PI Name: Joel Gittelsohn, PhD
PI Contact info: 410-955-3927, jgittels@jhsph.edu
PD Name: Charlotte Pratt, PhD
Institute: Johns Hopkins University
RFA/PA: PAR-11-346
Project Start: 07/01/2015
Project End: 03/31/2020

Abstract
American Indian (AI) populations experience disproportionately high rates of obesity and related chronic diseases (CD). Intervention trials aimed at modifying the food environment in AI communities have shown positive results, such as increasing the purchase and consumption of healthy foods. The current challenge is to facilitate the development of evidence-based policies in order to improve the sustainability of environmental interventions. The primary goal of the proposed research is to improve the food and physical activity (PA) environments in AI communities at multiple levels (worksites, schools, food stores) by working in partnership with tribal leaders to enact policies and programs that aim to reduce CDs. We will achieve this goal by developing, implementing, and evaluating a randomized controlled community-based trial which is supported or implemented by tribal leaders through policy. The study will take place in six AI communities located in Wisconsin and New Mexico. This project builds directly on our previous successful work in five AI communities where we conducted a multilevel obesity prevention trial (OPREVENT) targeting food stores, worksites and schools. This proposed trial (OPREVENT2) complements and expands upon the previous one, by fostering the development of relevant policies among tribal leaders which is key for sustainability.
The specific aims of OPREVENT2 are: 1) To conduct formative research to describe tribal policy development and enactment in participating AI communities, in order to support tribal health policy makers to identify effective policies to sustain obesity and chronic disease prevention/reduction programs, by building capacity and collaborative partnerships; 2) To develop a community-based CD prevention program for AI communities informed by our earlier trials, formative research from Aim 1 and best-practices from the scientific literature; an 3) To evaluate the impact of the CD related policies and programs on adiposity, psychosocial factors and obesity risk behaviors, including dietary quality (e.g., fruit and vegetable servings),nutrient intake, and PA in a community- randomized controlled trial. The proposed study directly addresses NIH PAR-11-346 priorities by developing and testing an innovative multilevel obesity prevention strategy in AI communities that combines supportive policy with a culturally appropriate multilevel intervention. The proposed study is also locally generated and, therefore, more likely to be self-sustaining. We expect to impact the following areas of interest to the PAR: engagement of tribal leaders in developing and implementing CD policy, development of culturally appropriate community-based CD prevention programs, and increased availability of healthy foods, improvements in diet and PA, and reductions in adiposity.

Grant Number: 1R01HL122148-01
Project Title: Innovative Multigenerational Household Intervention to Reduce Stroke and CVD
PI Name: Lonnie A Nelson, PhD
PI Contact Info: 573-424-0888, lonnie.nelson@wsu.edu
PD Name: Barbara L. Wells, PhD
Institute: Washington State University
RFA/PA: PAR-11-346
Project Start: 5/5/2014
Project End: 4/30/2018

Abstract
American Indians (AIs) are experiencing an epidemic of stroke morbidity and mortality, with higher prevalence and incidence, younger age at onset, and poorer survival than other racial and ethnic groups. With a stroke incidence more than twice that of the general U.S. population, stroke in AIs is a public health problem of staggering scope. AIs also have disproportionate burdens of many risk factors for stroke, including hypertension, smoking, obesity, and diabetes. However, no rigorous, population-based studies of stroke prevention have included AIs. Tribes urgently need evidence-based methods for preventing stroke that minimize clinic visits and lab tests and use affordably measured endpoints. One such endpoint is a stroke risk score. We developed a 10-year stroke risk score for AIs using data from the Strong Heart Study, a large, population-based cohort of 4,549 AIs from 12 tribes in Arizona, Oklahoma, and the Dakotas. We propose to address the need for effective, affordable, and sustainable stroke prevention methods in participants in the Strong Heart Family Study. This study collected family-cluster data on cardiovascular disease risk factors from 3,800 AIs based on 94 randomly selected index participants from the Strong Heart Study. With our partners, we have designed the "Family Intervention in the Spirit of Motivational Interviewing" (FITSMI), a program delivered at the household level to encourage lifestyle changes that transform the home environment and reduce stroke risk for all residents. FITSMI uses a "talking circle" format in which facilitators guide participants to identify goals for change and create a tailored plan for sustainable implementation that may target smoking, exercise, diet, or medication adherence. FITSMI requires just 2 sessions (baseline and 1 month post-baseline), with text messaging used to boost long-term adherence. In a group-randomized trial design, we will recruit 360 households where Strong Heart Family Study members aged 45 and older reside. We will assign half to FITSMI and half to a control condition that receives educational brochures. All household residents e 11 years old will be eligible. Primary outcomes are household-level improvement in stroke risk score for adult's e 45 years old, and selected modifiable risk factors for all participants. Our Specific Aims are: 1) Determine the effectivenes of FITSMI in AIs e 45 years old to lower stroke risk scores from baseline to 1-year follow-up, with coronary heart disease risk scores evaluated as a secondary outcome; and 2) Determine the effectiveness of FITSMI to improve individual modifiable stroke risk factors (e.g., smoking, blood pressure) in all household members e 11 years old from baseline to 1-year follow-up. This effort is aligned with an Institute of Medicine report recommending a shift from provider- and clinic-centered healthcare to "care based on continuous healing relationships." FITSMI is designed to facilitate adoption of healthy lifestyles to prevent stroke and improve cardiovascular health. If proven effective, FITSMI has broad, multigenerational public health implications for prevention of stroke and cardiovascular disease in AI and non-AI populations.

Grant Number: 1R01AA028201-01
Project Title: Chukka Auchaffi’ Natana: The Weaving Healthy Families Program to Promote Wellness and Resilience and Prevent Alcohol and Other Drug Abuse and Violence
PI Name: Catherine Burnette, PhD
PI Contact Info:  504-862-3495, cburnet3@tulane.edu
PD Name: Aria Davis-Crump, ScD
Institute: Tulane University
RFA/PA: PAR-17-496
Project Start: 5/15/2020
Project End: 04/30/2025

Abstract
Alcohol and other drug (AOD) abuse and family violence are co-occurring risk factors for Native American (NA) health disparities and are associated with the leading causes of death within this population, such as cardiovascular disease (CVD) and diabetes. However, extant interventions often fail to holistically promote resilience, health, and wellness, instead addressing problems in isolation. To our knowledge, there have been few NA culturally based and family-focused interventions that enhance family resilience and prevent and reduce AOD abuse and violence in families. Given the gap in community and culturally grounded programs to prevent AOD abuse and violence in families, there is a critical need to test the efficacy of such sustainable community-based interventions. The long-term goal of this research is to promote health and wellness, while preventing and reducing AOD abuse and violence in NA families by testing a culturally relevant and family-centered intervention for cross-national dissemination. Using community-based participatory research methods (CBPR), the overall objectives of the proposed research are to use a stepped-wedge trial design (SWTD) to test the efficacy of a culturally modified intervention that is facilitated by Tribally based community health representatives (CHRs) and to use the consolidated framework for implementation research (CFIR) to examine the barriers and facilitators for intervention sustainability and implementation. Our central hypothesis is that the community-based, "Weaving Healthy Families program"—a shortened, streamlined, and culturally adapted version of the Celebrating Families! Program—will reduce and postpone AOD use, decrease and prevent violence in families, and promote resilience and wellness (including mental health) among NA adults and youth. This intervention seeks to promote wellness by targeting key behavioral (AOD abuse), mental/emotional (emotional regulation/anger management, cognitions, and resilience), social and familial (healthy and non-violent relationships, the family environment, and parenting), cultural (values and traditions), and physical (nutrition and AOD abuse) factors. We accomplish the stated objectives through these aims: Aim 1: Test the efficacy of the modified intervention on AOD abuse and violence reduction and resilience enhancement. Using an open cohort, multiple baseline SWTD and multilevel and longitudinal modeling, we will test our working hypothesis that the intervention will reduce parental AOD abuse and violence, postpone youth AOD use, and enhance family members' resilience and wellness. Aim 2: Evaluate the sustainability and feasibility of the intervention's implementation. We will use the CFIR and a convergent mixed-method design to evaluate barriers and facilitators to intervention implementation, testing our working hypothesis that the modified intervention will provide a culturally relevant and feasible model to promote wellness in a sustainable way. The expected outcomes of the proposed research are an efficacious, culturally relevant, and sustainable community-based program to promote health and wellness for tribes cross-nationally.

Grant Number: 5R01AA025603-02
Project Title: Preventing Alcohol Exposed Pregnancy among Urban Native Young Women: Mobile CHOICES
PI Name: Carol E Kaufman, PhD
PI Contact Info: 303-724-1464, carol.kaufman@ucdenver.edu
PD Name: Tatiana Nikolayevna Balachova, PhD
Institute: University of Colorado Denver
RFA/PA: PAR-14-260
Project Start: 08/01/2018
Project End: 07/31/2023

Abstract
Fetal Alcohol Spectrum Disorders (FASD) result in neurodevelopmental deficits and lifelong disability; they are a leading cause of preventable birth defects in the U.S. According to the CDC, any sexually active woman of reproductive age who drinks alcohol and does not use effective contraception is at risk for an alcohol exposed pregnancy (AEP) that could cause FASD. By this definition, American Indian and Alaska Native (AIAN) young women are especially vulnerable to AEP, with high levels of alcohol consumption and sexual risk taking compared to their counterparts in other race/ethnic groups. Although an estimated 72% of AIAN young women live in urban areas, very little research has yet included them; urban AIAN needs are often ignored in research aimed at developing, implementing, and evaluating culturally appropriate services. Recent research indicates that mobile health (mHealth) interventions may offer a promising mechanism for delivering effective interventions to hard-to-reach populations. The goal of this project is to expand reach and services to urban AIAN young women through mHealth technology to prevent AEP and FASD. The proposed project builds on a prior NIAAA-funded project which used intensive community-based participatory research (CBPR) methods to adapt CHOICES, an evidence-based brief AEP intervention supported by the CDC, to American Indian Youth CHOICES (AIY-C). AIY-C contains features that make it highly amenable to mHealth approaches, including a framework for integrating diverse cultural teachings, few modules of short duration, and concrete opportunities for goal-setting and achievement. Innovative for this population is the plan to recruit young AIAN women from major urban areas in the US through social media—and to deliver AIY-C via mobile devices, increasingly ubiquitous among AIAN young adults. While social media recruitment and mHealth interventions are not new, only very recently have they been used with AIAN populations. We will partner with urban AIAN organizations to guide us through social media recruitment strategies, mHealth intervention translation and implementation, and evaluation in urban AIAN settings. We propose 3 specific aims: (1) Develop and pilot social-media-based recruitment strategies for urban AIAN young women; (2) translate AIY-C for mHealth delivery through an iterative and theoretically driven process and pilot the developed translated mHealth AIY-C intervention; and (3) recruit 700 (final N=525) urban AIAN young women using identified social media strategies, and conduct an RCT to rigorously evaluate the effectiveness of the mHealth translation of AIY-C for preventing AEP and FASD. The proposed project promises expansive reach to AIAN young women to address significant yet preventable public health concerns – AEP and FASD; importantly, the project also promises to advance a blueprint for preventive intervention research with urban AIAN populations largely ignored to date.

Grant Number: R01AA023755
Project Title: Strategies for Preventing Underage Drinking and Other Substance Use in Native American Tribal Communities
PI Name: Roland S. Moore, PhD (Pacific Institute for Research and Evaluation, Oakland, CA)
PI Contact Info:510-883-5770 office, 510-872-6201 cell, roland@prev.org
PD Name: Beverly Ruffin, PhD
Institute: NIAAA (with cofunding from OBSSR)
RFA/PA: PAR-14-260, INTERVENTIONS FOR HEALTH PROMOTION AND DISEASE PREVENTION IN NATIVE AMERICAN POPULATIONS (R01)
Project Start: 07/10/2016
Project End: 03/31/2021

Abstract
The goal of this research program is to implement and evaluate complementary interventions designed to address underage alcohol, marijuana, tobacco and other drug use and abuse among Native American youth residing in and around nine contiguous Indian reservations in rural San Diego County. The application directly builds upon the successful collaboration between a Southern California Tribal Health Clinic, PIRE's Prevention Research Center, and The Scripps Research Institute, with pilot and demonstration studies focusing on reducing the supply of and demand for alcohol by Native American youth through a series of environmental and individual interventions that have shown efficacy and have gained acceptability in the communities served by the clinics. The overall goal of the present proposal will be accomplished through two complementary efforts, one aimed at the community (supply) level and the other at the individual (demand) level. The community-based environmental prevention program will focus on reducing underage access through tailoring, implementing and evaluating a community mobilization and awareness intervention aimed at reducing the social availability of alcohol, marijuana, tobacco, and other drugs from adults, including family members. These community -level programs will be complemented with interventions at the individual level, including implementing and evaluating a culturally tailored motivational interviewing brief intervention to reduce demand for alcohol and other drugs for American Indian youth 13- 20 years of age who are substance users. We will evaluate the effectiveness of these programs by analyzing multiple data sources: (a) outcome data from a Motivational Interviewing-Psychoeducation trial among tribal youth, (b) data from school and community youth surveys on youths’ self -reported substance use and related problems including driving under the influence, (c) anonymous norms and intervention awareness surveys from adults from each of the communities; and (d) law enforcement data on alcohol/drug-related events. For the purposes of evaluation, these data from the Indian Health Council catchment area will be compared to data from surveys of both non-Native and Native American youth who were not involved in the intervention activities. The research will continue to build cohorts of expert Native American research staff and student interns for actualizing the research and interventions. The team will create intervention workbooks for standardized application of the intervention techniques in other Native American communities.

