Previous research has demonstrated that pre-exposure prophylaxis (PrEP) stigma serves as a common barrier to PrEP use across racial, ethnic, and sexual minority groups in the United States; however, there is a deficit in research focused on Indigenous populations. Therefore, the objective of this study was to identify drivers of PrEP stigma among Indigenous people. A cross-sectional survey was administered to examine PrEP knowledge, attitudes, and perceived barriers to use among Indigenous people in the United States, including PrEP stigma and the following hypothesized drivers: stigma towards drug use, 2SLGBTQ+ identity, and HIV; experienced discrimination; and medical mistrust. Participants reported that people in their communities associate PrEP use with drug use, 2SLGBTQ+ identities, living with HIV, and having multiple sexual partners. They also perceived high levels of stigma around these behaviors and identities in their communities and reported high levels of experienced discrimination and medical mistrust. Higher levels of each hypothesized driver were significantly associated with higher levels of perceived PrEP stigma among the respondents. The results generated from this study provide recommendations for interventions that aim to reduce the influence of these drivers on PrEP stigma.
This study compared rates of suicidal ideation and suicide attempts among adolescents categorized as American Indian/Alaska Native (AI/AN) using the computed raceeth variable in the Youth Risk Behavior Surveillance System (YRBSS) to those identified through self-reported ethnoracial identity. We conducted a cross-sectional analysis of the 2021 YRBSS, examining rates of suicidal ideation and attempts using both the raceeth variable and self-reported ethnoracial combinations. Population-weighted percentages were calculated using survey design and sampling weights. Adolescents categorized as AI/AN (non-Hispanic) using the raceeth variable had population-weighted suicidal ideation and attempt rates of 27.3% and 21.85%, respectively. However, those self-reporting as AI/AN with multiple ethnoracial identities had significantly higher rates. Suicidal ideation was highest among AI/AN + White (Hispanic) at 42.3%, AI/AN + Black (non-Hispanic) at 33.3%, and AI/AN + Black + White (non-Hispanic) at 41.05%. Suicide attempts were highest for AI/AN + Black + White (non-Hispanic) at 43.6% and AI/AN + White (Hispanic) at 32.43%. The raceeth variable may exclude key AI/AN subgroups at elevated risk. Addressing disparities among multiracial AI/AN adolescents requires healthcare awareness and inclusive public health research methods.
American Indian and Alaska Native (AI/AN) adolescents experience considerable mental health disparities, yet research on the prevalence of anxiety and depression remains limited. The objectives of this study were to assess available depression and anxiety data among AI/AN adolescents in the literature and to estimate depression prevalence and mean scores. A systematic review of the Medline, Embase, and PsycINFO databases identified publications reporting on anxiety or depression in AI/AN adolescents aged 10-19. Gray literature was searched in ProQuest Dissertation and Theses to minimize publication bias. Meta-analyses using random-effects models in R estimated the aggregate prevalence and mean scores of depression. Covariates included mean age, percent of male participants, geographical region, and setting. The systematic literature review extracted 82 relevant studies, with 77 citations reported depression data, 15 citations reported anxiety data, and 4 citations reported depression and anxiety prevalence data together but did not discriminate between the two conditions. Aggregate depression prevalence measured by the Center for Epidemiological Studies Depression (CES-D) scale was 34.6% (95% CI: 11.5-68.4%) across three studies (N=664), while the Children's Depression Index (CDI) indicated a prevalence of 14.5% (95% CI: 2.5-52.9%) in two studies (N=365). The aggregate CDI mean score was 9.81 (95% CI: 9.50-10.13) out of 54. No covariates significantly influenced depression outcomes (p>0.05). Generalized Anxiety Disorder 7-item (GAD-7) scale was the most frequently reported measurement of anxiety, in three studies. Due to limited data, meta-analyses for anxiety were not conducted. The results of this systematic review highlight the scarcity of data on depression and anxiety in AI/AN adolescents. This underscores the urgent need for culturally appropriate, evidence-based mental health research and services for AI/AN adolescents.
The majority of American Indian and Alaska Native (AI/AN) peoples reside in urban areas and experience significant health disparities relating to substance use. Nonetheless, very few randomized controlled trials (RCTs) have been conducted analyzing new substance use interventions for these populations, due, in part, to challenges with recruitment. This paper highlights recruitment strategies we employed from 2021-2023 in a study, Traditions, and Connections for Urban Native Americans (TACUNA), which analyzed the benefits of a new substance use intervention for urban AI/AN emerging adults (age 18 to 25). We navigated the COVID-19 pandemic by creating virtual platforms for the interventions used in our RCT and for our recruitment strategy. By utilizing algorithms identifying the interests of our recruitment audience and effective ad combinations on Facebook and Instagram, we were able to recruit 541 participants from 37 states. This study helps to identify recruitment strategies that may help to decrease health inequities as it relates to substance use research conducted among urban AI/AN peoples.
