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National Cancer Institute

Currently Funded Projects

Below is the list of centers that are currently supported by IRINAH, organized by funding institute.

National Cancer Institute

Grant#: 1R01CA192967
Project Title: Enhancing Prevention Pathways Towards Tribal Colorectal Health
PI Name: Mishra, Shiraz I.
PI Contact Info:(505) 925-6085; smishra@salud.unm.edu
PD Name: Breslau, Erica
Institute: University of New Mexico
RFA/PA: PAR-14-260
Project Start: 4/01/2016
Project End: 3/31/2021

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#: 1R01CA164533-01A1
Project Title: Community Intervention to Reduce Tobacco Use among Pregnant Alaska Native Women
PI Name: Patten, Christi A
PI Contact Info: (507) 266-2577, patten.christi@mayo.edu
PD Name: Land, Stephanie R
Institute: Mayo Clinic Rochester
RFA/PA: PAR11-346
Project Start: 7/1/2013
Project End: 4/30/2018

Abstract
DESCRIPTION (provided by applicant): 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#: 1R01CA174481-01
Project Title: Web-based Smoking Cessation Program for Tribal College Students
PI Name: Choi, Won S
PI Contact Info: (913) 588-4742,wchoi@kumc.edu
PD Name: Land, Stephanie R
Institute: University Of Kansas Medical Center
RFA/PA: PAR11-346
Project Start: 4/1/2013
Project End: 3/31/2018

Abstract
DESCRIPTION (provided by applicant): 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.


National Heart, Lung and Blood Institute (NHLBI)

Grant#: 1R01HL117729-01
Project Title: Tribal Health and Resilience in Vulnerable Environment (Thrive) Study
PI Name: Jernigan, Valarie J
PI Contact Info: (918) 660-3678, valarie-jernigan@ouhsc.edu
PD Name: Wells, Barbara L.
Institute: University Of Oklahoma Hlth Sciences Ctr
RFA/PA: PAR11-346
Project Start: 8/15/2013
Project End: 5/31/2018

Abstract
DESCRIPTION (provided by applicant): Background: 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#: 1R01HL117736-01A1
Project Title: Technology Innovations for Supporting Health in Alaska Native People
PI Name: Prochaska, Judith J.
PI Contact Info: (650) 724-3608, jpro@stanford.edu
PD Name: Wells, Barbara L.
Institute: Stanford University
RFA/PA: PAR11-346
Project Start: 4/15/2014
Project End: 3/31/2019

Abstract
DESCRIPTION (provided by applicant) 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#: 1R01HL122148-01
Project Title: Innovative Multigenerational Household Intervention to Reduce Stroke and CVD
PI Name: Buchwald, Dedra S
PI Contact Info: 206-685-1273, dedra@uw.edu
PD Name: Wells, Barbara L.
Institute: University Of Washington
RFA/PA: PAR11-346
Project Start: 5/5/2014
Project End: 4/30/2018

Abstract
DESCRIPTION (provided by applicant): 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#: 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: Wells, Barbara L.
Institute: University of Hawaii at Manoa
RFA/PA: PAR-11-346
Project Start: 4/2015
Project End: 1/31/2020

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.

Contact PI: Joel Gittelsohn, PhD
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: jgittels@jhsph.edu; 410-955-3927
PD Name: Barbara Wells
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.


National Institute on Alcohol Abuse and Alcoholism (NIAAA)

Grant#: 1R01AA022066-01
Project Title: Motivational Interviewing and Culture for Urban Native American Youth (MICUNAY)
PI Name: D'amico, Elizabeth J
PI Contact Info:  elizabeth_d'amico@rand.org
PD Name: Godette, Dionne
Institute: Rand Corporation
RFA/PA: PAR11-346
Project Start: 7/15/2013
Project End: 6/30/2018

Abstract
DESCRIPTION (provided by applicant): 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#: 1R01AA022068-01
Project Title: Tribal Colleges and Universities Behavior Wellness Study (TCU-BeWell)
PI Name: Duran, Bonnie M
PI Contact Info: bonduran@uw.edu
PD Name: Winn, Deborah M
Institute: University Of Washington
RFA/PA: PAR11-346
Project Start: 7/15/2013
Project End:    6/30/2018

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

Abstract
DESCRIPTION (provided by applicant): 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#: R01AA023755
Project Title: Strategies for Preventing Underage Drinking and Other Substance Use in Native American Tribal Communities
PI Name: Roland S. Moore, Ph.D. (Pacific Institute for Research and Evaluation, Oakland, CA)
PI Contact Info: roland@prev.org, (510)883-5770 office, (510)872-6201 cell.
PD Name: Jennifer Geisler, RN
Institute: NIAAA (with cofunding from OBSSR)
RFA/PA: PAR14-260, 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.


National Institute on Drug Abuse (NIDA)

Grant#: 1R01DA035111-01
Project Title: Culturally grounded early substance use prevention for American Indian families
PI Name: Whitesell, Nancy Rumbaugh
PI Contact Info: (303) 724- 1456
PD Name: Winn, Deborah M
Institute: University Of Colorado Denver
RFA/PA: PAR11-346
Project Start: 6/15/2013
Project End: 3/31/2018

Abstract
DESCRIPTION (provided by applicant): 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#: 1R01DA035141-01A1
Project Title: Inhalant Prevention Campaign for American Indian Youth
PI Name: Swaim, Randall C
PI Contact Info: (970) 491-6961, randall.swaim@colostate.edu
PD Name: Winn, Deborah M
Institute: Colorado State University
RFA/PA: PAR11-346
Project Start: 4/15/2014
Project End: 2/28/2019