Grant Number: 1R01AA022066-01
Project Title: Motivational Interviewing and Culture for Urban Native American Youth (MICUNAY)
PI Name: Elizabeth D’amico, PhD
PI Contact Info:  elizabeth_d'amico@rand.org
PD Name: Beverly Ruffin, PhD
Institute: Rand Corporation
RFA/PA: PAR-11-346
Project Start: 7/15/2013
Project End: 6/30/2020

Abstract
American Indian/Alaska Native (AI/AN) youth report higher rates of alcohol and drug (AOD) use, greater frequency and intensity of AOD use, earlier first AOD use, and much higher alcohol-related mortality than other racial/ethnic groups in the U.S. Data regarding urban AIs/ANs are limited; however, one study found that at-risk AIs/AN adults in an urban setting report an earlier onset of alcohol, marijuana, methamphetamine, and other drug use compared to all other ethnic/racial groups within LA County. This proposal responds to PAR-11-346, Interventions for Health Promotion and Disease Prevention in Native American Populations, which is focused on developing, adapting, and testing the effectiveness of health promotion prevention interventions in Native American populations. The two Co-PIs provide a unique blend of expertise that has resulted in the development of an innovative preliminary protocol for AI/AN youth: Motivational Interviewing and Culture for Urban Native American Youth (MICUNAY), which integrates traditional healing approaches with motivational interviewing (MI). Dickerson is an Alaska Native (Inupiaq) new investigator who worked with the AI/AN community to obtain community-based perspectives on decreasing AOD use and mental health problems. D'Amico is internationally recognized for her work focused on the development and testing of MI interventions targeting AOD use for culturally diverse adolescents across different settings. Dickerson and colleagues have demonstrated the need for culturally-appropriate interventions for AI/AN youth. His two community-based projects found that there is a lack of programs integrating tradition-based healing with evidenced based treatments (EBTs), and this was cited as a significant barrier to seeking care within urban AI/AN populations. Therefore, MICUNAY will integrate tradition-based healing with MI. It consists of 6 weekly 1-hour sessions (3 MI AOD sessions and 3 tradition activity sessions). Our proposal also incorporates a multi-system intervention approach. At the individual level, we will provide MICUNAY to urban AI/AN youth. At the community level, we will discuss AOD use and AOD prevention among AI/AN youth at existing Community Wellness Gatherings (CWG). The proposed 5-year study will consist of two main components: 1) A Developmental Phase in which we conduct focus groups across two clinical sites in Los Angeles and Oakland with the community to establish feasibility and sustainability of delivery, 2) A randomized controlled tria comparing youth who only attend a CWG (n=100) to youth who attend a CWG plus receive MICUNAY (n=100). We will compare outcomes at 3- and 6-month follow-up to determine (a) whether clinically significant changes in AOD expectancies, perceived prevalence of peer AOD use, alcohol consumption, marijuana and other drug use, and related consequences occur; (b) whether clinically significant changes in physical, social, emotional, and functional well-being a well as spirituality and cultural identification occur, and (c) if reductions occur, estimate effec sizes for the CWG group and the CWG plus MICUNAY group. Our study substantially extends work with AI/AN youth by intervening at both the community and individual level, and developing and testing an integrated tradition-based AOD MI group intervention for urban AI/AN youth.

Grant Number: 1R01AA023754-01
Project Title: Qungasvik (Toolbox): Prevention of Alcohol/Suicide Risk In Alaska Native Youth
PI Name: Stacy M. Rasmus, PhD
PI Contact info: smrasmus@alaska.edu
PD Name: Robert Freeman, PhD
Institute: University Of Alaska Fairbanks
RFA/PA: PAR-11-346
Project Start: 8/10/2015
Project End: 7/31/2020

Abstract
For the past 10 years we have focused on addressing two interrelated public health issues, alcohol use disorder (AUD) and suicide in 12-18 year old Yup'ik Alaska Natives (AN). AUD and suicide are among the leading causes of mortality among AN people and a significant health disparity in contrast to the U.S. general population (1). AN mortality rates from all alcohol-induced disorders between 2001 2005 were 53.8/100,000 in contrast to 6.3/100,000 for other ethnic groups in Alaska (2), while the age-adjusted rate for suicide is twice the national average (3). Overall, between 1960-95 AN suicide rates increased approximately 500% (4). More recent data indicate continuation of these trends and also identify cluster suicide behavior as a feature of AN youth suicide (5). Yup'ik community leaders have made addressing AUD and suicide among their highest priorities. In response, working with several communities, a community-based and led intervention (Qungasvik - toolbox) was designed. The intervention is designed to develop protective factors that will ultimately reduce the incidence of AUD and suicide. Our research leading up to the currently proposed study has shown that it is possible to: (1) deliver the intervention in remote rural communities; (2) obtain valid and reliable measures of two ultimate outcomes (i.e., Reflective Processes regarding alcohol consequences and Reasons for Life) and intermediate protective factors variables that underlie them; (3) show a dose-response effect: the more intervention sessions a person attends (dose) the stronger the measured protective factors (response); and (4) obtain a maximum protective effect from the intervention by lengthening the duration of the intervention from one to two years. The proposed study is an assessment of a modified version of the intervention and focuses on three specific aims (SA): (SA1) test Qungasvik intervention efficacy through impact on the two protective factors and to link those measures to direct measures of alcohol use and suicidal ideation; (SA2) examine the mechanisms of change in response to the intervention through growth in: (a) intermediate outcome measures of protective factors at the individual, family, peer, and community level; (b) social network characteristics of supportive relationships with elders, immediate and extended kinship relations, and community adults and describe social network change; and (c) using qualitative interviewing and grounded theory analysis techniques, describe process and impact of the intervention from community elder and parent perspectives; and (SA3) examine the fidelity of implementing the intervention.

Grant Number: 1R01AA022068-01
Project Title: Tribal Colleges and Universities Behavior Wellness Study (TCU-BeWell)
PI Name: Bonnie M. Duran, DrPH
PI Contact Info: bonduran@uw.edu
PD Name: Marcia S Scott, PhD
Institute: University Of Washington
RFA/PA: PAR-11-346
Project Start: 7/15/2013
Project End:    6/30/2019

Abstract
This research fulfills the NIAAA's mission to address health disparities by reducing alcohol use and improving academic outcomes in a high-risk population of American Indian and Alaska Native (AIAN) Tribal College and University (TCU) students through implementation and evaluation of a low cost screening and brief intervention (SBI). The Brief Alcohol Screening and Intervention for College Students (BASICS), an SBI pioneered and tested by UW investigators on this study, represents a cost effective means to reduce alcohol use. A college- level intervention for policy and systems change will also be tested aimed at: (1) instituting a harm reduction policy that supports a shift from zero tolerance alcohol policies, (2) integrating behavioral health resources for the benefit of high-risk TCU students, and, (3) ensuring TCU SBI implementation fidelity. BASICS has reduced alcohol consumption and consequences in mainstream colleges and this proposal would, using a Community- based Participatory Research approach, provide a cultural contextualization of BASICS and test this intervention for the first time in AIAN TCU students. The specific aims are to adapt, manualize and implement a culturally contextualized version of BASICS: (a) To test whether a culturally appropriate BASICS intervention will surpass a wait list control condition by significantly reducing indices of hazardous or harmful drinking and alcohol-related negative consequences; (b) To test the effect of the intervention in significantly improving retention and academic performance among TCU students; and, (2) Implement a system-level policy intervention moving from zero-tolerance to harm reduction policies at the college-level and providing capacity to integrate services for improved referral and treatment for high risk TCU students to test whether an environmental approach will positively impact the SBI intervention and its outcomes. This study's primary hypothesis is that a culturally contextualized adaptation of SBI, as identified by the TCU/AIHEC/UW partnership, will surpass a wait list control condition in reducing hazardous or harmful drinking and alcohol- related negative consequences and improve academic outcomes, with a significantly greater effect in TCU with the policy intervention.

Grant Number: 1R01DA056417-01A1
Project Title: A multiregional RCT of Parenting in 2 Worlds for Urban Indian Families
PI Name: Stephen Kulis
PI Contact Info: kulis@asu.edu; 602-496-3333
PD Name: Aria Crump, ScD
Institute: Arizona State University
RFA/PA: PAR-20-238
Project Start: 06/01/2022
Project End: 04/30/2027

Abstract
A large and rapidly growing majority of American Indian/Alaska Native (AI) families now reside in urban areas. Although they experience severe health disparities associated with substance abuse, risky sexual behavior, depression and suicide, few evidence-based prevention interventions address their distinctive needs. Family disruption, stresses due to migration and poverty, and cultural and social losses are often implicated in adverse health outcomes for urban AI families. By improving effective parenting skills and overall family functioning, culturally grounded parenting interventions enable parents to model and promote their children's well-being and reduce their children’s vulnerability to risk behaviors. The proposed study extends the project team's prior research on a culturally grounded parenting intervention for urban AIs, Parenting in 2 Worlds (P2W), which was co-developed with a coalition of urban Indian non-profit organizations, tested in three Arizona cities, and demonstrated efficacious. The research team joins two AI and two non-AI investigators, who together have extensive experience conducting collaborative research with AI populations in urban and tribal settings. This proposed multi-regional study will create new knowledge in four areas. First, the study will test P2W’s effectiveness beyond Arizona in improving parenting and family functioning, among a wider and more diverse group of urban AI communities located in cities spread across four regions: Northeast (Buffalo/Niagara), Midwest (St. Paul/Minneapolis), Mountain (Denver), and Southwest (Phoenix). Through the auspices of collaborating urban Indian center partners, the trial will recruit 720 families of AI youth age 12-17 (180 per city) and individually randomize them to receive P2W or an informational family health curriculum. Second, the study will test for moderators of the effectiveness of P2W, whether desired outcomes vary by the level of socioeconomic vulnerability, experiences of historical loss, or AI cultural identity of the parent participants. Third, the study will expand on the original Arizona trial to examine the adolescent’s reports on family functioning and an enlarged range of youth health behaviors potentially impacted by the P2W intervention, including mental health (depressive symptoms, suicidality) as well as substance use and risky sexual behaviors. Fourth, the study will test for mediation—whether positive changes in parenting and family functioning that result from P2W lead to changes in the youth health behaviors. This would be the first cross- site multiregional trial of a culturally grounded parenting intervention designed specifically for urban AIs. It will advance critical knowledge on community prevention interventions for an under-served group severely affected by health disparities, and establish whether urban Indian centers and their communities can readily employ P2W to strengthen urban AI families and promote the behavioral health of their youth. It will also provide a foundation for advancing knowledge on effective prevention interventions in urban AI communities that have different migration histories and tribal compositions.

Grant Number: 1R01DA053791-01
Project Title: Randomized Controlled Trial of Indigenous Recovery Planning for American Indians
PI Name: Monica Skewes, PhD
PI Contact Info: 406-994-3814, monica.skewes@montana.edu
PD Name: Julia Zur, PhD
Institute: Montana State University - Bozeman
RFA/PA: PAR-17-496
Project Start: 01/04/2021
Project End: 02/28/2026

Abstract
Although there are high rates of abstinence among American Indians (AIs), there also is evidence of alcohol and drug use disorders disproportionately affecting Native communities. As a result of generations of systemic racism and historical trauma, AIs experience serious health disparities associated with substance use disorders (SUDs). Effective treatments for SUD are critically needed for improving health equity in AI communities, but there are few culturally grounded evidence-based interventions developed or tested with AIs. With this study, Randomized Controlled Trial of Indigenous Recovery Planning for American Indians, we aim to help fill this gap. Our research uses a community-based participatory research (CBPR) framework to test the efficacy of a culturally adapted relapse prevention intervention designed collaboratively by community partners from the Fort Peck Indian Reservation in northeastern Montana and research partners from Montana State University. Indigenous Recovery Planning (IRP) employs trained Fort Peck community members to deliver manualized intervention content culturally adapted from Relapse Prevention (RP), one of the most studied and efficacious treatments for SUD. Using data from 4 mixed-methods preliminary studies, we have worked closely with a community advisory board (CAB) to modify RP to focus on strengths, increase levels of protective factors, address culturally specific risk factors, and overcome barriers to engagement in treatment. We now will test the efficacy of IRP in a prospective randomized controlled trial with 150 tribal members with SUD using a waitlist control group, a design desired by the community partners. Using random assignment to IRP (immediate intervention; n = 75) or to a waitlist control group (delayed intervention; n = 75), we will test the effects of IRP on primary outcomes (percent days abstinent) and secondary outcomes (substance-related consequences, quality of life) assessed post-intervention. We also will examine maintenance of changes in treatment outcomes at 12-week post-intervention follow-up and examine hypothesized culturally specific mediators of treatment effects (AI identity, spirituality, communal mastery, grief and loss, distress from historical trauma, lateral violence, and racism) identified in our preliminary studies. Finally, we will conduct a process evaluation to examine the acceptability and sustainability of the intervention to ensure that IRP addresses barriers to evidence-based SUD interventions as designed. This research will fill an important gap in scientific knowledge regarding the efficacy and acceptability of culturally adapted evidence-based treatments tested in AI populations. This knowledge may be transferable to other communities with similar cultural values and barriers to treatment. By increasing access to efficacious treatment, this research has the potential to improve health outcomes and decrease SUD-related health disparities for underserved AI communities locally and nationally.

