Importance American Indian and Alaska Native individuals report higher rates of substance use disorders and psychological distress compared with individuals from other racial and ethnic groups. However, few evidence-based, culturally grounded programs address substance use and mental health for urban American Indian and Alaska Native emerging adults. Objective To test 2 culturally grounded virtual interventions for substance use among urban American Indian and Alaska Native emerging adults. Design, Setting, and Participants In this randomized clinical trial, participants were recruited across the US from December 1, 2020, to October 27, 2023. Participants completed an online screening questionnaire. Eligibility criteria included (1) age 18 to 25 years; (2) living in an urban area in the US (not a rancheria or a reservation); (3) self-identification as American Indian or Alaska Native; (4) no opioid use disorder; and (5) English speaking. The participants completed baseline surveys, were randomized to 1 of 2 culturally grounded virtual interventions, and completed 3-, 6-, and 12-month surveys. Follow-up was completed January 28, 2025. Analysis was based on intention to treat. Interventions Participants received either 3 Traditions and Connections for Urban Native Americans (TACUNA) workshops and a wellness circle, or an opioid education health and wellness cultural (HWC) workshop (usual care). Main Outcomes and Measures Surveys focused on opioid, alcohol, and cannabis use (primary outcome) and consequences of alcohol and other drug use, mental health, cultural connection, and peer influence (secondary outcomes). Results Among the 541 randomized participants (451 [83.2%] female; mean [SD] age, 22.1 [2.2] years), the TACUNA and HWC groups both reported decreased frequency of cannabis use (B [SE], −0.44 [0.20] and −0.54 [0.21], respectively) and decreased rates of positive screens for alcohol (B [SE], −0.03 [0.01] and −0.02 [0.01], respectively) and cannabis (B [SE], −0.02 [0.01] and −0.03 [0.01], respectively) use disorders. Rates of time spent with peers who use alcohol and prescription opioids, clinical depression and anxiety, alcohol and cannabis consequences, and peer norms around alcohol, cannabis, prescription opioids, and heroin use improved in both groups. Only TACUNA participants reported decreases in frequency (B [SE], −0.51 [0.20]) and quantity (B [SE], −0.25 [0.09]) of alcohol use and quantity of cannabis use (B [SE], −0.07 [0.03]). In addition, TACUNA participants reported greater decreases in time spent around peers using cannabis and heroin and greater decreases of anxiety compared with HWC participants. Conclusions and Relevance In this randomized clinical trial of 2 virtual culturally grounded interventions for substance use, virtual recruitment and intervention successfully reached urban American Indian or Alaska Native emerging adults with decreased access to resources. Both groups reduced consequences and cannabis use; however, only TACUNA participants reported decreases in quantity of alcohol and cannabis use and time spent around peers using cannabis and heroin and greater decreases in anxiety. These findings emphasize the role of bringing American Indian and Alaska Native emerging adults together to discuss ways to reduce alcohol and other drug use and socially connect with their tribal communities in the urban environment in a virtual setting. Trial Registration ClinicalTrials.gov Identifier: NCT04617938

HIV disparities among U.S. Latino men who have sex with men (LMSM) persist alongside lower PrEP use. We examined correlates of PrEP cascade outcomes among 287 cisgender immigrant LMSM. PrEP conspiracy beliefs were negatively associated with HIV testing (OR = 0.77, 95

Reduction of internalized HIV stigma is key to increasing HIV disclosure and engagement in peer advocacy for HIV prevention—and these latter processes may also be important for making further inroads into minimizing stigma. We examined mediators of the effect of a peer advocacy training intervention, Game Changers for HIV Prevention (GC-HIV), on reduced internalized HIV stigma among persons living with HIV (PLWH) in Uganda. A randomized controlled trial was conducted with 210 PLWH (105 in each of the intervention and usual care control arms) who were assessed at baseline and months 6, 12 and 18. Internalized HIV stigma was measured with the 6-item Internalized AIDS-Related Stigma Scale. A repeated measures linear regression model found an intervention effect on reduced internalized HIV stigma. Path analysis performed for each mediator separately revealed that this stigma reduction effect was partially mediated with significant indirect effects for increased HIV disclosure [beta (SE) = − 0.05 (0.03); p = .046] and increased prevention advocacy [beta (SE) = − 0.12 (0.05); p = .01], as well as a significant direct effect; inclusion of both these mediators in the model did not alter this result. HIV knowledge did not act as a mediator of the intervention effect on stigma. Findings support not only the value of the intervention for reducing internalized stigma, but also the benefits of HIV disclosure and encouraging others to protect against HIV for stigma reduction and self-acceptance for PLWH. Clinicaltrials.gov registration (NCT05098015), 2021-10-18.