Abstract
DESCRIPTION (provided by applicant): 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#: 1R01DA035143-01A1
Project Title: Intertribal Talking Circle for the Prevention of Substance Abuse in Native Youth
PI Name: Lowe, John R
PI Contact Info: (954) 236-1275, nativescholars@yahoo.com
Institute: Florida State University College of Nursing
RFA/PA: PAR11-346
Project Start: 5/1/2014
Project End: 4/30/2019

Abstract
DESCRIPTION (provided by applicant): 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#: 1R01DA037174-01
Project Title: Family Listening Program: Multi-Tribal Implementation and Evaluation
PI Name: Wallerstein, Nina B
PI Contact Info:  505.277.0130, nwallerstein@salud.unm.edu 
Institute: University Of New Mexico Health Scis Ctr
RFA/PA: PAR11-346
Project Start: 4/1/2014
Project End: 3/31/2019

Abstract
DESCRIPTION (provided by applicant): 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#: 1R01DA037176-01
Project Title: Yappalli Choctaw Road To Health
PI Name: Walters, Karina Lynn
PI Contact Info: (206)543-5647
Institute: University Of Washington
RFA/PA: PAR11-346
Project Start: 6/1/2014
Project End: 5/31/2019

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

Abstract
DESCRIPTION (provided by applicant): 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.


National Institute of Nursing Research (NINR)

Grant#: 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: dcp@pitt.edu; 412-624-6953
PD Name: Denise Charron-Prochownik, PHD
Institute: University of Pittsburgh
RFA/PA: Nursing Research 93.361
Project Start: 05/08/2015
Project End: 03/31/2020

Abstract
According to the Centers for Disease Control (CDC), American Indian and Alaskan Native (AI/AN) populations are “disproportionately impacted by gestational diabetes mellitus (GDM), yet there is minimal research being conducted on GDM. Multisite research is needed to reduce the incidence of GDM and support  GDM prevention programs and keep these women from developing T2D later in life.” The CDC’s AI/AN Stakeholder Group and the National Diabetes Education Program (NDEP) have identified a particular interest in “developing and distributing programs with messages for girls about sexual health and GDM that are cultural and age appropriate and can help address the GDM burden among the AI/AN population.”

Using a community-engaged multi-tribal approach, we are proposing to adapt a validated developmentally appropriate preconception counseling (PC) intervention to be specifically tailored and culturally sensitive for AI/AN teens, called STOP-GDM, as a primary prevention against GDM. This study will be conducted online for easy access and dissemination. This proposal provides a unique opportunity to impactAI/AN female adolescents at risk for GDM and diabetes and their future children by reducing health disparities and risk factors. Giving teens and their mothers free accessible online PC could promote the development of sustainable healthy lifestyle and reproductive health behaviors and improve health outcomes. The potential impact is broad and significant for young AI/AN women of childbearing potential at risk for GDM and for their future offspring. This application encompasses: adaptation of an efficacious intervention to a high risk disadvantaged patient population, a rigorous evaluation, and its dissemination. We have assembled an outstanding team, including AI/AN researchers, that is uniquely trained to deliver this novel intervention that proposes a broad reach to all the IHS community. We believe our aims are realistic, and when achieved, will lead to a significant and sustained impact on the AI/AN community. We hope that we will not be denied the privilege and opportunity to serve the AI/AN population which so desperately needs and deserves this program.

Grant#: 1R01NR014153-01
Project Title: A Primary Prevention Trial to Strengthen Child Attachment in a Native Community
PI Name: Booth-laforce, Cathryn L
PI Contact Info: ibcb@uw.edu
PD Name: Winn, Deborah M
Institute: University Of Washington
RFA/PA: PAR11-346
Project Start: 9/18/2013
Project End: 6/30/2018

Abstract
DESCRIPTION (provided by applicant): 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.


National Institute of Environmental Health Sciences (NIEHS)

Grant#: 1R01ES022583-01A1
Project Title: Residential Wood Smoke Interventions Improving Health in Native American Populations
PI Name: Noonan, Curtis William
PI Contact Info: curtis.noonan@umontana.edu
PD Name: Winn, Deborah M
Institute: University Of Montana
RFA/PA: PAR11-346
Project Start: 6/19/2014
Project End: 2/28/2019

Abstract
DESCRIPTION (provided by applicant): 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
Grant number: 5R01ES025135-02
Project Title: PARTICIPATORY INTERVENTIONS TO REDUCE ARSENIC IN AMERICAN INDIAN COMMUNITIES
PI Name: Christine Marie George
PI Contact info:  cgeorg19@jhu.edu; 410-955-2485
PD Name: Symma Finn
Institute: Johns Hopkins University
RFA/PA: PAR-11-346
Project Start: 07/01/2015
Project End: 03/31/2020

DESCRIPTION (provided by applicant)
Background: 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.


National Institute on Minority Health and Health Disparities (NIMHD)

Grant#: 1R01MD011266-01
Project Title: Diet Intervention for Hypertension: Adaptation and Dissemination to Native Communities
PI Name: Jernigan, Valarie Blue Bird
PI Contact Info: (918) 660-3678
PD Name: Wells, Barbara
Institute: University of Oklahoma Health Sciences Center
RFA/PA: PAR 14-260
Project Start: 09/1/15
Project End: 3/3/2020

Abstract
DESCRIPTION (provided by applicant): 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.

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

Abstract
DESCRIPTION (provided by applicant): Background: 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#: 1R01MD011574-01
PI Name: (206) 330-1997, pearsonc@uw.edu
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)
PD Name: Hunter, DeLoris (NIMHD)
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.