Grant Number: 1R01DA050521-01A1
Project Title: Discovering Our Story, to Develop the Chemawa Journey of Transformation
PI Name: Tessa Evans-Campbell, PhD
PI Contact Info: tecamp@uw.edu
PD Name: Aria Davis-Crump, ScD
Institute: University of Washington
RFA/PA: PAR-17-496
Project Start: 04/01/2021
Project End: 02/28/2026

Abstract
Substance use and sexual health risk are increasingly prevalent, costly, and deadly fueling a synergistic epidemic in the United States that disproportionately affects American Indian and Alaska Native (AI/AN) communities. AI/AN youth are at the heart of the AI/AN health crisis. AI/AN youth are disproportionately affected by many of these historical, structural, social, and behavioral factors that contribute to significant health disparities including high alcohol, tobacco, opiate, and other drug (ATOD) use and sexual and reproductive health risks (SHR; ATOD-SHR). The overall mean age of tobacco use, alcohol use, and marijuana initiation for AI/AN is much younger (11.5 years) than the general population, with AI/AN youth having the highest prevalence of smoking and the earliest age of first use of ATOD. Alarmingly, more that 20% of Native high school students who used a prescription pain med without a prescription also used heroin in the past 30 days. Substance use is one of the most significant risk factors for unprotected sex and AI/AN youth have the earliest age of first sexual intercourse. AI/ANs under 25 years of age have three times the rate of chlamydia, gonorrhea, and syphilis compared to White youth. Taken together, these ATOD-SHR disparities underscore the urgent need for interventions that simultaneously target ATOD and SHR among AI teens. While there is a paucity of research addressing the ATOD-SHR prevention needs of AI/AN youth in general, there is even less information available on ATOD-SHR-related disparities for the nearly 1 out of 10 AI/AN youth attending the 183 tribal day or boarding schools nationwide. To address this crisis and the dearth of evidence-based programs for this population, the proposed study, prepared in response to PAR-17-496, involves a 5-year RO1 to test the preliminary efficacy of the Chemawa Journey of Transformation–Native Youth Health Leadership Program (CJOT) which is an adapted and expanded version of the Discovering Our Story intervention, a 2010 SAMSHA-identified best practice AI/AN strengths-based comprehensive substance use and health risk prevention and health leadership program for AI/AN youth. The CJOT emphasizes a holistic, positive youth approach that incorporates storytelling with traditional archetypes and responsibilities as both a process and metaphor for guiding AI/AN youth through behavioral change. The CJOT is a culturally centered experiential 8-week (10 sessions) school-based positive youth health leadership development intervention to prevent ATOD use and SHR among AI/AN youth (ages 13-16). The program involves a 2-month intervention (3 individual sessions plus 10 sessions) plus 5 booster sessions including digital storytelling training plus 1 community event (digital and oral storytelling premiere) that targets behavior change relative storytelling and a youth-led storytelling event.

Grant Number: 1R37DA047926-01
Project Title: Evaluation of an Optimized Intervention to Prevent Early Substance use Among American Indian Youth: Examination of Expanded Impacts on Youth and Parents
PI Name: Nancy Whitesell, PhD
PI Contact Info: 303-724-1456, nancy.whitesell@cuanschutz.edu
PD Name: Aria Davis-Crump, ScD
Institute: University Of Colorado Denver
RFA/PA: PAR-17-496
Project Start: 04/01/2019
Project End: 02/29/2024

Abstract
The recent opioid crisis across the United States has drawn national attention and resulted in the allocation of significant federal resources to substance use treatment and prevention efforts. American Indian (AI) communities, however, have faced a substance use crisis of similar scope for many years, without the benefit of proportionate attention and resources. Disparities in substance use disorder impacting AI populations are well-documented, and the roots of these disparities can be traced to significantly higher adolescent substance use among AIs compared to other ethnic groups in the United States. AI youth report earlier initiation of substance use than their non-AI peers. National trends of escalating opioid use are evident among AI populations as well, and appear, in fact, to be even more pronounced, reflecting the overall pattern of disparities observed across substances, with AI youth reporting greater heroin and OxyContin use than youth from other racial and ethnic groups. The imperative remains strong to direct attention and resources to focus on early prevention efforts for AI youth. In response to this need, researchers at the Centers for American Indian and Alaska Native Health in the Colorado School of Public Health at the University of Colorado have recently completed an intensive community-engaged process to rigorously adapt the Strengthening Families Program for Parents and Youth 10-14 for the cultural context of a Northern Plains AI community, creating a program optimized for AI families, Thiwáhe Gluwáš'akapi (TG, sacred home in which family is made strong). The current study will test the effectiveness of TG for delaying the onset of substance use among young adolescents. Based on evidence that the original Strengthening Families program may impact risk behaviors beyond substance use, and in response to requests from participating families and community partners to help address suicide risk among their youth, the current study will also test the impact of TG on suicidal ideation among youth. In addition, in recognition of the potential for the TG program to have a reciprocal influence on the adults participating in the program with their children, capitalizing on parents' motivation to protect their youth and make concomitant positive changes in their own lives, the current study will examine effects on adult substance use as well. Examining effects on adult substance use is especially timely as the opioid epidemic rages in in this community, as around the country. In summary, this study will address three specific aims, testing effectiveness of the TG prevention program on three distinct sets of outcomes: (1) Substance use among youth: delaying the onset of use and reducing use among youth who initiated prior to program participation; (2) Suicide risk among youth: reducing suicidal ideation and other risk factors for suicide and increasing protective factors; and (3) Substance use among adults: reducing use among adults participating in the program with their children who report problematic levels of use at program entry.

Grant Number: 1R21DA053789-01
Project Title: Tribal Reservation Adolescent Connections Study
PI Name: Jerreed Ivanich, PhD
PI Contact Info: jerreed.ivanich@cuanschutz.edu
PD Name: Kathy Etz, PhD
Institute: University of Colorado Denver
RFA/PA: PAR-17-464
Project Start: 04/15/2021
Project End: 03/31/2023

Abstract
American Indian (AI) youth demonstrate early initiation of substance use and subsequently high rates of substance misuse. One factor contributing to ongoing risk for these youth is the relative lack of prevention strategies that leverage contextual and cultural strengths to optimize effectiveness and sustainability. Rich cultural and traditional practices, including collateral kinship networks, make interpersonal relationships particularly vital for AI youth, but these networks are largely untapped in prevention approaches. Research in other populations demonstrates the role of social networks in both risk and resilience, but data on AI social networks are sparse and data on how networks relate to risk for early substance use are virtually nonexistent. There are reasons to suspect that social network theories may require some adaptation for the culture and context of AI communities. To effectively inform interventions, we must first confirm which principles translate well and create new metrics where needed. This mixed-methods study will collect quantitative social network surveys and qualitative interviews with adolescents on a Northern Plains reservation to explore how these networks are structured and the principles under which they operate. Network characteristics will be examined in relation to substance use and related risk factors, most notably suicide and exposure to violence, to begin to understand how networks impact both risk and resilience. Network characteristics are likely to influence substance use, exposure to violence, and suicide risk in complex ways that are shared in both common and differential patterns. An explanatory sequential mixed method design (QUAN → Qual) will be used to accomplish two specific aims: Aim 1: Describe peer, kinship, and community social networks of AI adolescents. Hypothesis: Standard metrics of social networks will require modification to characterize social networks of AI adolescents; networks will have less homophily and more intergenerational and community relationships. Aim 2: Explore how social network characteristics predict risk and protective factors for substance use independently and in combination with violence and suicide. Hypothesis: Risk and protective characteristics of youth networks will be related in both common and unique ways to substance use, violence, and suicidality. This project will be led by a multidisciplinary team of early-stage Principal Investigators who are themselves American Indian and Alaska Native. These researchers have substantive expertise in substance use; exposure to violence and suicide among AIs; methodological expertise in community-engaged research with tribal communities; social network theory and analyses; and quantitative, qualitative, and mixed methods approaches. This project leadership team will be supported by a senior researcher with extensive experience in most of the areas relevant to this study and 18 years of experience conducting research with the reservation where the study will take place.

Grant Number: 1R21DA050518-01
Project Title: Assessing the Role of Culture in Reducing Recidivism Among Alaska Native and American Indian Women
PI Name: Katie Schultz, PhD
PI Contact Info: 734-647-6376, katieasc@umich.edu
PD Name: Kathy Etz, PhD
Institute: University of Michigan-Ann Arbor
RFA/PA: PAR-17-464
Project Start: 04/15/2020
Project End: 03/31/2022

Abstract
Women are the fastest growing segment of the criminal justice population; Alaska Native and American Indian (AN/AI or Native) women are disproportionately represented within this growing population, and most arrests are alcohol or drug related. Although rates vary by region and tribe, Native women face significant substance use disorder (SUD) treatment needs, and nearly half of all treatment referrals originate in the criminal justice system. Trauma is an established antecedent to SUDs and justice-involvement, and 84% of AN/AI women have experienced intimate partner violence or sexual assault in their lifetime with 40% in the past year. Cultural beliefs and practices are protective in reducing substance misuse and healing from trauma among AN/AI women, yet little is known about the protective role of cultural beliefs and practices among justice involved AN/AI women and how those might be leveraged in an intervention to reduce recidivism. (Recidivism is broadly defined as the return to criminal behavior after a person has been convicted of a prior offense.) The goal of this study is to develop a culturally informed model by identifying modifiable risk and protective factors associated with lower recidivism among AN/AI women on probation or parole in Alaska. Women on probation or parole have greater access to alcohol and drugs than incarcerated women and are at elevated risk of interpersonal violence—both of which contribute to recidivism. Native women in Alaska are 19% of the population but are 28% of women under community supervision. Alcohol, opioids, and other drug use account for approximately one third of their criminal involvement. This study uses a convergent mixed methods design (QUAL + QUAN). Aim 1: Explore the role of substance misuse and interpersonal violence as risk factors for AN/AI women’s involvement in the justice system and identify the most salient cultural beliefs and practices that may influence factors related to recidivism through focus groups with AN/AI women on probation or parole (6 groups; N = 36). Aim 2: Identify modifiable factors associated with lower recidivism using administrative data and surveys with AN/AI women on probation or parole (N = 150) to investigate: 2a. associations between coping behaviors, cognitions, positive relationships, prosocial activities, and recidivism; 2b. the impact of substance misuse and interpersonal violence on recidivism; and 2c. the moderating effect of cultural beliefs and practices on these relationships. This study will be among the first to provide data on the influence of SUDs and interpersonal violence as primary risk factors for justice-involvement among AN/AI women and is the first to examine the role that AN/AI cultural beliefs and practices may play in the reduction of risk for recidivism among this population. Findings will inform development of a culturally responsive intervention to reduce recidivism among AN/AI women to be tested in a subsequent study.

Grant Number: 1R21DA047940-01
Project Title: Investigating Maternal Opioid Use, Neonatal Abstinence Syndrome and Response in NW Tribal Communities
PI Name: Tam Lutz, MPH, MHA
PI Contact Info: tlutz@npaihb.org
PD Name: Keisher Highsmith, DrPH
Institute: Northwest Portland Area Indian Health Board
RFA/PA: PAR-17-464
Project Start: 08/01/2019
Project End: 07/31/2021

Abstract
Medical and nonmedical use of prescription opioids has skyrocketed in the United States over the past two decades. The rise in opioid use during pregnancy marked disparities among American Indian/Alaskan Native (AI/AN) women and newborns. While there are evidence-based treatment strategies recommended for use during pregnancy and in the postnatal use period, use of these strategies is substantially lower in AI/AN across the United States. As sovereign nations, tribes are often responsible for policies, practices, and infrastructure improvements to address these problems. The Northwest (NW) Tribal Epidemiology Center (The EpiCenter) is tasked with responding to the data needs of the 43 NW Tribes, including opioid use, neonatal abstinence syndrome (NAS), and access and utilization of treatment related information. We initiate this proposal in response to these requests and needs of the tribes. We plan to perform an epidemiologic assessment to determine the magnitude and impact of maternal substance use during pregnancy and NAS among AIs in the NW. We will leverage ongoing and planned work in The EpiCenter to estimate race-corrected rates and trends of maternal substance use during pregnancy and NAS in hospital discharge data. We will also investigate opioid use and treatment in the NW as reported in Indian Health Service’s national data repository. We will complement these quantitative data with qualitative data to help us understand the environmental, social, and organizational structures, processes, and policies, as well as individual behaviors that influence access to, or use of, treatment in NW Tribes. This proposal will bring together epidemiologic and content experts as advisory board members to respond to the data and ensure that analyses and reports are useful to decision-makers in various capacities. Upon successful completion of the proposed study aims, we will be poised to implement and evaluate future tribal interventions and policies, which in the long term could reduce the effect of the opioid crisis in NW AI communities.

Grant Number: 5R01DA035141-05
Project Title: Substance Use Prevention Campaign for American Indian Youth
PI Name: Randall C. Swaim, PhD
PI Contact Info: 970-491-6961, randall.swaim@colostate.edu
PD Name: Aria Davis-Crump, ScD
Institute: Colorado State University
RFA/PA: PAR-11-346
Project Start: 4/15/2014
Project End: 2/29/2020

Abstract
Inhalants pose a particularly dangerous risk to middle-school youth, and American Indian (AI) youth are at particular risk for inhalant use. We have found over the course of more than three decades that inhalant use among AI youth is consistently higher than that of other ethnic/racial groups. Although inhalant use rates for AI youth gradually declined from a peak of 31% in 1984 through 2004, our data show a substantial increase in lifetime prevalence of inhalants among AI 7th - 12th grade youth -- from 10% to 25%. Schools are often the site for adolescent drug prevention efforts, but results from these efforts are often modest or even disappointing. This intervention adapts an existing campaign (Be under Your Own Influence; BUYOI) that has been found to be effective in reducing substance use and that uses campaign messages that are congruent with AI culture. The intervention will be adapted using significant contributions from tribal members, including youth, teachers, parents, elders, and other community members. This proposal includes active involvement of local advisory boards, hiring of a local AI liaison, focus groups, a youth photo voice component, and use of AI staff from our Center and from the Native American Cultural Center at our university. The adapted anti-inhalant communications campaign will be delivered by selected high school students to 7th grade students. A distinguishing feature of the BUYOI campaign is a message that targets outcome expectations related to aspirations, autonomy, and physical harms. The campaign will use multiple channels of communication including print (e.g., posters and fliers), video and audio spots, presentations, and social media to deliver messages that are designed to alter outcome expectancies, intentions, and ultimately inhalant use among targeted youth. The campaign will be delivered to two cohorts of 7th graders, with 4 longitudinal measurement occasions for each cohort. Seven middle schools (and their corresponding high schools) have been recruited for the study, where four of these will be randomly assigned to the intervention condition and three to the control condition. Multilevel data analysis will test for effects of campaign exposure on autonomy, aspirations, perceived harm, and intentions to use. Because of the heavy involvement of the school and community in the development and delivery of the intervention, we will be able to incorporate sustainability into the design of all integrated components. Ultimately, our goal is to develop a turnkey package for the broader population of reservation-based AI youth and schools and to develop components that can incorporate flexibility and creativity in their delivery. For example, a school or local group may implement the campaign in its original form or they may modify aspects to make them more pertinent to their community.