Despite histories of loss and discrimination, more American Indian, Alaska Native, and Native Hawaiian (AI/AN/NH) people are living into old age. Risk and protective factors for AI/AN/NH Elder mental health are poorly described. Data from the 2017-2020 Identifying Our Needs (ION): A Survey of Elders needs assessment of 19,143 AI/AN/NH Elders receiving nutrition, socialization, and caregiver-assistance services through Title VI of the Older Americans Act were analyzed. We hypothesized that (1) family, cultural, and social engagement are protective factors, (2) limitations in activities of daily living (ADL) and instrumental activities of daily living (IADL) are risk factors for mental health status, and (3) status of grandparent caregiver is associated with lower mental health scores. As hypothesized, frequent engagement in traditional cultural activities was protective for mental health status. ADL/IADL limitations were the largest risk factor for poor mental health among AI/AN/NH Elders, while engagement in social activity was the strongest protective factor. Additionally, the status of a grandparent as a primary caregiver for their grandchildren was associated with poorer mental health. Indigenous-serving programs need expanded funding to support both cultural and personal/family services to the growing population of AI/AN/NH Elders in the United States.
American Indian and Alaska Native (AI/AN) communities have relied on traditional ceremonial practices (TCPs) for survival and resilience for generations. Research examining the role of TCPs on wellness in urban, multi-tribal communities, however, has only recently emerged over the last several decades. This study explored the association between TCP-related variables and substance use in an urban AI/AN community in Montana. Specifically, participant knowledge, attitudes, and beliefs (KAB) regarding TCPs, their level of intent to participate in TCPs, and past year substance use were measured. This cross-sectional study used survey data from 194 AI/AN adults (66% female, 5% nonbinary; M age = 44). Positive KAB toward TCPs was found in 56.4% of respondents. Greater level of intent to participate in TCPs was found in 36.7% of respondents. Multivariate logistic regression showed individuals with positive KAB were less likely to report past year alcohol [adjusted odds ratio (AOR): 0.49; 95% confidence interval (95% CI): 0.26, 0.93] or other drug use (AOR: 0.30; 95% CI: 0.11, 0.76). Individuals who reported a greater level of intent to participate in TCPs were also less likely to report past year alcohol (AOR: 0.51; 95% CI: 0.26, 0.98) or other drug use (AOR: 0.31; 95% CI: 0.08, 0.91). The findings highlight a need for further examination of the potential effectiveness of substance use interventions for urban AI/AN adults that incorporate TCP-related factors.
Adverse childhood experiences (ACEs) predict poor adulthood health. ACEs are most common among American Indian/Alaska Native (AI/AN) and Multiracial groups, two groups that overlap substantially in population. We aimed to determine if the Multiracial population's high mean ACE score differs by those who do and do not identify as AI/AN. We analyzed Waves 1, 3, and 4 (1994-2009) of the National Longitudinal Study of Adolescent to Adult Health (N = 12,372), estimating race-specific mean ACE scores and component prevalence, and disaggregating the Multiracial group by AI/AN identity. We compared means and prevalence ratios using Bonferroni-corrected Tukey's honestly significant tests of differences. Mean scores on a 10-point scale were higher among AI/AN (mean = 3.21, 95% CI: 2.54, 3.97), Multiracial AI/AN (2.95, 95% CI: 2.71, 3.18), Multiracial non-AI/AN (2.88, 95% CI: 2.57, 3.19), and Black (2.84, 95% CI: 2.65, 3.02) groups than White (2.35, 95% CI: 2.26, 2.44) and Asian/Pacific Islander (2.32, 95% CI: 2.09, 2.54) groups. Tests of mean and prevalence differences between the AI/AN and two Multiracial groups were all insignificant. The Multiracial population's high mean ACE score does not differ by those that do and do not identify as AI/AN. ACEs prevention strategies should be tailored to meet the specific needs of groups at higher risk of exposure to improve health equity.
The purpose of this study was to gain an understanding of how historical trauma and one's degree of ethnic identity relate to symptoms of depression, due to controversy in the literature about such variables. Participants in this study self-identified as American Indian/Alaska Native (AI/AN), were over the age of 18, and were currently enrolled or had been previously enrolled at a university. Participants completed a survey online via Qualtrics to gather information about their ethnic identity, frequency of historical loss thinking, and symptoms of depression. Survey data was analyzed using multiple regressions, correlation analyses, mediation analyses, and follow-up t-tests. Historical loss thinking was found to be very prevalent among this sample, and this was found to contribute significantly to depressive symptoms in AI/AN college students. Various aspects of ethnic identity may contribute to an increase or decrease in historical loss thinking and subsequent depressive symptoms, and this has significant implications for clinicians working with AI/AN college students.