Internalized HIV stigma, defined as negative self-perceptions among people living with HIV (PLWH) based on the societal stereotype, is a significant barrier to effective HIV prevention and care in Sub-Saharan Africa. This study examined longitudinal correlates of internalized HIV stigma among PLWH in Uganda. The sample included 105 participants (mean age = 39.3 years (SD = 10.5); 69.5

Pathways through which advocacy training enhances engagement in advocacy among persons living with HIV (PLWH) are not well understood. In a secondary analysis from a randomized controlled trial of a peer advocacy training intervention for PLWH, we examined mediators of intervention effects on HIV prevention advocacy (i.e., encouraging others to engage in HIV protective behaviors) across members of their social network. A sample of 210 PLWH (105 in each of the intervention and control arms) provided information about their advocacy to their social network members at baseline, and 6-, 12-, and 18-month follow-up. Repeated measures linear regressions showed that PLWH in the intervention group targeted more social network members with advocacy for HIV testing, condom use, pre-exposure prophylaxis (PrEP) use, HIV care, and ART use over the follow-up period compared to those in the control group. In path analysis that examined each mediator in a separate model, reduced internalized HIV stigma and increased HIV knowledge as measured at month 6, each fully mediated the intervention effect on HIV care advocacy; reduced stigma partially mediated the effects on advocacy targeting each of the other four HIV protective behaviors, while increased knowledge partially mediated effects on HIV testing, condom and PrEP use advocacy. Results were unchanged when examining the joint mediation of stigma and knowledge. HIV disclosure and advocacy self-efficacy had no mediating effect. These findings highlight the importance of helping PLWH to cope with HIV stigma and gain knowledge about basic facts and common misconceptions related to HIV, to propel their engagement in advocacy for multiple HIV protective behaviors within their social networks.The trial was registered 2021-10-18 (NCT05098015).

Importance:American Indian and Alaska Native individuals report higher rates of substance use disorders and psychological distress compared with individuals from other racial and ethnic groups. However, few evidence-based, culturally grounded programs address substance use and mental health for urban American Indian and Alaska Native emerging adults. Objective:To test 2 culturally grounded virtual interventions for substance use among urban American Indian and Alaska Native emerging adults. Design, Setting, and Participants:In this randomized clinical trial, participants were recruited across the US from December 1, 2020, to October 27, 2023. Participants completed an online screening questionnaire. Eligibility criteria included (1) age 18 to 25 years; (2) living in an urban area in the US (not a rancheria or a reservation); (3) self-identification as American Indian or Alaska Native; (4) no opioid use disorder; and (5) English speaking. The participants completed baseline surveys, were randomized to 1 of 2 culturally grounded virtual interventions, and completed 3-, 6-, and 12-month surveys. Follow-up was completed January 28, 2025. Analysis was based on intention to treat. Interventions:Participants received either 3 Traditions and Connections for Urban Native Americans (TACUNA) workshops and a wellness circle, or an opioid education health and wellness cultural (HWC) workshop (usual care). Main Outcomes and Measures:Surveys focused on opioid, alcohol, and cannabis use (primary outcome) and consequences of alcohol and other drug use, mental health, cultural connection, and peer influence (secondary outcomes). Results:Among the 541 randomized participants (451 [83.2%] female; mean [SD] age, 22.1 [2.2] years), the TACUNA and HWC groups both reported decreased frequency of cannabis use (B [SE],  -0.44 [0.20] and -0.54 [0.21], respectively) and decreased rates of positive screens for alcohol (B [SE], -0.03 [0.01] and -0.02 [0.01], respectively) and cannabis (B [SE], -0.02 [0.01] and -0.03 [0.01], respectively) use disorders. Rates of time spent with peers who use alcohol and prescription opioids, clinical depression and anxiety, alcohol and cannabis consequences, and peer norms around alcohol, cannabis, prescription opioids, and heroin use improved in both groups. Only TACUNA participants reported decreases in frequency (B [SE], -0.51 [0.20]) and quantity (B [SE], -0.25 [0.09]) of alcohol use and quantity of cannabis use (B [SE], -0.07 [0.03]). In addition, TACUNA participants reported greater decreases in time spent around peers using cannabis and heroin and greater decreases of anxiety compared with HWC participants. Conclusions and Relevance:In this randomized clinical trial of 2 virtual culturally grounded interventions for substance use, virtual recruitment and intervention successfully reached urban American Indian or Alaska Native emerging adults with decreased access to resources. Both groups reduced consequences and cannabis use; however, only TACUNA participants reported decreases in quantity of alcohol and cannabis use and time spent around peers using cannabis and heroin and greater decreases in anxiety. These findings emphasize the role of bringing American Indian and Alaska Native emerging adults together to discuss ways to reduce alcohol and other drug use and socially connect with their tribal communities in the urban environment in a virtual setting. Trial Registration:ClinicalTrials.gov Identifier: NCT04617938.