Grant Number: 5R01DA035143-05
Project Title: Intertribal Talking Circle for the Prevention of Substance Abuse in Native Youth
PI Name: John R. Lowe, PhD, RN
PI Contact Info: 850-644-5635, jrlowe@fsu.edu
PD Name: Aria Davis-Crump, ScD
Institute: Florida State University College of Nursing
RFA/PA: PAR-11-346
Project Start: 5/1/2014
Project End: 4/30/2020

Abstract
Substance abuse among American Indians (AI) is a critical health disparity and accounts for many life- threatening and deadly problems such as accidents, chronic liver disease, cirrhosis, homicide, and suicide. The high rate of substance abuse found among AI adolescents is believed to be associated with a variety of environmental and historical factors. These include poverty, historical trauma, bi-cultural stress, and changing tribal and family roles. There are few evaluated programs addressing early adolescent AI substance abuse. Tribal communities must be actively engaged in program development and implementation to ensure cultural relevance and sustainability of prevention programs. This project proposes to evaluate an after-school substance abuse prevention intervention, the Intertribal Talking Circle (ITC), targeting 6th grade AI youth in three AI communities: Ojibwe/Chippewa in Minnesota, Choctaw in Oklahoma, and Lumbee in North Carolina. A community-based participatory research approach will be used to culturally and technologically adapt the ITC. A two-condition controlled study will evaluate the efficacy of the ITC to increase AI youth Native self- reliance while decreasing AI youth substance use involvement. An adult training program second level intervention study is also proposed to train tribal personnel from the three regional tribes on how to implement the Intertribal Talking Circle intervention as a tribl program beyond the study period. Effectiveness will be determined by a small partial cross-over randomized trial comparing ITC intervention to a Wait-List Control (WLC) condition. Process evaluations will focus on the future adoption and implementation of the ITC, and recommendations for sustainable adaptations. The project will also build AI capacity to address health disparities, as experienced Native investigators will mentor three Junior Native Investigators.

Grant Number: 1R01DA037174-01
Project Title: Family Listening Program: Multi-Tribal Implementation and Evaluation
PI Name: Nina B. Wallerstein, DrPH, MPH
PI Contact Info:  505-277-0130, nwallerstein@salud.unm.edu
PD Name: Aria Davis-Crump, ScD
Institute: University Of New Mexico Health Scis Ctr
RFA/PA: PAR-11-346
Project Start: 4/1/2014
Project End: 3/31/2020

Abstract
With substance abuse concerns plaguing tribal communities, health preventive approaches for American Indian (AI) children need urgent attention. Mainstream programs fall short by failing to speak to AI children on their own terms. Not so with the Family Listening/Circle Program (FL/CP) which integrates an evidence-based family-strengthening core, with cultural values and practices for 4th graders, their parents and elders? Through previous Native American Research Centers for Health funding (Indian Health Service & National Institutes of Health partnership) the FL/CP was created and piloted by community-based participatory research (CBPR) partnerships between the University of New Mexico Center for Participatory Research and three tribal communities: Pueblo of Jemez, Ramah Band of Navajo and Mescalero Apache Nation. FL/CP fills a gap in substance abuse prevention by recapturing historic traditions of cultural transmission, such as family dinner story
telling where elders connect with children, supporting enhanced child-family communication and psycho-social coping through traditional dialogue, indigenous languages and empowerment where children and families create community action projects addressing community substance abuse. With initial FL/CP pilot and feasibility research completed, Tribal Research Teams (TRTs) from the Pueblo of Jemez, Ramah Band of Navajo and Mescalero Apache Nation are now in place for full program implementation and effectiveness testing through a longitudinal quasi-experimental design involving a long-term, multi-tribal/academic research partnership. Under this five-year R01 effectiveness trial, tribal partners are committed to assessing the program's effectiveness and disseminating the approach and intervention within Indian Country as a best practice in reducing substance abuse health disparities, with TRTs collaborating on all research activities, implementation, interpretation/analysis, and dissemination plans. Three specific aims are 1) To rigorously test effectiveness of FLCP; with a comparative longitudinal design within and across the tribes, with 4th graders to prevent substance initiation/use and strengthen families; 2) Through CBPR, support TRTs to transform their research capacities into local prevention research infrastructures and partnering; 3) To assess additional program effects on other health/education programs and leadership within the tribes. In sum, this multi-tribal/academic partnership builds on accomplishments to test the effectiveness of an innovative intervention. This grant provides an unparalleled opportunity to reduce substance abuse in three tribal communities, strengthen tribal research capacities, and impact substance abuse prevention research designs nationally, by illustrating how CBPR processes can integrate evidence-based and cultural-centered practices to create effective programs that generate community ownership and sustainability.

Grant Number: 1R01DA037176-01
Project Title: Yappalli Choctaw Road To Health
PI Name: Karina Lynn Walters, MSW, PhD
PI Contact Info: 206-543-5647
PD Name: Aria Davis-Crump, ScD
Institute: University Of Washington
RFA/PA: PAR-11-346
Project Start: 6/1/2014
Project End: 5/31/2020

Abstract
Obesity and substance abuse are increasingly prevalent, costly, and deadly--fueling a twin epidemic in the United States. The importance of addressing obesity and alcohol and other drug (AOD) use simultaneously is supported in part by recent research at NIDA linking the brain mechanisms that fuel drug addiction and compulsive eating behaviors. Although AOD abstention and abuse patterns vary considerably by region and tribe, American Indian (AI) drug-related deaths are 1.5 times higher than for all other ethnic groups in the US. AI women in particular exhibit significant disparities with other women in obesity and AOD prevalence and higher rates of premature mortality and morbidity as a result. Based on preliminary research, we have developed the Yappalli Choctaw Road to Health, a culturally focused, strengths-based outdoor experiential obesity-AOD risk prevention and health leadership program. The 3-month intervention (i.e., 3 individual meetings; 8 group-sessions + 2-day culture boot camp + 10-day Choctaw Trail of Tears walk) is grounded in the PI's Indiginest Stress-Coping Model and the Information-Motivational- Behavioral Skills framework, with activities consistent with Motivational Interviewing and leadership development principles. This RO1 application, prepared in response to PAR-11-346 (Interventions for Health Promotion and Disease Prevention in Native American Populations), proposes to evaluate the program among 150 at-risk adult Choctaw women across 5 regions of the Choctaw Nation of Oklahoma (CNO), where Native women have some of the highest obesity, physical inactivity, and excessive drinking prevalence in the country. We will conduct a longitudinal study using a cluster randomized stepped-wedge design to evaluate the intervention impact on the AOD and obesity prevention primary aims of: (1) substance use harm reduction (SUHR) and AOD use and intentions to use; and (2) reduction in weight/BMI and increase in leisure-time physical activity and healthful food habits. The project is multidisciplinary community-based participatory research collaboration among experienced AI researchers at the Universities of Washington and Minnesota and Choctaw behavioral health leaders and providers. A unique feature of the proposed project is its direction at both the university and tribal levels by Choctaws. The project is supported by pilot and tribal acceptability data; addresses a critical public health issue among a group experiencing considerable health disparities; and strengthens the research infrastructure in partnership with the Tribe. If efficacious, it has the potential for widespread dissemination and could be generalizable to other chronic co-occurring mental health and physical health conditions (e.g., diabetes and depression).

Grant Number: 1R01DA037177-01A1
Project Title: A RCT of a Family-Centered Ojibwe Substance Abuse Prevention
PI Name: Leslie B. Whitbeck, PhD
PI Contact Info: 402-472-3673, lwhitbeck2@unl.edu
PD Name: Aria Davis-Crump, ScD
Institute: University of Nebraska-Lincoln
RFA/PA: PAR-11-346
Project Start: 6/15/2015
Project End: 4/30/2020

Abstract
This application seeks funding for a multi-reservation randomized controlled trial (RCT) of a popular, widely disseminated, substance abuse prevention program targeted at Anishinabe (Ojibwe) preadolescents aged 8-10 years, their parents/caretakers, and extended family adults who have daily influence over the target child's behaviors. The Bii-Zin-Da-De-Dah (BZDDD) (Listening to One Another) program was the first American Indian (AI) adaptation of the Iowa Strengthening Families Program. Now in its third generation, BZDDD has been adapted for Dakota, Lakota, Pueblo, and Navajo cultures and is currently the center piece of a Canadian national Indigenous mental health promotion funded by Public Health Agency of Canada. Although BZDDD has been extremely popular at the grassroots level and has been adapted to numerous cultures there has never been a large-scale empirical evaluation of the program's efficacy for reducing adolescent alcohol and drug use. Our overall goal is to implement a RCT of a fourth-generation BZDDD prevention program that can be replicated cross-culturally by other North American Indigenous cultures to decrease substance use among early adolescents and improve mental health outcomes. This goal will be accomplished through four specific aims: 1) Complete a final adaptation of the 14-week BZDDD prevention program for the U.S. reservations; 2) Implement a RCT of BZDDD to assess its efficacy for delaying and/or preventing adolescent onset of alcohol and drug use; 3) Empirically address cultural challenges for RCTs involving Indigenous cultures by evaluating contamination and informal diffusion in communities and extended families; and 4) Work with our Anishinabe research partners to develop a plan to sustain the prevention. Using intent to treat design, the RCT will involve 255 treatment and 255 waitlist control families who live on or near five Anishinabe reservations in Minnesota and Wisconsin. There will be a pretest and initial post-test, with subsequent 6, 12, 18, 24, 30, and 36 month follow-ups, thus evaluating the target children through the critical years of substance use initiation. The proposed RCT will leave behind an empirically-based, family-centered prevention program that is easily woven into existing tribal social and health services or school settings. It also will be a template for adaptation to other Indigenous cultures.

Grant Number: 1R01DA035111-01
Project Title: Culturally Grounded Early Substance use Prevention for American Indian Families
PI Name: Nancy R. Whitesell, PhD
PI Contact Info: 303-724-1456
PD Name: Aria Davis-Crump, ScD
Institute: University Of Colorado Denver
RFA/PA: PAR-11-346
Project Start: 6/15/2013
Project End: 6/30/2019

Abstract
Problematic substance use is widespread in many American Indian communities, and early adolescence is a critical period for the development of subsequent substance problems. Efforts to prevent early substance abuse are ongoing on many reservations but often are not informed by scientific evidence of effectiveness - largely because such evidence is sorely lacking. We propose to partner with a reservation community with high rates of substance problems to adapt, implement, and rigorously evaluate a program designed to prevent early initiation of substance use and the myriad of problems that accompany early use. The identification of early substance use as a target and the selection of the particular intervention approach we propose have directly resulted from a longstanding university-tribal community relationship and, in particular, from community input within the context of two recent projects funded by NIDA (RC4DA029974, Whitesell & Beals, PIs; and R01DA027665, Whitesell, PI). A clear message arising out of both projects has been the need to engage families and culture in the prevention of early onset substance use. In this project, we will continue this partnership to translate a rigorously evaluated evidence-based practice for use with tribal families, adapting and anchoring it within a cultural practice arising from within the community. We will draw on the strengths of both university and community partners, implementing innovative intervention development methods within a community collaborative research and evaluation context. We will address three specific aims: 1. Develop a culturally grounded, family-based early substance use prevention intervention tailored to a Northern Plains American Indian Reservation. "Use an evidence-based practice approach to implement a proven program (Iowa Strengthening Families Program/ISFP) within a new context, working with community partners to translate ISFP for the local context, including deep and meaningful adaptations in how the curricular content is delivered. "Use a practice-based evidence approach to integrate a cultural curriculum (Seven Directions/SD) developed within the community into the ISFP curriculum, drawing on local knowledge of effective practices to further ground substance use prevention efforts within the cultural context. 2. Pilot the adapted Seven Directions for Stronger Families (SDSF) program to determine feasibility, refine details, and maximize fit within the community. 3. Use the principles of the Multiphase Optimization Strategy (MOST) for intervention evaluation and development, to determine the relative effect size of different intervention components and inform a final SDSF program that balances effectiveness and efficiency. 4. Set the stage for broad implementation of SDSF by the tribal health administration and a randomized controlled trial of the full intervention.