Rates of opioid use and overdose in the United States increased during the COVID-19 pandemic, while opioid use disorder (OUD) treatment facilities faced disruptions to services during this time. American Indian and Alaska Native (AI/AN) communities were amongst those most affected by the pandemic, while also experiencing some of the highest rates of opioid-related overdose deaths. As such, this study aimed to investigate the ways in which AI/AN-servicing OUD treatment centers and their communities were impacted by the pandemic. Semi-structured interviews were conducted with ten service providers working at AI/AN-servicing OUD treatment centers between January and April 2021. Treatment centers were located in the Pacific Northwest, the North Midwest, and the South Atlantic regions, and all provided medications for OUD. Using thematic content analysis, three broad domains were identified: (1) impacts to the AI/AN communities; (2) impacts to family and social life; and (3) impacts to OUD treatment services. Our findings indicate that AI/AN clientele and communities were negatively impacted by the suspension of AI/AN traditional practices. The importance of family and community support within treatment was emphasized and how this was impacted during the pandemic, while positive changes to services brought about by the pandemic were also reported.
Experiences of discrimination are linked to mental health in American Indians. Less is known about how place of residence (i.e., living on or off a reservation) relates to discrimination frequency and whether the strength and nature of the relationship between discrimination and mental health varies as a function of different living environments. In the current study, we examined frequency of discrimination, main reasons for discrimination, and relationships between discrimination for American Indians living both on and off a reservation. Relative to American Indian adults living off a reservation, American Indian adults living on reservation reported more experiences of discrimination (F(1, 846) = [15.94], p<.01, η² = .02) and identified more reasons for discrimination (F(1, 846) = [17.789], p<.001, η² = .02). Across residential contexts, race-related discrimination was most common, followed by gender discrimination. The relationship between discrimination and anxiety was significant in both residential contexts, while the relationship between discrimination frequency and depressive symptoms was only significant for those living outside of a tribal reservation. These findings highlight the importance of understanding how environmental context may affect patterns of discrimination and the relationship between discrimination and mental health in American Indians. Future research should elucidate resilience factors that are specific to living environments to reduce the negative impacts of discrimination on mental health for American Indian adults.
American Indians and Alaska Natives (AI/ANs) were disproportionately affected by the COVID-19 pandemic, experiencing excess hospitalization, mortality, and economic losses compared to the non- Hispanic Whites. This study sought to document the Indigenous determinants of health (IDOH) in AI/AN communities that shaped mental wellbeing for four groups: educators, traditional knowledge holders/practitioners, first responders, and substance abuse recovery community, during the pandemic. This work was a collaboration with and had research approval from three Native nations in Arizona. In-depth interviews were conducted from May to November 2021; 92 participants were interviewed. The most prevalent IDOH and associated themes included strategies to cope with emotional and social stressors and the impact on physical and mental health, relationships, kinship, cultural continuity, and self-determination. The groups experienced differences in mental wellbeing aligned with their occupation. For example, first responders experienced disruption and social dissonance in the workplace due to varying political views, and traditional knowledge holders/ practitioners experienced a revitalization of cultural strategies to maintain health. Although the differences between occupational groups are striking, the similarities that did exist were grounded in Indigenous identity and worldview that emphasize relationships and connection to the natural environment.
This study utilized interpretive phenomenological analysis to explore the experiences of three American Indian/Alaska Native counselors working on federal Indian reservations. Data analysis yielded four themes: the worth and weight of counseling on a reservation, the impact of culture and community on counseling, four forms of trauma impacting the counselor, and the effects of personal and professional wellness. This research contributes valuable insights into the nuanced experiences of American Indian/Alaska Native counselors working within reservation contexts and highlights the importance of addressing the unique challenges they face in delivering counseling services to their communities. Future research, support infrastructure, and counselor training initiatives should prioritize specialized training and systemic support for counselors tailored specifically to address the needs of American Indian/Alaska Native counselors and the communities they serve.
A mixed methods community-based participatory research study was conducted with Native American Lifelines of Baltimore to: (1) understand prevalence, correlates, and lived experiences with food insecurity and (2) explore the effects of and potential solutions to food insecurity. An online survey was completed by 250 American Indian and Alaska Native adults, and a subset of survey respondents (N=11) completed interviews. Quantitative analysis revealed food insecurity prevalence of 28% and increased odds of food insecurity with higher levels of food stress and COVID-19 hardships. Qualitative inquiry revealed harmful long-term effects of food insecurity on eating behaviors and several food sovereignty-oriented solutions to food insecurity.