Peer advocacy has been shown to influence HIV protective behaviors, but few studies have examined whether advocacy within social networks is diffused—a process whereby the recipient of advocacy engages in further advocacy with others. Advocacy diffusion is critical for wide dissemination of knowledge and behavioral change throughout a network. In a randomized controlled trial of a peer advocacy training intervention for people living with HIV (PLWH) in urban Uganda, 210 PLWH were enrolled as index participants along with 599 of their social network members (alter participants), all of whom were assessed at baseline and months 6, 12 and 18. Prevention advocacy engagement was assessed with a 10-item scale of frequency of discussion of various HIV prevention topics with others in the past 3 months. Repeated-measures linear regression models examined predictors of change in HIV prevention advocacy engagement among 596 alters who completed at least one follow-up assessment. Alter engagement in HIV prevention advocacy increased significantly across follow-up (from 2.08 at baseline to 3.53 at month 18; possible range: 1–5), and this increase was predicted by general increased engagement in advocacy reported by the index participant who recruited them, receipt of any behavior-specific advocacy from this index, older age, and greater HIV disclosure (if the alter was living with HIV). These findings provide evidence of an initial step of HIV prevention advocacy diffusion from index to first-degree alter, thereby highlighting the possibility of diffusion throughout the wider network and the potential for scaled-up dissemination of knowledge and behavior change for HIV prevention.

CONTEXT:Young adults experiencing homelessness (YAEH) have higher rates of pregnancy than stably housed young adults. Pregnant and parenting YAEH face several challenges, but little is known about outcome change over time. METHODS:276 YAEH (aged 18-25, 28% female sex at birth) receiving services at drop-in centers in Los Angeles, California, participated in an intervention study to address substance use and sexual health. At each survey, participants reported whether they experienced pregnancy or got someone pregnant in the past 3 months. Regression models examined associations between pregnancy and several outcomes at 24 months (education, employment, income, health, substance use, service use, and housing), controlling for intervention and outcomes at baseline. RESULTS:Fifty-six participants (20%, n = 26 female sex, n = 30 male sex) reported being pregnant or getting someone pregnant over the course of the study. For women, pregnancy was associated with higher odds of staying in transitional housing (OR = 5.01, 95% CI: 1.22-20.60) and emergency shelters (OR = 8.32, 95% CI: 1.57-44.02) at 24 months, controlling for baseline. For men, getting someone pregnant was associated with greater importance of cutting down alcohol use (b = 2.06, SE = 0.89, p = 0.02) and higher odds of education service use at 24 months (OR = 3.00, 95% CI: 1.16-7.79). CONCLUSIONS:Pregnancy may be associated with greater use of housing services among female YAEH, and increased importance of cutting down alcohol and use of education services among male YAEH. Continued support is needed to improve long-term outcomes of pregnant and parenting YAEH. TRIAL REGISTRATION:ClinicalTrials.gov identifier: NCT03735784. https://clinicaltrials.gov/ct2/show/record/NCT03735784.