Grant Number: 1R01NR018400-01A1
Project Title: I kua na'u "Let Me Carry Out Your Last Wishes" Advance Care Planning for Native Hawaiian Elders
PIs Name: Michael K. Paasche-Orlow, MD, MA, MPH
Contact PI Info: mpo@bu.edu
PD Name: Lynn Adams, PhD
Institute: Boston University Medical Center
RFA/PA: PAR-17-496
Project Start: 05/20/2020
Project End: 02/28/2025

Abstract
Communication surrounding serious illness decision making is formalized in Advance Care Planning (ACP), a process involving verbal or written information designed to inform patients of possible medical options including palliative and hospice care services. Numerous studies have suggested that improved ACP rates better align health care delivery with patient preferences. Despite expansion of ACP services in the health care system, Native Hawaiians (NHs) consistently have negligible rates of ACP and low use of palliative and hospice care services. To address these shortcomings, our multi-disciplinary community and research group has partnered to create the I kua na'u "Let Me Help Carry Out Your Last Wishes" ACP video intervention. Our community-based collaborative approach will create, develop, and test the I kua na'u comprehensive video-based ACP program honoring the history, opinions, and culture of NHs. Indeed, NH culture is primarily an oral tradition in which the spoken word permeates the life of NHs and is the normal way of interacting with neighbors, including in its most recent adaptation with the use of video media. The I kua na'u program will include videos tailored for the different settings in which older NHs live and get medical care. The videos will explain the importance of ACP, empower NHs to tell their story ('olelo Kama'ilio; "Talk Story") by allowing the recording of personal video declarations of ACP wishes, and the ability to share the personal video declaration with family, friends, and clinicians. The overall objective is to conduct a five-year program that includes two years of development of the I kua na'u ACP video program with focus group testing, and then three years of implementation in the NH community. Demonstrating the effectiveness of using the video program in NHs represents an essential step to implement this tool in practice. The specific aims are: (1) To conduct focus groups and group interviews of NH elders, their families, and their providers to inform the creation and pilot-testing of NH ACP videos that would embrace the NH concept of I kua naʻu - "Let me help carry out your last wishes" among three different types of organizations serving NH elders and their families (NH homestead, group assisted living, and ambulatory care); (2) To compare the ACP engagement, knowledge, decisional conflict, and ACP completion rates in 220 NHs over the age of 55 in: (a) a pre-post study design in 110 people living on homestead or assisted living using the video intervention, and (b) a randomized trial of 110 people recruited from ambulatory clinics; (3) To conduct a qualitative assessment of personal video declarations from 165 NHs using the intervention; and (4) To compare ACP documentation and end-of-life health care utilization of NHs compared to non-NHs living in Hawaiʻi before and after the intervention program using electronic health records and/or insurance data. Conventional ACP programs do not meet the unique needs of NHs. Creating and implementing a unique video-based intervention for NHs can help support decision making in this community and decrease disparities in serious illness care.

Grant Number: 1R01NR015417-01A1 REVISED
Project Title: Back to Basics: Addressing Childhood Obesity Through Traditional Foods in Alaska
PI Name: Timothy K Thomas, MD
PI Contact Info: 907-729-3095, tkthomas@anthc.org
PD Name: Sung Sug Yoon RN, PhD
Institute: Alaska Native Tribal Health Consortium, 3900 Ambassador Drive, Anchorage, AK
RFA/PA: PAR-14-260: Interventions for Health Promotion and Disease Prevention in Native American Populations
Project Start: 09/25/2017
Project End: 07/31/2022

Abstract
Back to Basics is a mixed-methods intervention trial to reduce the prevalence of obese Alaska Native children by increasing the proportion of nutrient-dense traditional and non-traditional foods consumed, and decreasing consumption of sugar sweetened beverages (SSBs). This 5-year intervention trial targeting 0-5 year olds is conducted in partnership with Rural Action Community Action Program, Inc. (RC) Head Start, Early Head Start, and Parents as Teachers programs in 12 rural Alaskan communities, where each site is assigned to either a 9-month nutritional education and meal program intervention or a standard education and meal program repeating annually.

Once a nomadic population that lived entirely off the land, river, and sea, Alaska Native people have experienced an abrupt nutritional shift towards greater consumption of store-bought manufactured foods and a more sedentary lifestyle. A recent study of dietary adequacy among Alaska Native women in western Alaska found that traditional foods accounted for only 17% of calories, but provided 34% of protein, as well as disproportionately large amounts of essential vitamins and minerals. SSBs were consumed more than any other dietary item and accounted for 8% of calories.

Over the past three decades, childhood obesity has emerged as a serious public health problem, increasing three-fold across all races and ethnicities. Obesity is highest among Hispanic and Alaska Native/American Indian (AN/AI) children and adults, with 41% of Alaska Native children 2-5 years of age overweight or obese in 2009. Substantial evidence suggests that obesity in early childhood, ages 0-5 years, is a critical factor in the development of adolescent and adult obesity. Obesity, in childhood and adulthood, is a major risk factor for serious immediate and long-term life-threatening health conditions, such as glucose intolerance, hypertension, diabetes, and cancer.

Back to Basics has an unprecedented opportunity to incorporate the lessons learned through past research (Store Outside Your Door) and build on previous study designs and interventions (Hip-Hop to Health, Jr.) in implementing an effective intervention to improve dietary quality through promotion and reincorporation of traditional foods in at-risk young children and their families. A home-based nutrition education curriculum and Head Start center-based meal service focused on traditional foods, will serve as the foundation of the intervention. If effective, this strategy can be adapted and implemented by other Head Start programs across the state to further improve diet quality of all Alaska Native children.

Grant Number: 5R01NR014831-03
Project Title: Supporting AI/AN Mothers and Daughters in Reducing Gestational Diabetes Risk
PIs Name: Denise Charron-Prochownik, PHD & Kelly Moore, MD
Contact PI Info: 412-624-6953, dcp@pitt.edu
PD Name: Rebekah S Rasooly, PhD
Institute: University of Pittsburgh
RFA/PA: Nursing Research 93.361
Project Start: 05/08/2015
Project End: 03/31/2020

Abstract
Gestational diabetes mellitus (GDM) has escalated to epidemic proportion and can cause maternal and child complications. GDM is a significant maternal risk factor for subsequent development of type 2 diabetes (T2D) and places the fetus at increased risk for congenital morbidity/mortality and for future onset of diabetes. American Indian and Alaska Native (AI/AN) women are twice as likely to develop GDM and T2D; mostly due to healthcare disparities (e.g., limited access to resources, lack of culturally relevant programs). The need for an inexpensive accessible GDM intervention in this population is compelling. The intervention should be delivered during adolescence and prior to sexual debut. Preconception counseling (PC) prevents unplanned pregnancies and significantly reduces risks of complications. If GDM in a previous pregnancy is an indicator of high risk in subsequent pregnancies, then preventing GDM in a first pregnancy is imperative. For a significant and innovative shift in paradigm, we propose a primary prevention PC intervention for AI/adolescent females at risk for GDM to enhance healthy lifestyle behaviors and family planning vigilance prior to this first pregnancy. We will target girls starting at the age of 12 to coincide with boththe Coming-of-Age rituals for AI/AN girls during which many receive womanly advice from elder female family members, and the American Diabetes Association recommendation that PC in all females should start at puberty. This new directive will require support from the teens mothers (or their female caregiver) and well-informed community health care professionals (HCP). Our objective is to adapt our current PC intervention (validated for teens with diabetes) using a sequential mixed-method design with a multi-tribal AI/AN community-based participatory research (CBPR) approach (e.g., Navajo, Cherokee, 40 Oklahoma tribes; 8 project members are AI/AN) by first using focus groups of teens, mothers, HCP, and Tribal leaders; and then testing this culturally appropriate PC theory-based intervention named STOP-GDM in AI/AN adolescent females 12 to <20yrs at risk for GDM (e.g., pre-diabetes or BMI> 85%). Teens and their mothers will receive STOP-GDM to raise their awareness of the risks of GDM and benefits of healthy lifestyle to reduce these risks. By also providing mothers with PC knowledge and skills they can naturally weave cultural/social influences into their communications with their daughters. The multi-level intervention will be directed at the individual, familial and institutioal levels simultaneously. AI/AN community-researcher partnerships have been established. A randomized controlled trial with a 15mos follow-up will test the effects of receiving online STOP-GDM on mother-daughter (M-D) cognitive/psychosocial and behavioral outcomes, and daughter family planning vigilance. The final online STOP- GDM program will be provided at no cost to the Indian Health Service (IHS) for dissemination to all their sites. HCPs at each clinical facilit will be given free access to a continuing education program for PC training. This proposal provides a unique opportunity for a broad dissemination to significantly impact all IHS AI/AN female teens at risk for GDM, and help to prevent them and their future children from developing T2D. PUBLIC HEALTH RELEVANCE

Grant Number: 1R01NR014153-01
Project Title: A Primary Prevention Trial to Strengthen Child Attachment in a Native Community
PI Name: Cathryn Booth-LaForce, PhD
PI Contact Info: ibcb@uw.edu
PD Name: Sung Sug Yoon RN, PhD
Institute: University Of Washington
RFA/PA: PAR-11-346
Project Start: 9/18/2013
Project End: 6/30/2020

Abstract
Children are considered gifts and play a central role in American Indian (AI) culture. However, AI children are at elevated risk for experiencing poverty, parental mental health disorders, household exposure to substance use, domestic violence, and maltreatment, all of which increase their risk of poor mental and physical health outcomes as adolescents and adults. Virtually no evidence-based programs exist that can be administered in a resource-poor tribal setting, can be culturally adapted, can be exported, and hold promise for sustainability. The needs of these vulnerable AI children, thus, remain almost entirely unmet. Decades of research have shown that secure attachment in infancy and early childhood is a key developmental building block that predicts adjustment and promotes resilience in children who grow up under stressful circumstances. Because secure attachment develops from caregiver sensitivity and responsiveness, it is critical to address caregiver sensitivity in early childhood. We will, therefore, test the Promoting First Relationships (PFR) program, a theoretically driven, relationship- and strengths-based primary prevention program. Several studies have shown the diverse positive effects of PFR on the caregiver-child relationship for at-risk populations. The University of Washington Partnerships for Native Health have nurtured a strong, long term collaboration with the Fort Peck Tribes, whose reservation lies in a remote area of northeastern Montana. The tribes’ Elders Involved Initiative has stated that the health and well-being of children and young adults are their primary concern, recommending a return to traditional parenting values. With our tribal partner, we will adapt PFR to ensure cultural appropriateness, then conduct a randomized, controlled trial to compare the PFR intervention with a control group receiving information on resources and referrals. Our primary purpose is to test the effectiveness of PFR in improving the caregiver's sensitivity to the child (primary outcome). We will also examine child attachment security to the caregiver and the child's social and emotional functioning. Our specific aims are to 1) adapt the PFR intervention using focus groups; 2) assess the adequacy of training by examining the pre- and post-training attitudes and consultation strategies used by community-based PFR providers with caregivers and infants; and 3) compare the PFR and control group on caregivers’ sensitivity and responsiveness and children's social and emotional competencies and attachment security. Effective primary preventive interventions are critically needed for AI children who grow up under stressful circumstances. By promoting sensitive caregiving and child attachment security, we can minimize the impact of contextual stressors on children living on the Fort Peck reservation and, foster resilience, and improve their risk outlook.

Grant Number: 1R21ES031553-01A1
Project Title: Aeroallergens, Air Pollution and Respiratory Health in the Chickasaw Nation A1
PI Name: Amanda Janitz, PhD, MPH, BSN
PI Contact Info: amanda-janitz@ouhsc.edu
PD Name: Claudia L. Thompson, PhD
Institute: University of Oklahoma Health Sciences Center
RFA/PA: PAR-17-464
Project Start: 05/01/2021
Project End: 04/30/2023

Abstract
American Indians are disproportionately impacted by asthma. The Chickasaw Nation, located in southcentral Oklahoma, reports clinic visits for asthma as one of the top diagnoses, accounting for 7% of patients at Chickasaw Nation Department of Health. Due to the high patient burden for asthma in Chickasaw Nation, the Tribe has identified a need to better understand risk factors for asthma-related morbidity. The long-term goal of this research is to understand the impact of aeroallergens and anthropogenic air pollution on asthma morbidity in Chickasaw Nation and to investigate more efficient ways to monitor, control, and ultimately prevent asthma morbidity among this highly susceptible population. The Chickasaw Nation provides clinical and public health services for the majority of American Indians residing within their jurisdictional area in southcentral Oklahoma; thus, improving the health of the Tribe promotes the health of the overall community. This study provides a unique opportunity to evaluate the effect of ambient aeroallergens (pollen) and anthropogenic air pollution (particulate matter, ozone) on asthma-related morbidity using a novel device to measure the time and location of metered-dose inhaler (MDI) use in a rural, American Indian population. This in-depth study will allow researchers and the Tribe to: 1) evaluate the association of spatially and temporally resolved aeroallergens and anthropogenic pollutants with Global Positioning System (GPS)-enabled MDIs among Chickasaw Nation community members with asthma, and 2) compare the participants' perceived individual and neighborhood asthma triggers to the spatial and temporal data collected through the MDIs using sketch maps and interviews. We are partnering with Propeller Health to use GPS-enabled MDIs to measure asthma exacerbations, which will allow us to collect the exact time and location of the MDI actuation. We will evaluate whether the measured exposures are associated with MDI actuation using a time-series model accounting for lag times up to one week. At the end of the study, the participants will develop sketch maps that describe the perceived geographic locations of their asthma triggers. Our central hypothesis is that aeroallergen and air pollution levels in Chickasaw Nation interact synergistically to increase the prevalence of asthma-related morbidity. Longitudinal data on aeroallergens and asthma are sparse in American Indian populations and awareness of triggers will help improve asthma management in Chickasaw Nation. This study provides a unique opportunity to evaluate the effect of aeroallergens and anthropogenic air pollution on asthma morbidity using a novel device to measure the time, frequency, and location of MDI use in this population.

