Mary Cwik

The COVID-19 pandemic highlighted longstanding health inequities, particularly among American Indian/Alaska Native (AIAN) communities, which experienced disproportionately high morbidity and mortality. This manuscript documents the implementation, adaptation, and lessons learned from a randomized controlled trial (RCT) conducted during a rapidly evolving pandemic context. The RCT tested two public health interventions: (1) a motivational interviewing strategy to promote COVID-19 testing and preventive behaviors, and (2) a symptom monitoring tool to assess COVID-related symptoms. As the public health landscape shifted with the introduction of vaccines and evolving guidance, protocols required frequent adaptation to remain relevant. Four major amendments were made to adapt the study to evolving conditions, including changes to inclusion criteria, the addition of community-prioritized content such as vaccine hesitancy, and adjustments to accommodate mixed vaccination statuses within households. Delays in multiple IRB approvals often rendered changes outdated by the time they could be implemented. Recruitment was limited, and intervention delivery faced challenges including low survey completion and technological barriers. Nonetheless, strong collaboration with tribal partners and respect for tribal sovereignty enabled culturally grounded, community-responsive adaptations throughout the study. Lessons from the implementation process underscore the need for flexible, adaptive research approaches that maintain rigorous community and tribal oversight. Future research on urgent, ongoing health issues can be strengthened through streamlined regulatory pathways and sustained partnerships with AIAN communities in future emergencies like the COVID-19 pandemic. ClinicalTrials.gov Identifier: NCT04765475.

Suicide is the second leading cause of death for American Indian youth, far surpassing the rates of suicide experienced by other races. The White Mountain Apache Tribe has made significant impacts on suicide risk by implementing a robust suicide prevention program which includes a community-led database and case management follow-ups. Due to the success of the program in preventing suicides, the White Mountain Apache team has worked with other tribal communities to adapt the program. We wanted to understand the factors that are most important to implementing and sustaining this model and how these factors compare with existing implementation science frameworks. We employed an adapted nominal group technique to compile facilitators and barriers to implementation of the suicide prevention model across settings with five partner teams. Two researchers independently coded the resulting list of facilitators and barriers using the Consolidated Framework for Implementation Research (version 1.0) codebook. The final list of cross-site prioritized facilitators and barriers included 41 factors. Some factors did not match easily with the framework’s constructs. The White Mountain Apache suicide prevention team noted that seven of the top prioritized factors are considerations they most try to emphasize to new communities working in suicide prevention. The factors fall into two key themes: staffing and tribal engagement. This finding affirms their focus when they conduct suicide prevention trainings with new communities and provides an opportunity for more structure and in-depth training in those two areas. Several factors could not be easily coded to the framework, especially around the sociocultural characteristics of suicide prevention work in Native communities. This contributes to the larger discussion in implementation science concerning the ways in which Indigenous approaches to public health differ from Western models.

Indigenous communities in the United States (U.S.) have been disproportionately impacted by COVID-19, yet they have led efforts to combat the pandemic by providing local solutions that minimize viral transmission and promote vaccine uptake. Understanding facilitators and barriers to recommended behaviors can increase adherence and reduce COVID-19 transmission. We conducted a descriptive qualitative study using in-depth interviews with 19 Indigenous adults residing on Tribal Lands in the Southwest U.S. between June and December 2021. Interview questions explored obstacles and motivators to testing, as well as behavioral recommendations to reduce COVID-19 transmission and increase vaccination. Using a qualitative content analysis approach, we identified barriers and facilitators to behavioral change. Barriers to testing included fear of exposure to COVID-19 at testing locations and discomfort from nasal swabs. Facilitators of testing were access, required testing, and protecting loved ones. Barriers to vaccination were discouraging stories about vaccination side effects and uncertainty about the ingredients and effectiveness of vaccines. Another barrier to vaccination was confusion and fairness related to vaccine eligibility, which discouraged some people from becoming vaccinated, despite intentions to do so. This study identified obstacles and motivators influencing COVID-19 testing and vaccination. The results may help address information gaps and improve public health efforts to reduce COVID-19 transmission and other similar infectious agents in Indigenous communities.

Background: Native American youth, primarily living on reservations, suffer the highest burden of suicide of any racial group in the USA. Implementation and sustainability of culturally grounded, evidence-based interventions are needed to address suicide in Native American populations. For nearly 40 years, Montana has ranked at or near the top nationwide for suicide. Fort Peck Tribal leadership declared a state of emergency in 2010 after six suicides and 20 attempts that occurred over a 5-month period. Methods: We used a community-based participatory research approach for adapting the Celebrating Life (CL) program with a specific focus on long-term sustainability, which has demonstrated efficacy in addressing suicide with the White Mountain Apache. The aims were to (1) adapt the CL program intake forms through roundtable discussions, (2) conduct asset and resource mapping to identify community and cultural resources to leverage for the CL program within the Fort Peck context, and (3) develop a sustainability plan for CL in Fort Peck through qualitative approaches informed by the Program Sustainability Assessment Tool. Results: Roundtable discussions resulted in adapted intake forms that capture variables relevant to the Fort Peck context. Asset mapping identified 13 community assets and 10 cultural resources to incorporate within the CL implementation process. Focus group discussions yielded four key themes that were incorporated into a plan for sustainability: (1) strategic partnerships, (2) long-term funding, (3) communication planning, and (4) workforce planning and engagement. Conclusions: This paper outlines an avenue for using culturally adapted tools to design an implementation system driven by community and cultural assets within tribal communities and for integrating program planning for sustainability early in the implementation process.