In a secondary analysis from a randomized controlled trial of a peer advocacy training intervention for people living with HIV (PLWH), we examined effects on advocacy targeting specific HIV protective behaviors among enrolled social network members (alters), and whether alter behaviors were predicted by advocacy receipt and tone of delivery. 210 PLWH and 599 alters enrolled and were followed over 18 months. Repeated measures logistic regressions showed that PLWH in the intervention group targeted more alters with advocacy for HIV testing, condom use, pre-exposure prophylaxis, and HIV care, compared to those in the control group. Alters targeted with HIV testing advocacy were more likely to report increased HIV testing at the subsequent assessment. Among alters with HIV-negative main partners, receipt of condom use advocacy predicted increased consistent condom use at the subsequent assessment. Advocacy training for PLWH can increase targeted HIV prevention advocacy, which then promotes HIV testing and condom use.

Latino gay, bisexual, and other men who have sex with men (LGBMSM) are disproportionally affected by HIV in the U.S. We tested a culturally tailored community-based group HIV prevention intervention (“Siempre Seguiré”) for immigrant LGBMSM that uses cognitive behavior therapy to address coping with intersectional stigma and medical mistrust. A total of 289 immigrant LGBMSM were randomized (144 control, 145 intervention) and completed surveys at baseline and 4-, 8-, and 12-months (79

In Uganda, where HIV prevalence remains above 5% among those aged 15 and older, we conducted a randomized controlled trial of Game Changers , an 8-session peer-facilitated group intervention that empowers people living with HIV (PLHIV) to engage in HIV prevention advocacy with their social network members (“alters”). A total of 210 index PLHIV participants (105 intervention, 105 control) and 599 alters were enrolled; assessments were conducted at baseline and 6-, 12-, and 18-months post-baseline. Intention-to-treat repeated measures regressions indicated significant intervention effects on reduced internalized stigma and increased HIV prevention advocacy, prevention advocacy self-efficacy, and disclosure among index participants. In within-intervention group analyses, alters exposed to prevention advocacy showed higher likelihoods of HIV testing and condom use. Game Changers had direct psychosocial benefits for index participants, and indirect benefits for improved HIV prevention behaviors among alters. Implementation research is needed to determine conditions under which Game Changers is most effective. NCT05098015, Registered 2021-10-18.

This study investigates the impact of internalized HIV stigma on sleep problems and depression in people living with HIV (PLWH) in Botswana. It also explores whether sleep problems mediate the relationship between internalized HIV stigma and depressive symptoms, given that sleep disturbance is a symptom of depression and often predates a depressive episode. Secondary analysis was conducted using baseline data from a pilot randomized controlled trial on 58 virally unsuppressed PLWH in Gaborone, Botswana. Internalized HIV stigma, sleep disturbance and daytime impairment, and depressive symptoms were assessed using validated scales. Multiple linear regression and simple mediation models with bootstrap procedures were employed. Covariates for the adjusted models were age and sex assigned at birth. One in five participants reported experiencing moderate to extreme sleep problems. Internalized HIV stigma was associated with greater nighttime sleep disturbance, but not with daytime impairments or depressive symptoms. An indirect effect between internalized HIV stigma and depressive symptoms via nighttime sleep disturbance was identified; however, this path was no longer significant after adjusting for covariates. No significant indirect effects were found via daytime impairments. The findings of this study extend the existing literature by exploring the interplay between internalized HIV stigma, sleep disturbances, and depression among PLWH in Africa. While internalized HIV stigma contributes to nighttime sleep disturbance, its indirect role in affecting depressive symptoms is less clear, potentially due to small sample size. The study suggests the need for targeted interventions addressing sleep disturbances to potentially mitigate the psychological impacts of internalized HIV stigma.