Grant Number: 5R01ES027793-02
Project Title: Promoting Smoke-free Homes in Lakota Communities.
PI Name: Patricia Nez Henderson, MD, MPH
PI Contact Info: 605-348-6100, pnhenderson@bhcaih.org
PD Name: Claudia L Thompson, PhD
Institute: Black Hills Center for American Indian Health
RFA/PA: PAR-14-260
Project Start: 09/15/2017
Project End: 07/31/2021

Abstract
Secondhand smoke (SHS) is recognized as a class A carcinogen and has no safe level of exposure. Nonsmokers from the Cheyenne River Sioux Tribe, a Lakota tribe from South Dakota, disproportionately share the burden of SHS, especially in their homes. Our own recently completed research finds that 19% of Lakota non-smoking adults (including those on Cheyenne River) have cotinine levels (a metabolite of nicotine) >15 ng/ml, which are comparable to levels typically seen in active smokers. With smoking prevalence as high as 50% among this population, the consequences of SHS already manifest in this tribe, including high prevalence of childhood asthma and sudden infant death syndrome. Further complicating matters, the expanded use of commercial tobacco products for ceremonial and cultural practices is creating challenges not typically seen in non-American Indian communities. Therefore, eliminating SHS exposure in a culturally appropriate manner is a fundamental step in decreasing morbidity and mortality among Cheyenne River Sioux Tribe and other Northern Plains Tribes. Our primary study objective is to develop and test a culturally tailored intervention to encourage adoption of home smoking restrictions in Cheyenne River Sioux Tribal households where nonsmokers are present. We propose to conduct a randomized, controlled trial to test our culturally-tailored advocacy training both with and without urinary biomarker feedback. Biomarker feedback is an intervention method that can give personalized information, including levels of urinary or serum cotinine and/or tobacco-specific pro-carcinogen markers, back to individuals in order to characterize evidence of the negative sequelae of smoking in the household. Previous studies, including our pilot project, have focused on providing children's biomarker feedback back to decision-making smokers, but the evidence that this approach can promote in-home smoking restrictions is thus far mixed. This study appears to be the first to use biomarker feedback with adult nonsmokers for advocacy efforts. Our Specific Aims are to:

1) Assess knowledge, attitudes and beliefs about secondhand smoke exposure and perceived barriers to adoption of smoking restrictions in tribal member households on the Cheyenne River Sioux Tribe Reservation; 2) Augment, implement, and evaluate a nonsmokers’ urinary cotinine and carcinogen biomarker feedback intervention on the adoption of household smoking restrictions; and 3) Determine the effect of the intervention on health-related quality of life 6 months after implementation of the advocacy and biomarker feedback intervention.

Grant Number: 1R01ES022583-01A1
Project Title: Residential Wood Smoke Interventions Improving Health in Native American Populations
PI Name: Curtis William Noonan, PhD, MA
PI Contact Info: curtis.noonan@umontana.edu
PD Name: Claudia L Thompson, PhD
Institute: University Of Montana
RFA/PA: PAR-11-346
Project Start: 6/19/2014
Project End: 2/29/2020

Abstract
A critical need exists for efficient community-based interventions aimed at reduction of environmental exposures relevant to health. Biomass smoke exposures due to residential wood heating are common among rural Native American communities, and such exposures have been associated with respiratory disease in susceptible populations. In many of these communities wood stoves are the most economic and traditionally preferred method of residential heating, but resource scarcity can result in burning of improper wood fuels and corresponding high levels of indoor particulate matter. In response to the funding announcement "Interventions for Health Promotion and Disease Prevention in Native American Populations" (PAR-11-346), we propose a two-level intervention strategy to reduce exposure to indoor biomass smoke among elderly tribal members in two reservation communities: Nez Perce and Navajo Nation. Community-based participatory research techniques will be used to adapt intervention approaches to meet the cultural context of each participating community. At the community level, we will facilitate local development of a tribal agency-led wood bank program ensuring that elderly and/or persons with need have access to dry wood for heating. At the household level, we will use a three arm randomized placebo-controlled intervention trial to implement and assess education/outreach on best burn practices (Tx1). The content and delivery strategies of the education intervention will be adapted to each community according to stakeholder input. This educational intervention will be evaluated against an indoor air filtration unit arm (Tx2), as well as a placebo arm (Tx3, sham air filters). Tx3 will be used in comparison with the other two treatment arms to evaluate the penetration and efficacy of the community-level wood bank program. Outcomes will be evaluated with respect to changes in pulmonary function measures and respiratory symptoms and conditions among household elders. We hypothesize that locally-designed education-based interventions at the community and household levels will result in efficacious and sustainable strategies for reducing personal exposures to indoor particulate matter, and lead to respiratory health improvements in elderly Native populations. This study will advance knowledge of cost-effective environmental interventions within two unique Native American communities, and inform sustainable multi-level strategies in similar communities throughout the US to improve respiratory health among at-risk populations.

Contact PI: Christine Marie George, PhD
Grant number: 5R01ES025135-02
Project Title: Participatory Interventions to Reduce Arsenic in American Indian Communities
PI Name: Christine Marie George, PhD
PI Contact info: 410-955-2485, cgeorg19@jhu.edu
PD Name: Claudia L Thompson, PhD
Institute: Johns Hopkins University
RFA/PA: PAR-11-346
Project Start: 07/01/2015
Project End: 03/31/2020

Abstract
In the Strong Heart Study (SHS), chronic low-to-moderate arsenic exposure in drinking water is associated with an increased risk of cardiovascular disease, diabetes, kidney disease, and cancer in American Indians (AI) from Arizona, Oklahoma, and North/South Dakota. Effective interventions are urgently needed to mitigate arsenic exposure in AI communities who rely on private wells as the main source of water for drinking and cooking. Objective: The purpose of the study is to design, implement, and evaluate multi-level participatory interventions that can lead to a sustained reduction in arsenic exposure in AI communities in North/South Dakota that remained exposed to elevated arsenic levels in drinking water. Preliminary studies: In a recent pilot study, >50% of private wells from Spirit Lake (North Dakota) and Pine Ridge (South Dakota) had arsenic levels in drinking water exceeding the US Environmental Protection Agency standard (10 ¿g/L). Design and setting: This study will be divided into 3 phases: (1) Formative research and planning; (2) Implementation and evaluation of the multi-level intervention; and (3) Dissemination at the household, tribal, regional, and national levels. The formative research and planning phase will develop and pilot arsenic interventions through in- depth interviews and focus group discussions, a community advisory board workshop, and a pilot study. We will build local capacity to ensure the long-term sustainability of the intervention program by developing a training program for community members to test water sources for arsenic using rapid field kits, installing and maintaining point of use arsenic removal devices, and disseminating the developed health messages. During the intervention phase we will conduct a two-arm cluster-randomized controlled trial to prospectively follow 300 households and 600 participants (2 per household) to evaluate the effectiveness of the developed multi- level intervention in reducing urine arsenic concentrations and biomarkers of cardiovascular disease (cell adhesion molecules) and diabetes (glycated hemoglobin) during a 6 month period. The first arm will receive water arsenic testing and an arsenic removal device during one home visit by a community promoter (standard program). The second arm will receive water arsenic testing, an arsenic removal device, and an intensive health promotion program of 5 home visits by a community promoter (intensive health promotion program). To assess the long-term sustainability, we will measure arsenic in urine and water, and collect meter-based water use and self-reported device maintenance data 1 to 3 years after baseline. During the dissemination phase, we will work closely with tribal leaders and the Indian Health Service to disseminate study findings and develop sustainable arsenic mitigation policies to upscale the developed intervention programs to include other AI communities. Significance: This study will be the first to develop, implement, and evaluate a participatory multi-level intervention to reduce arsenic exposure from private wells in AI communities and to determine if the intervention can reduce arsenic exposure and early biomarkers of cardiovascular disease and diabetes.

Grant Number: 1R01MD015003-01A1
Project Title: Standing Strong in Tribal Communities: Assessing Elder Falls Disparity
PI Name: Vallabh Shah, PhD, MS, FASN
PI Contact info: vshah@salud.unm.edu
PD Name: Nathan Stinson Jr., PhD, MD, MPH
Institute: University of New Mexico Health Sciences Center
RFA/PA: PAR-17-496
Project Start: 04/12/2021
Project End: 04/30/2026

Abstract
Native elders are essential to preserving the culture and history of tribal communities, but fall-related injuries can jeopardize their ability to age in place. The Zuni Pueblo is geographically isolated with limited access to rehabilitative and supportive services. Home health physical therapy services are unavailable at the Pueblo. Therefore, Zuni elders must choose between leaving their community and social network for rehabilitative care or remain in the community with unmet needs and increased risk of not regaining their prior level of function. We propose to culturally tailor the traditional physical therapy delivered Otago Exercise Program (OEP), to evaluate its effectiveness in reducing falls risk and to empower elders and their families to engage in preventing falls in their community. Native Zuni CHRs will deliver OEP using novel consultation and telehealth with a physical therapist. The community health representatives (CHRs) offer the important advantage of speaking “Shiwi” (Zuni tribal language) and understanding Zuni traditions, family structures, and elders’ preferences for receiving health information. Our overall objective is to compare the effectiveness of a CHR-delivered, culturally adapted OEP fall prevention program to the standard of care education-based fall risk management. Our disparity driven aims are: Aim 1: Foster a sustainable multi-directional, participatory collaboration between the Zuni’s tribal leadership, stakeholders, Zuni Indian Health Services, and University of New Mexico Health Sciences Center to enhance fall prevention training, education, and research; Aim 2: To culturally adapt the evidence-based OEP for use with the Zuni elder population. Approach: We will train CHRs to utilize the CDC Stopping Elderly Accidents, Deaths & Injuries (STEADI) toolkit for fall risk screening and education, and CHRs will culturally adapt the education and OEP with input from Zuni elders; Aim 3: To compare the effectiveness of the adapted OEP to an education-based fall risk management usual care program in improving strength and balance and reducing the risk of falls. Approach: Screen 400 Zuni elders, aged 65yrs and older, to identify 200 elders with elevated fall risk. Randomize 200 Zuni elders at risk for falls into a 6-month OEP intervention versus education-based control; and Aim 4: To compare the effectiveness of the adapted OEP to an education-based fall risk management program in improving overall health status, self-management of daily activities, and social engagement. Approach: We will administer SF-12 Health Survey and Short Form Patient-Reported Outcomes Measurement Information System® (PROMIS®) measures Self-Efficacy for Managing Daily Activities and Ability to Participate in Social Roles and Activities to all randomized participants, at baseline and 6 months, and during the final follow up visit at 12 months.

Grant Number: 1R01MD016191-01
Project Title: Osage Community Supported Agriculture Study (OCSA)
PI Name: Valerie Blue Bird Jernigan, DrPH, MPH
PI Contact info: bluebird.jernigan@okstate.edu
PD Name: Dorothy Castille, PhD
Institute: Oklahoma State University Center for Health Sciences
RFA/PA: PAR-17-496
Project Start: 08/12/2021
Project End: 04/30/2026

Abstract
The food system is comprised of food production, access, and marketing. Public health efforts have been increasingly focused on food systems given that poor diet is the number one risk factor for preventable disease in the United States. American Indians (AIs) experience substantial diet-related health disparities: AI adults are 50% more likely to be obese, 30% more likely to have hypertension, and twice as likely to have diabetes compared to Whites. In 2013, the Osage Nation in Oklahoma launched Bird Creek Farm (BCF) with the mission to facilitate Indigenous food sovereignty, defined as the right and responsibility of Indigenous peoples to healthy and culturally appropriate foods produced through traditional Indigenous practices. By 2015, BCF had 12 employees and began providing food to tribal programs. In the same year, in collaboration with BCF, our team launched the NIMHD-funded FRESH farm-to-school program (R01MD011266). Preliminary findings from this tribally driven community-based participatory research (CBPR) study show an increase in vegetable and fruit intake among children and adults and a decrease in food insecurity. Building upon our eight-year CBPR partnership, the proposed study will implement a new community supported agriculture (CSA) program in which Osage citizens will receive a weekly share of freshly grown farm produce for 6 months. CSAs have improved diet and health in non-AI populations and are evidence-based strategies recommended by the Centers for Disease Control and Prevention and the Institute of Medicine to reduce health disparities, but no randomized controlled trial of a CSA program has been conducted in the AI population. Accordingly, we will test the efficacy of a CSA program combined with culturally tailored nutrition and cooking education on diet and health outcomes among Osage adults, evaluate its cost-effectiveness, and develop a multimedia toolkit for disseminating findings. Our specific aims are to: 1) Conduct a randomized controlled trial to test the newly developed CSA program’s effect on diet, blood pressure, and blood lipids (primary outcomes) and on body mass index (BMI), hemoglobin A1c (HbA1c), food insecurity, and health status (secondary outcomes) among 600 AI adults (aged 18-75) with overweight/obesity; 2) Perform an economic evaluation for individual (e.g., health-related quality of life), organizational (e.g., healthcare utilization costs), and community-level (e.g., prevention of cardiometabolic diseases) outcomes; and 3) Document and disseminate study processes and findings using participatory video methods, and compile a web-based toolkit for other AI communities to use CBPR to improve tribal food systems. This study is the first to rigorously intervene across all components of the food system to address poor diet and health among AIs. Building upon Osage Nation assets and priorities, guided by a CBPR and Indigenous food sovereignty orientation, and based upon recommended strategies to eliminate disparities, study findings will inform research and policy efforts to create sustainable food access in reservations with high rates of chronic disease as well as urban AI communities where CSAs are available and could be tailored to AIs.