The community mental health center era in the United States was based on delivering services cataloged in three areas of behavioral health needs; (1) primary prevention of mental illness: the prevention of illness before it develops; (2) secondary prevention services: the early treatment of mental illness to reduce the severity of illness, and (3) tertiary prevention: treatment aimed at the reduction of the burdens of chronic mental illness. To attain these goals in a particular state in the United States has been very difficult, and Alaska, which has only been a state since 1959, is not close to attaining these goals. As a matter of fact, this paper will demonstrate that Alaska has had more trouble than most states in providing even rudimentary services in several of these areas. Yet, because of a curious constellation of factors, this paper presents the reader with a hopeful possible alignment of programs which, if more fully developed and linked in Alaska, can become an integrated public behavioral health system open to all the residents in the state.
Community health needs assessments (CHNAs) often lack sufficient community member participation. This lack of participation contributes to a continuation of unmet needs and systematic inequities. Southcentral Foundation (SCF) is an Alaska Native-owned, nonprofit healthcare organization serving 70,000 Alaska Native and American Indian (AN/AI) people living in and around Anchorage and 55 rural villages. Results of a 1993 CHNA shaped the organizational mission, vision, organizational principles, objectives, and initiatives as SCF assumed care from the Indian Health Service. We describe methods used by SCF to maximize participation of diverse community members in a second large-scale CHNA in 2018, how results align with existing organizational values and priorities, and how results were disseminated. We discuss the benefits of periodic CHNAs and ongoing community engagement.
Gardening for Health Utilizing Traditions (GHUTS) is a new diabetes prevention intervention for urban American Indian and Alaska Native (AI/AN) adults receiving mental health treatment in Los Angeles County. The two main objectives of this study are to: 1) further our understanding of diabetes prevention and the role of gardening for urban AI/AN adults receiving mental health treatment and 2) finalize the development of GHUTS. To inform the feasibility of the intervention and to gain perspective, three focus groups were conducted among urban AI/AN adults receiving mental health treatment (n = 7), providers who serve urban AI/AN people (n = 7), and the GHUTS Community Advisory Board (n = 5). Three overarching conceptual themes emerged: 1) Diabetes is an important issue among urban AI/AN people receiving mental health treatment, 2) AI/AN traditional practices have an important role in diabetes prevention among urban AI/AN adults receiving mental health treatment, and 3) Gardening is beneficial for AI/AN people. Feedback on the GHUTS curriculum featured diabetes education, cultural elements, concerns specific to AI/AN people in Los Angeles County, cooking, physical exercise and diet, prayer and mindfulness, community sharing, and field trips. This study highlights the process of developing a community-grounded diabetes prevention intervention for urban AI/AN adults receiving mental health treatment.
American Indian and Alaska Native (AI/AN) youth have the highest commercial tobacco smoking rate of any group in the United States. Unified by the aim to reduce AI/AN youth commercial tobacco use, six separately funded tobacco prevention programs serving Southern California tribes formed the Southern California Tribal Tobacco Coalition (SCTTC). Since joining forces, the SCTTC has hosted various activities and events that encourage community involvement, youth leadership, and commitment to tradition. The SCTTC's pinnacle event, the annual Inter-Tribal Tobacco Prevention Youth Summit, is an inspiring example of the organization's collaborative efforts, as it features youth- and elder-led activities and presentations by local tribal members. These community events have grown in participation from year to year and are widely supported by the surrounding AI/AN communities. This paper includes narratives from several coalition members, including youth activity organizers, that showcase the power of collaboration through the SCTTC's partnership and its success to date. The purpose of this paper is to share the SCTTC's positive impact in Southern California tribes and encourage similar programs across the nation to amplify their program impacts by forming a coalition of their own and embracing youth-led interventions.
This article releases the Gathering of Native Americans (GONA) Fidelity Tool to the public. The paper describes the methods in the development of the GONA Fidelity Tool and how it is used in planning, implementing, evaluating, and in further tailoring the GONA process more precisely to the community's needs and strengths. Development and revision of the tool occurred over 10 years with participation and input from 7 Urban Indian Health Organizations funded under Title V of the Indian Health Care Improvement Act, using the tool to advance local GONAs across the state of California. Participating organizations used the tool in partnership with Indigenous evaluators to measure GONA implementation. Process evaluations were conducted to support tool advancements over time and an Annual GONA Training of Facilitators provided a forum for consensus building of GONA best practices for tool revisions. Results indicate that the tool is useful in the planning, implementation, and quality improvement to advance local GONAs over time. The most effective use of the tool is when the items are adapted to the local culture, context, and spiritual practices of the community(ies) served. The tool is now being used nationally and has become an important resource for measuring practice-based evidence and community-defined evidence in the implementation of GONA for Indigenous communities.