This article describes change in health status by analyzing key health domains at two time points before and during the COVID-19 pandemic among a sample of American Indian/Alaska Native (AI/AN) adolescents living outside of tribal land (n = 114) throughout California. Data were analyzed from a longitudinal study, Native American Youth Sleep Health and Wellness (NAYSHAW). To test changes in health from baseline (March 2018–March 2020) to follow-up (December 2020–June 2022), we ran a series of linear regression models for continuous measures and repeated measures logistic regression models for dichotomous measures for physical health, behavioral health, and cultural contexts of health and well-being. For physical health, body mass index percentile significantly decreased (p = 0.02), and both systolic and diastolic blood pressure significantly increased (p < 0.001 for both), although both measures remained within the normal range for adolescents. For behavioral health, depression and anxiety significantly increased (p = 0.005 and 0.008, respectively), although they remained within subclinical levels, and no significant changes were observed with alcohol and cannabis use. For cultural contexts of health and well-being, both cultural identity and sense of historical loss significantly increased (p < 0.001 and p = 0.03, respectively). We observed a mix of positive and negative health changes among AI/AN adolescents living outside of tribal land before and during COVID-19. Findings highlight that enhanced cultural identity during adolescence may have helped foster resilience during this difficult period.

OBJECTIVE:Young adults experiencing homelessness are at high risk for alcohol-related consequences, but protective behavioral strategies (PBS) have not been investigated as a harm reduction approach in this population. This study examines longitudinal associations between PBS and alcohol-related consequences following a group-based alcohol intervention. METHOD:Data come from AWARE, a randomized controlled trial of a group-based motivational intervention to reduce substance use and risky sex compared to usual care. Participants include 276 young adults experiencing homelessness (Mage = 22.08, 30% female, 84% non-White) receiving drop-in center services in Los Angeles County, California. Surveys were conducted at baseline and 3-, 6-, 12-, and 24-month follow-up. Bivariate latent change score models examined cross-lagged associations between PBS and alcohol consequences for participants who drank at least once over the course of the study, controlling for demographics and intervention condition. RESULTS:PBS were associated with significant wave-to-wave reductions in alcohol consequences (δ range = -2.53 to -11.22), and alcohol consequences were associated with significant reductions in PBS usage between the 3- and 6-month follow-ups (δ = -0.02, p = .01) and between the 12- and 24-month follow-ups (δ = -0.08, p = .004). In addition, the AWARE intervention was associated with increased PBS usage between the 3- and 6-month follow-ups (δ = 0.30, p = .02). CONCLUSIONS:Among young adults experiencing homelessness, greater use of PBS is associated with significant reductions in alcohol consequences over time. Furthermore, PBS may increase following a group-based motivational intervention. PBS are a promising harm reduction strategy for this population. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

BackgroundWhile a number of tools exist to predict mortality among older adults, less research has described the characteristics of Medicare Advantage (MA) enrollees at higher risk for 1 year mortality.ObjectivesTo describe the characteristics of MA enrollees at higher mortality risk using patient survey data.Research DesignRetrospective cohort.SubjectsMA enrollees completing the 2019 MA Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey.MeasuresLinked demographic, health, and mortality data from a sample of MA enrollees were used to predict 1-year mortality risk and describe enrollee characteristics across levels of predicted mortality risk.ResultsThe mortality model had a 0.80 c-statistic. Mortality risks were skewed: 6% of enrollees had a ≥10% 1-year mortality risk, while 45% of enrollees had 1% to < 5% 1-year mortality risk. Among the high-risk (≥10%) group, 47% were age 85+ versus 12% among those with mortality risk <5%. 79% were in fair or poor self-rated health versus 29% among those with mortality risk of <5%. 71% reported needing urgent care in the prior 6 months versus 40% among those with a mortality risk of 1 to<5%.ConclusionsRelatively few older adults enrolled in MA are at high 1-year mortality risk. Nonetheless, MA enrollees over age 85, in fair or poor health, or with recent urgent care needs are far more likely to be in a high mortality risk group.