Grant Number: 1R01MD015011-01
Project Title: Family Listening Program (FLP) Culturally Centered Dissemination & Implementation Project
PI Name: Lorenda Belone, PhD, MPH
PI Contact info: lorenda@unm.edu
PD Name: Jennifer Alvidrez, PhD
Institute: University of New Mexico
RFA/PA: PAR-17-496
Project Start: 08/26/2020
Project End: 06/30/2025

Abstract
The goal of this application is to strengthen dissemination and implementation (D&I) science by testing the implementation of our indigenous-focused Family Listening Program (FLP), which is a culturally transformed intervention through the use of a community-based participatory research (CBPR) approach. FLP is currently undergoing a rigorous R01 examination with three distinct southwest tribal communities (Jemez Pueblo, Ramah Navajo, and Mescalero Apache), who have established their own active Tribal Research Teams (TRTs). In this new study we introduce an innovative process called CBPR Culture-Centered System (CCS), which will be integrated with the Interactive Systems Framework (D&I structures and functions to bridge science and practice) for an examination of the uptake, cultural acceptance, and sustainability of evidence-based strategies moved into practice with three new southwest tribal communities—Torreon-Star Lake, Nahata Dziil, and Zia Pueblo—who will each develop their own research community advisory board (CAB). This grant will continue the long-term research partnership with the current R01 TRT partners that provides a solid foundation for collaborating on the synthesis and translation of the following tools that will facilitate the three new CAB partners to adapt their own FLP curriculum and evaluation measures into their own distinct cultural knowledge, histories, values, and practices for implementation: a) Quality Implementation Tool; b) CAB Development Guide; c) Culture-Centered Coaching Guide; d) Digital Story Modules; and e) Culture-Centered FLP Toolkit. Preliminary findings have shown FLP's early effectiveness in reduced child depression, anxiety, and enhanced protective factors of cultural connectedness and coping skills. In this application, the University of New Mexico (UNM) College of Education with the UNM Center for Participatory Research and our TRT partners will provide a support system to the CABs in the cultural recentering and implementation of their own FLP program in which the delivery system will be rigorously evaluated. The FLP is perfectly poised to take the next step of D&I, and this study will facilitate bi-directional knowledge translation between academic and tribal partners while utilizing a CBPR CCS—an innovation that represents the intersection of academic and tribal spheres of influence and knowledge—to create a novel implementation approach. This study has three specific aims: 1) With TRT partners, “synthesize and translate” previous R01 research findings into pre-implementation steps with three new tribes, i.e., build new CABs; assess contextual facilitators and barriers, and re-center FLP curricula into new cultures for sustainability; 2) Test a bi-directional coaching “support system” with UNM and the TRTs providing technical assistance and trainings to new CABs and producing, as co-learners, digital stories for the final CBPR CCS Guide; and 3) Evaluate the capacity of the “delivery system” of the CABs to implement the practice-based FLP Toolkit (curriculum and program evaluation tool), re-centered into their cultural knowledge and context.

Grant Number: 1R01MD014127-01A1
Project Title: Achieving American Indian Youth Energy and Mental Health Balance
PI Name: Francine Gachupin, PhD, MPH
PI Contact info: fcgachupin@arizona.edu
PD Name: Dorothy Castille, PhD
Institute: University of Arizona
RFA/PA: PAR-17-496
Project Start: 04/13/2020
Project End: 12/31/2024

Abstract
American Indian (AI) youth have the highest prevalence of obesity of all ethnic groups in the United States, placing them at disproportionate risk for adult obesity and obesity-driven metabolic disease including diabetes, cardiovascular disease, high blood pressure, stroke, and cancer. In fact, greater than 41.7% of the children and adolescents from the Hopi Tribe, Pascua Yaqui Tribe, Salt River Pima-Maricopa Indian Community, and the Yavapai Apache Nation—tribal communities collaborating in the proposed study—are obese. Health behaviors can modify obesity risk and associated morbidities such as diabetes and cardiovascular disease. To enhance the impact of our efforts, we recognize the intervention must include parental support and attention to emotional well-being and coping skills through the integration of mind-body medicine (MBM). The goal of the Achieving American Indian Youth Energy and Mental Health Balance (AYEM-B) Study is to develop and test a culturally relevant, community-led intervention that incorporates the principles of MBM skills training and parental /caregiver engagement to support AI youth in achieving healthy lifestyle choices and in reducing risk for adult obesity and related metabolic diseases. Our hypothesis is that participation in a community-led intervention that includes MBM and the family will reduce obesity-related chronic disease risk factors in AI adolescents (n=224), as assessed by changes in body mass index z-score (primary outcome) and the objective measures of moderate/vigorous physical activity and fruit and vegetable intake (secondary outcomes) at 6 months. We will test our hypothesis by addressing the following specific aims: Specific Aim 1: Integrate an existing week-long residential wellness camp program for AI adolescents with novel MBM and parental engagement components to establish a 6-month community-led obesity prevention intervention for AI adolescents (aged 10–15 years) and their parents/caregivers. Specific Aim 2: Assess the preliminary efficacy of the newly established program on body mass index z-score, physical activity, and fruit and vegetable intake in AI adolescents at baseline, 3, and 6 months using a within-subjects design. Also, evaluate changes in individual risk factors (lipids, hemoglobin A1C, fasting glucose) pre- and post-intervention. Specific Aim 3: Evaluate indicators of successful program implementation and the potential for sustainability across participating tribal communities, including acceptability and relevance to participants, parents, and the community, and program adoption, feasibility, fidelity, and costs.

Grant Number: 1R01MH115840-01A1
Project Title: WaKan YeZah: Enhancing Caregivers and Childrens Well-being Through an Evidence-based and Culturally Informed Prevention Intervention
Funding NIH Institute: Johns Hopkins University
PI Name: Teresa Brockie, PhD, MSN, RN
PI Contact info: 410-955-1730, tbrocki1@jhu.edu
PD Name: Eve Reider, PhD
Institute: Johns Hopkins University
RFA/PA: PAR-17-496
Project Start: 04/01/2019
Project End: 01/31/2024

Abstract
The overall goal of this study is to develop, adapt and evaluate an intergenerational prevention intervention, named “Wa’ Kan ye’ zah (Little Holy One),” with Fort Peck Assiniboine and Sioux caregivers and their 3-to-5- year-old children. The intervention aims to: 1) reduce symptoms of historical trauma and everyday stress among parents/caregivers, 2) improve parenting, and 3) improve children’s emotional and behavioral developmental outcomes to reduce future risk for suicide and substance use. The scientific premise of this work is rooted in understanding that high rates of historical and current trauma in Native communities compromise caregivers’ mental health and parenting, which in turn affect early childhood behavior problems and adverse events that increase children’s risk for suicide and substance use in adolescent and young adulthood. Without intervention, this intergenerational cycle may repeat. Wa’ Kan ye’ zah will combine adapted elements of: 1) Trauma-Focused Cognitive Behavioral Therapy, an evidence-based intervention proven effective to reduce stress, depression and trauma-related symptoms, 2) Family Spirit, an evidence-based parent training program to promote positive early child development in Native American communities, and 3) cultural components informed by tribal-specific risk and protective factors for suicide and substance abuse identified in community-based studies that led to this proposal. The intervention will consist of 12 weekly individual lessons taught to parents and children (ages 3 to 5) at the Poplar and Wolf Point Head Start facilities by indigenous community health workers, a delivery strategy selected to enhance participant engagement, local acceptability and sustainability. Intervention timing is focused at a critical developmental phase—when primary attachment is still to parents, but while children are transitioning to greater self-regulation and cooperation with teachers and peers in Head Start classrooms. This study will use a randomized control trial (RCT) with an embedded single-case experimental design (SCED) to determine the effectiveness of the intervention on mental health and behavioral outcomes among N=120 parent-child dyads, while empirically exploring the added benefit of specific cultural components on parent/caregiver outcomes. on mental health and behavioral outcomes among N=120 parent-child dyads, while exploring the added benefit of cultural components on parent outcomes. The study plan is situated within a well-established trust relationship with tribal communities, innovative formative research that led to this proposal, and an experienced, multi- disciplined study team led by an indigenous PI.

Grant Number: 7R01MH112458-02
Project Title: Promoting Community Conversations About Research to end Native Youth Suicide in Rural Alaska
Funding NIH Institute: University Of Massachusetts Amherst
PI Name: Lisa M Wexler, PhD, MSW
PI Contact info: 413-824-1190, lwexler@umich.edu
PD Name: Eve Reider, PhD
Institute: University Of Massachusetts Amherst
RFA/PA: PAR-14-260
Project Start: 06/19/2018
Project End: 03/31/2023

Abstract
With rates up to 18 times higher for rural Alaska Native (AN) young people when compared to all American youth (124 vs 6.9 per 100,000), the health disparity of youth suicide continues to plague rural Indigenous communities in Alaska. The current system of care—with a focus on mental health—is not effective: 79% of suicide decedents and 62% of attempters received NO mental health care. Vulnerable AN youth are more likely to come into contact with healthcare providers, school personnel, public safety workers, and other community members. Additionally, friends and family members noticed signs of risk beforehand in 62% of all recorded suicidal behavior. These villagers can offer culturally-specific social support and safety measures to avert a suicide crisis, but they are not trained to initiate primary and secondary prevention. Currently, three times out of four, community members mobilize only when the person is in `imminent risk' of suicide. This level of risk means that vulnerable AN youth are taken 500 air miles away for assessment in a confined hospital room many associate with `jail'. After this experience, most AN youth return home less likely to seek help the next time they feel suicidal. Late intervention cuts off options for cultural, family and community-based care, which is preferred by AN youth and their families. To initiate activities to promote wellness, safety and support before a suicide crisis, our tribal working group developed and piloted PC CARES: Promoting Community Conversations About Research to End Suicide. This promising and feasible educational intervention is led by local facilitators, and offers village stakeholders a series of learning circles to study `what we know' from prevention research and figure out how they can apply it to their jobs, families, and lives. The goal of the intervention is to enhance knowledge, skills and attitudes among service providers, family members and tribal residents so that they promote wellbeing, recognize risk, support vulnerable youth, and work with others in their community to take supportive and safety actions when they notice signs of vulnerability. Our community intervention utilizes indigenous pedagogy and prevention science to increase village members' and service providers' capacity to find `up-stream', self-determined and culturally-responsive ways to reduce suicide risk. Using a community-based, participatory research (CBPR) approach, our specific aims track change on both individual and community levels. Aim 1: Track the effect of PC CARES on participants' knowledge, attitudes and behavior, and identify key factors influencing these outcomes over time. Aim 2: Document the community-level impact of PC CARES by tracking the number and type of interactions aimed at preventing youth suicide and promoting wellness in participating villages, and describe changes in the supportive social networks of young people before and after the intervention. IMPACT: Our scalable model offers under-resourced Native communities a practical method for translating scientific research into culturally relevant efforts to reduce suicide risk factors, and increase safety, help-seeking and support to prevent suicide.

Grant Number: 5R01MD012761-03
Project Title: We are Here now - a Multi-level, Multi-component Sexual and Reproductive Health Intervention for American Indian Youth
Funding NIH Institute: National Institute on Minority Health and Health Disparities (NIMHD)
PI Name: Elizabeth Lynne Rink, PhD MSW
PI Contact info: 406-994-3833, elizabeth.rink@montana.edu
PD Name: Beda Jean-François, PhD
Institute: Montana State University - Bozeman
RFA/PA: PAR-14-260, Interventions for Health Promotion and Disease Prevention in Native American Populations (R01)
Project Start: 04/01/2018
Project End: 11/30/2022

Abstract
American Indian (AI) communities in the United States (US) are disproportionately affected by sexual and reproductive health disparities, compared to other populations, placing current and future generations of AI societies in jeopardy. Our study, “Nen ŨnkUmbi/EdaHiYedo (N/E - “We are Here Now”)”, utilizes a culturally tailored ecological intervention in which the prevention of sexual-risk behaviors among AI youth that lead to STIs, HIV, HCV, and teen pregnancy are addressed. N/E takes place on the Fort Peck Reservation in northeastern Montana. N/E is a community-based participatory research sexual and reproductive health (SRH) intervention, constructed on Ecological Systems Theory. Based on Fort Peck tribal members' desire to implement a holistic SRH intervention for the tribes' youth, N/E includes: 1) A school-based SRH curriculum called Native Stand, designed to address individual-level factors that lead to risky behaviors; 2) a family-level curriculum called Native Voices, tailored to increase communication between adult family members and youth about SRH topics; 3) a cultural mentoring component at the community-level that pairs AI youth with adults and elders to discuss traditional AI beliefs and practices about SRH; and 4) a systems-level strategy to activate a multi-sectoral network of local youth servicing organizations to coordinate SRH services. The overarching aim of this proposal is to refine and tailor the components of N/E and evaluate its efficacy. N/E is a 5-year study involving 456 15- to 18-year-old AI youth and their parent/legal guardian. AIM 1 begins with a year of formative work to refine and tailor the components of N/E. Our community advisory board and the Fort Peck-based and MSU-based research team will design culturally appropriate adaptations for N/E's 4 levels. AIM 2 tests the efficacy of N/E using a cluster-randomized stepped-wedge design (SWD), in which the 5 high schools that Fort Peck youth attend are randomized into the intervention 1 at a time. N/E's primary outcome is increased condom use during sexual intercourse. Secondary outcomes are delayed onset of sexual intercourse, number of sex partners, frequency of sexual intercourse, pregnancy history, consistent use of birth control during sexual intercourse, and whether alcohol and/or other drugs are used during sexual intercourse. Tertiary outcomes are increased parent/legal guardian-child communication about SRH topics, increased understanding of cultural values related to traditional AI beliefs regarding SRH, and increased use of SRH services. Quantitative data collection includes: student surveys at baseline, 3, 9 and 12 months; parent/legal guardian surveys at baseline, 9 and 12 months. Qualitative data collection includes SRH service provider discussion groups at baseline and thereafter once a year over the 5-year study, with logs to track coordination and implementation at baseline and 3, 6, 9 and 12 months. AIM 3 will evaluate the fidelity and acceptability of N/E with focus groups, activity logs, and staff meeting notes and staff field notes.