This chapter synthesizes data on health disparities in suicide rates and lack of service access and discusses current gaps in research, training, and program implementation for underserved populations. We highlight emerging best practices in underserved communities that are innovative and low cost (e.g., frugal interventions) and discuss their implications for the suicide prevention field. Themes covered include the urgency of utilizing a community-based framework, the importance of early identification and upstream approaches to drive down suicide rates, the value of a comprehensive/holistic approach that is strengths-based and includes culture/spirituality, and the critical role of innovative service delivery models.

Purpose: Morbidity and mortality due to nonprescription use of opioids has been well documented following the significant increase in the availability of prescription opioids in the early 2000s. The aim of this paper is to explore community beliefs about correlates of opioid risk, protective factors, and behavioral functions of opioid misuse among American Indian youth and young adults living on or near a reservation.Methods: Qualitative in‐depth interviews were conducted with N = 18 youth and young adults who were enrolled in a parent research trial focused on American Indian youth suicide prevention. Participants were eligible if they endorsed the use of opioids themselves or by close friends or family members at any point during their trial participation.Findings: Major themes discussed include: (1) description of opioid use and those who use opioids; (2) acquisition; (3) initiation; (4) motivation to continue using; (5) consequences; and (6) possibilities for intervention. Family played an important role in the initiation of use, but was also highlighted as an important factor in treatment and recovery. A need for upstream prevention methods, including increased employment and after‐school activities, was described.Conclusions: The insights gained through this work could help to inform treatment and prevention programs in the community. This work is timely due to the pressing urgency of the opioid epidemic nationally, and community capacity to address opioid use locally.

Relative to the general population, Native Americans (NA) bear a disproportionate burden of suicide-related mortality rates. NA males and females aged 15 to 24 years experience suicide rates nearly 3 times than the U.S. all races rates in this age group. Although efforts have been made to understand and reduce suicide in tribal communities, a large portion has focused on individual characteristics with less attention given to social factors that may also inform suicide. This article aims to build on a local conceptual model of NA youth suicide by examining additional potential social factors through qualitative interviews. Findings from the thematic analysis resulted in the identification of seven perceived social influences: contagion, violence and abuse, discrimination and bullying, negative expectations, spirituality, social support, and cultural strengths. Public health approaches to reduce suicide should consider local social factors that resonate with tribal communities to build resilience.

Background: Machine learning algorithms for suicide risk prediction have been developed with notable improvements in accuracy. Implementing these algorithms to enhance clinical care and reduce suicide has not been well studied. Objective: This study aims to design a clinical decision support tool and appropriate care pathways for community-based suicide surveillance and case management systems operating on Native American reservations. Methods: Participants included Native American case managers and supervisors (N=9) who worked on suicide surveillance and case management programs on 2 Native American reservations. We used in-depth interviews to understand how case managers think about and respond to suicide risk. The results from interviews informed a draft clinical decision support tool, which was then reviewed with supervisors and combined with appropriate care pathways. Results: Case managers reported acceptance of risk flags based on a predictive algorithm in their surveillance system tools, particularly if the information was available in a timely manner and used in conjunction with their clinical judgment. Implementation of risk flags needed to be programmed on a dichotomous basis, so the algorithm could produce output indicating high versus low risk. To dichotomize the continuous predicted probabilities, we developed a cutoff point that favored specificity, with the understanding that case managers’ clinical judgment would help increase sensitivity. Conclusions: Suicide risk prediction algorithms show promise, but implementation to guide clinical care remains relatively elusive. Our study demonstrates the utility of working with partners to develop and guide the operationalization of risk prediction algorithms to enhance clinical care in a community setting.

Suicide among adolescents is a significant public health concern in the U.S., especially within American Indian and Alaska Native (AIAN) communities. Lack of quality of life (QoL) estimates for both suicide ideation and depression specific to the AIAN population hinders the ability to compare interventions in cost-effectiveness analysis. We surveyed 200 AI youth and young adults from the Fort Apache Indian Reservation to estimate utility weights for experiencing suicide ideation and depression. Our results indicate that, on a scale of 0–100, with higher scores indicating better health, the general community rates both suicide ideation and depression at 15.8 and 25.1, respectively. These weights are statistically significantly different and lower than for other cultures. Culturally specific QoL values will allow the comparison and identification of the most effective and feasible interventions to reduce the suicide burden among tribal communities.