Grant Number: 1R01MD011574-01
Project Title: Preventing HIV Among Native Americans Through the Treatment PTSD & Substance Use
Funding NIH Institute: National Institute on Minority Health and Health Disparities (NIMHD)
PI Name: Cynthia R. Pearson, PhD
PI Contact info: 206-330-1997, pearsonc@uw.edu
PD Name: Nadra Chante Tyus, DrPH, MPH
Institute: Indigenous Wellness Research Institute National Center of Excellence
University of Washington
RFA/PA: PAR-14-260, Interventions for Health Promotion and Disease Prevention in Native American Populations (R01)
Project Start: 09/27/2016
Project End: 06/30/2021

Abstract
Untreated PTSD elevates risk of concurrent alcohol and drug dependence (>50% and >30% respectively), which in turn elevates risk of HIV sexual-risk behavior (HSB). A meta-analysis of HIV prevention, found few interventions address risk factors such as trauma exposure, mental health, or SUD and interventions which failed to do so had poorer condom use outcomes and were less effective for those with PTSD. From a public health perspective addressing PTSD and substance use disorders (SUD) is an important but overlooked means of preventing HIV/STI. American Indian (AI) communities are at disproportionate risk for untreated PTSD, SUD and HIV/STI risk. Self-medication of PTSD through substance use leads to development of SUDs, and exacerbates HSB. Therefore, treatment of PTSD that also decreases substance use in individuals may prevent the initiation or relapse of HIV risk behaviors. Similarly, directly intervening to reduce substance use via increasing motivation to decrease use and enhance coping strategies should prevent SUD development, and improve HSB and PTSD. Thus addressing PTSD or substance use may effectively prevent HSB. Built on an 8-year community-based participatory partnership, in full collaboration with the Tribal Nation, this study proposes a 5-year two-arm randomized comparative effectiveness trial to evaluate prevention of HIV/STI sexual risk behavior by directly addressing PTSD or substance use. We will evaluate Narrative Exposure Therapy (NET) versus Motivational Interviewing with Skills Training (MIST) in HIV/STI prevention. AI elder and community leaders have insisted that “we can keep providing substance use or sexual risk programs but until we get to the underlying cause – trauma – then we’ll keep replacing one means of avoidance for another”. This study will help address this community-generated clinical and empirical question. The overall goal is to compare two evidence based treatments, each addressing a different HSB causal pathway. NET addresses PTSD preventing SUD and HSB. MIST addresses substance misuse preventing SUD and HSB.
Aim 1: To examine a PTSD versus a substance use-focused intervention to prevent HSB. We will conduct a two-arm randomized comparative effectiveness trial comparing NET (n=100) to MIST (n=100) among AI men and women with PTSD symptoms. We will evaluate the effect of reductions in PTSD severity and substance use (e.g., frequency, quantity, intentions, relapse, and initiation of use) on HSB (e.g., number of partners, sex while using substances, unprotected sex, and sex with high-risk partners) at post, 6, and 12-month follow-up.
Aim 2: To examine theoretical mediators of treatment on HSB outcomes including emotional regulation, cognitive reappraisals, coping self-efficacy, communication skills, assertiveness, and community connectiveness.

Grant Number: 5R01MH106419-04
Project Title: Caring Texts: A Strength-based, Suicide Prevention Trial in 4 Native Communities
Funding NIH Institute: Washington State University
PI Name: Lonnie A Nelson, PhD
PI Contact info: 573-424-0888, lonnie.nelson@wsu.edu
PD Name: Eve Reider, PhD
Institute: Washington State University
RFA/PA: PAR-14-260
Project Start: 06/01/2016
Project End: 03/31/2021

Abstract
High rates of suicide are endemic in American Indian and Alaska Native (AI/AN) young adults. A recent study found that rates for young AI/AN adults in the Northern Plains and in Alaska are more than 4 times higher than for Whites of the same age in the same regions. Building social connections is a key goal of suicide prevention. One validated theoretical model asserts that belonging to a group is a fundamental human need. When this need is thwarted by social isolation or inadequate social support, a desire for death emerges. Studies of suicide prevention in AI/ANs underscore the cultural importance of connection to friends, family, caring neighbors, and community leaders. These traditions of community cohesion can be leveraged to protect young AI/AN adults against suicidal ideation and behavior. Caring Contacts is a suicide prevention program that supplements standard care by promoting human connectedness. People at risk for suicide often lose contact with the healthcare system and receive no follow-up care. For 1 year after an initial presentation, Caring Contacts seeks out such individuals to send messages expressing care, concern, and interest. It is the only intervention shown to prevent suicide in any population in a randomized, controlled trial. Based on an almost two year collaborative process with four tribal partners as part of a pilot grant, we have designed a locally feasible, culturally appropriate Caring Contacts intervention that will use text messaging, the dominant communication method for young AI/AN adults. This study uses a randomized, controlled trial (RCT) to evaluate this approach to suicide prevention in 1,200 high-risk AI/ANs aged 18-34 from our four partner communities. Our Specific Aims are to: 1) Compare the effectiveness of usual care (control) to the control condition plus caring text messages (intervention) for reducing suicidal ideation, suicide attempts, and suicide- related hospitalizations. 2) Evaluate social connectedness as a mediating factor for the effect of Caring Contacts via text message on suicidality. The US Surgeon General's National Strategy for Suicide Prevention identifies connectedness to others as the primary protective factor against suicidality.53 By adapting and disseminating the Caring Contacts approach, which has demonstrated effectiveness in non-Native populations, our study will evaluate a low-cost, sustainable intervention for addressing the profound disparity of suicide risk experienced by young adult AI/ANs.

Grant Number: 1R01MD011266-01
Project Title: Food Resource Equity and Sustainability for Health "FRESH"
Funding NIH Institute: National Institute on Minority Health and Health Disparities (NIMHD)
PI Name: Valarie Blue Bird Jernigan, DrPH, MPH
PI Contact info: 410-955-2485, cgeorg19@jhu.edu
PD Name: Dorothy Castille, PhD
RFA/PA: PAR-14-260
Project Start: 05/12/16
Project End: 12/31/2020

Abstract
Food insecurity increases the risk of obesity, diabetes, hypertension, and cancer. American Indians (AIs) in Oklahoma are three times as likely as Whites to be food-insecure (21% vs. 7%) and have burdens of obesity (42%), hypertension (38%), and diabetes (15%) that exceed those of the general US population. While individual-level obesity prevention efforts have been implemented with AIs, few environmental interventions to reduce food insecurity and improve fruit and vegetable intake have been conducted with tribal communities. Community gardening interventions have been shown to increase vegetable and fruit intake, reduce food insecurity, and lower BMI among children and adults; however, to date, no such interventions have been evaluated with AI families. The proposed study, entitled "Food Equity Resource and Sustainability for Health (FRESH)," will assess the impact of a tribally-initiated community gardening intervention on vegetable and fruit intake, food insecurity, BMI, and blood pressure in families living on the Osage Nation reservation in Oklahoma. The intervention will take place in the inaugural year of Osage Nation's Bird Creek Farm and Community Gardens, where 120 garden plots will be allocated to participating reservation families. The study is guided by the principles of community-based participatory research (CBPR) and the Indigenous food sovereignty movement, which seeks to revitalize seasonal growing and gathering practices and reverse the tide of unhealthy eating caused by the historical loss of tribal lands. Aims and Methods: Led by an AI (Choctaw) Investigator, the study will: Aim #1: Characterize the Osage Nation reservation's food environment by using both objective and perceived measures, and then examine the relationships between these measures and intake of vegetables and fruits, food insecurity, BMI, hypertension, and diabetes. Aim #2: Develop a culturally relevant community gardening intervention and conduct a randomized controlled trial (RCT) to evaluate its efficacy in increasing vegetable and fruit intake and reducing food insecurity, BMI, and blood pressure among Osage families. Aim #3: Create and disseminate a Web- based multimedia manual and documentary film, and evaluate their effectiveness in increasing tribal readiness and capacity to improve local food environments. Innovation: The proposed study will be the first RCT ever conducted of a community gardening intervention, as well as the first community gardening intervention with AI families. The study will also be one of the first environmental interventions o simultaneously address healthy food production, access, preference, and intake among AIs. Significance and Impact: The community gardening intervention will be developed as part of a larger Osage Nation initiative on food security and food sovereignty and as such, is likely to be sustainable if it proves effective. Research findings and products will be disseminated to AI/AN communities nationwide and will help to identify environmental strategies that will improve tribal food environments and the health and quality of life of AI families.

Grant Number: 1U01DE028508-01
Project Title: Great Beginnings for Healthy Native Smiles
Funding NIH Institute: Northern Arizona University
PI Name: Julie Ann Baldwin, PhD
PI Contact info: 928-523-6566, julie.baldwin@nau.edu
PD Name: Darien Jerome Weatherspoon, DDS, MPH
Institute: Northern Arizona University
RFA/PA: PAR-17-496
Project Start: 06/01/2019
Project End: 05/31/2023

Abstract
Early Childhood Caries (ECC) is the most common chronic disease among children. American Indian (AI) children are 4 times more likely to have untreated dental decay than white children. If left untreated, ECC can lead to chronic pain, loss of teeth, poor nutrition, and impaired growth. The proposed study aims to reduce the burden of ECC in two AI communities through an innovative, community based participatory approach. The project will: 1) partner with 2 tribes, the Hopi Tribe (Arizona) and the Crow Tribe (Montana), to conduct a formative assessment on oral health (OH); 2) adapt a “bundled” best practices OH intervention to be locally and contextually relevant for each of our tribal communities; and 3) conduct a randomized, controlled study to evaluate the impact of the “bundled” best practices OH intervention (compared to a standard prenatal/postnatal healthy lifestyle intervention) on the reduction of ECC. Community health representatives (CHRs) will be trained to deliver the interventions with pregnant women and follow them until the child’s last exam (24-36 months). The OH intervention will consist of 4 intervention components known to be effective (best practices) in the prevention of ECC: 1) dietary and OH education provided during pregnancy and the postnatal period; 2) OH care of children including the application of fluoride varnish; 3) motivational interviewing with children’s mothers; and 4) patient navigation of existing OH and other social services in each study community, facilitated by CHRs. Caries experience (dmfs) and severity will be compared across both conditions at the 1, 2, and 3- year exams. Mother knowledge, attitudes, and behaviors related to ECC will be also measured for both conditions at pre-test and post-test. Surveys will assess each level of the social ecological model. Individual level domains will include: 1) demographics of mother and baby (pre-test only); 2) dental health of the child to date; 3) mother’s and child’s OH (postnatal); 4) mother’s knowledge, beliefs, and attitudes about best practices in OH; 5) mother’s perception of self-efficacy and susceptibility; and 6) mother’s prenatal health and experiences. Interpersonal level domains will include: 1) current living situation and family support; 2) availability of emotional, informational, and instrumental support; and 3) perceptions of peers’ and family members’ attitudes toward caregiving and OH. Community level domains will include: 1) tribal identity and related experiences; 2) care coordination, transportation, and access to social and OH services; and 3) perceptions of cultural congruence of CHR interactions and intervention materials. If successful, this community-based approach may prove to be a feasible method for improving OH of AI children and reducing the burden of ECC in many Native communities with limited access to regular dental care.

Grant Number: 1U01DE027629-01A1
Project Title: Reducing Sugared Fruit Drinks in Alaska Native Children
Funding NIH Institute: University of Washington
PI Name: Donald Leslie Chi, DDS, PhD
PI Contact info: 206-616-4332, dchi@uw.edu
PD Name: Darien Jerome Weatherspoon, DDS, MPH
Institute: University of Washington
RFA/PA: PAR-17-496
Project Start: 06/01/2019
Project End: 05/31/2022

Abstract
Project Abstract Yup’ik children in Alaska’s YK Delta consume an average of 50 teaspoons of sugar each day, 16 times the American Heart Association’s recommended maximum. Most of this sugar is from fruit drinks like Tang and Kool-Aid consumed at home. Consequently, Yup’ik children experience tooth decay rates that are 16x the U.S. average and suffer from oral health inequalities compared to children from communities that are better off. Tooth decay is a multifactorial disease, but our pilot work shows sugared fruit drinks are the key risk factor. YK Delta communities have expressed a desire to target sugared fruit drinks that continue to harm their children. This study is a culmination of over 5 years of engaged research within YK Delta communities to co-develop a culturally-appropriate, feasible, and sustainable program to address persisting public health problems caused by sugared fruit drinks. We propose a 2-arm quasi-experimental behavioral trial in 3 small, isolated Alaska Native communities to test the hypothesis that Community Health Worker-led health education and self- efficacy training for caregivers will decrease child added sugar intake. We will introduce families to sugar-free water enhancers that will be made available through local stores. The Specific Aims are to: (1) Complete pre- intervention activities and finalize the intervention; (2) Implement the intervention and assess outcomes; and (3) Identify intervention improvement opportunities and disseminate findings. This application builds on previous R56 research by the study team and will for the first time seek to change sugared fruit drink intake in Alaska Native communities. 3 communities will be assigned to 1 of 2 arms based on the order communities were recruited into the study. In Communities A and B, 136 Yup’ik children ages 0-10 years will be recruited to test the 6-month culturally-adapted, 5-session intervention consisting of interactive health education and self- efficacy training delivered in-person by an indigenous Community Health Worker. In Community C, 56 children will be recruited to a comparison condition in which health education with the same culturally-adapted content is delivered by mail. Health education will address misinformation about sugared fruit drinks and promote sugar-free water enhancers. Self-efficacy training will empower caregivers to sustain behavior change over time. Local stores in all 3 communities will stock sugar-free water enhancers (Tang, Kool-Aid, and other popular flavors) as a tool to help shift children from sugared fruit drinks. The primary outcomes at the child level are sugared fruit drink intake (24-hour food recalls) and added sugar intake (validated, non-invasive biomarker) and will be measured at baseline and at 1, 3, 6, and 12 months. The Yukon Kuskokwim Health Corporation will maintain and disseminate the program if it works to address a critical problem facing 15,000+ Alaska Native children in the YK Delta. Moreover, it can be adapted to meet the needs of other populations with similar problems, including the millions of indigenous children in the Lower 48. PUBLIC HEALTH RELEVANCE Project Narrative Alaska Native and American Indian children suffer from high rates of tooth decay that lead to poor health, low quality of life, and broader problems like learning difficulties in school that have life-long consequences. In response to the Notice of Funding Opportunity (NOFO) calling for health promotion interventions focusing on Native American populations, the proposed study will target sugared fruit drinks that cause dental problems in children through a community- based program that builds on proven approaches that have not yet been implemented in Alaska Native communities. The proposed work addresses Healthy People 2020’s Nutrition and Weight Status Objective 17 (reduce added sugars), Oral Health Objective 1 (reduce the proportion of children with tooth decay), and Early and Middle Childhood Objective 1 (increase the proportion of children who are ready for school by ensuring healthy physical development); and NIDCR Strategic Goal 3 (apply rigorous multidisciplinary research to overcome dental disparities).