Black sexual minority men (SMM) are disproportionately impacted by HIV in the United States. Intimate partner violence (IPV), substance use, and depression are associated with HIV risk behavior such as condomless sex. In this study, we assessed cross-sectional associations between multiple types of IPV victimization and condomless sex with serodiscordant partners. We then evaluated the mediating roles of mental health and substance use, in a sample of 213 Black SMM living with HIV. We used validated scales to assess IPV victimization, depression, post-traumatic stress symptoms, general mental health, and substance use. All independent variables (IPV type) that had at least a marginal ( p < .10) association with the dependent variable (condomless sex with a serodiscordant partner) and any potential mediator were included in mediation models. Mediator role was determined based on a statistically significant outcome ( p < .05) in the mediation model. Physical assault, injury-inducing IPV, and sexual coercion were each positively correlated with condomless sex. Depression, overall mental health, and substance use were associated with physical assault and injury-inducing IPV, and depression was associated with sexual coercion IPV. Both physical assault and injury-inducing IPV were associated with overall mental health, but none of the mental health and substance use measures mediated the associations between IPV and condomless sex. Findings suggest that HIV prevention efforts for Black SMM may need to incorporate IPV screening and prevention services. Further research is needed to understand the psychosocial pathways by which physical forms of IPV relate to condom use.

BACKGROUND AND OBJECTIVES:Limited research has examined how discrimination in young adulthood relates to substance use. We examined how multiple and specific types (e.g., race-based) of experiences of unfair treatment are related to problematic alcohol and cannabis use. METHODS:We analyzed cross-sectional data from a diverse cohort of young adults (mean age 24.7) predominantly residing in southern California (n = 2303) to examine associations of multiple (count) and specific experiences (race-, sexual orientation-, gender-based) of perceived everyday discrimination with self-reported alcohol and cannabis use outcomes (consequences, use disorders, and solitary use). We also tested interactions between the three specific discrimination experiences and sociodemographic characteristics (e.g., race-based discrimination × race/ethnicity). RESULTS:In this diverse sample (e.g., 47% Latinx/o and 22% Asian; 22% sexual/gender diverse; 56% female) of young adults, about 46% reported up to four different discrimination experiences and 27% reported race-, 26% gender-, and 5% sexual orientation-based discrimination. Race- and gender-based discrimination and experiencing more types of discrimination were associated with worse cannabis use outcomes. Race-based discrimination was associated with fewer alcohol consequences and lower Alcohol Use Disorders Identification Test (AUDIT) scores. Associations with sexual orientation-based discrimination and the interactions were not significant. DISCUSSION AND CONCLUSIONS:Findings build on limited research on associations of discrimination with cannabis use in young adults. More work is needed to understand the mechanisms by which discrimination influences drinking behaviors. SCIENTIFIC SIGNIFICANCE:This study advances the field by examining the unique contributions of specific and multiple types of discrimination experiences in young adulthood, a critical developmental period in which substance use peaks.

Purpose Mental health inequalities continue to persist among American Indian/Alaska Native (AI/AN) people. However, few studies have examined the association of social networks and depression and anxiety among urban emerging AI/AN adults. Methods This study analyzes the association of social network characteristics with depression and anxiety among a sample of urban AI/AN emerging adults. A second set of regression models tested the same associations but controlling for respondent sexual and gender minority (SGM) status. Data were from a sample of 150 AI/AN emerging adults residing in urban areas from 20 different states (86% female; mean age 21.8; 48.0% SGM) who participated in a randomized controlled trial analyzing the effects of culturally grounded interventions on alcohol and other drug use and cultural connectedness. Results Participants with a higher proportion of network members who were around the same age reported significantly less anxiety. Those who had a higher proportion of network members who they sometimes/often argue/fight with were more likely to report greater depression and anxiety. Participants with higher proportions of social network members who have ever lived on a reservation/Rancheria/tribal land/tribal village reported significantly less depression. However, participants with higher proportions of social network members who lived 50 miles away or more reported significantly more depression. Controlling for SGM status, results were largely similar. Discussion Results highlight the role of social connections on the mental well-being of urban AI/AN emerging adults.

Importance Adolescent sleep problems are prevalent, particularly among racial and ethnic minority groups, and can increase morbidity. Despite the numerous strengths of their racial and ethnic group, urban American Indian and Alaska Native adolescents face significant health disparities but are rarely included in health research. Understanding how sleep problems are associated with health outcomes among American Indian and Alaska Native adolescents may elucidate novel targets for interventions to promote health equity. Objective To assess whether baseline sleep problems are associated with changes in behavioral and cardiometabolic health outcomes among urban American Indian and Alaska Native adolescents 2 years later. Design, Setting, and Participants American Indian and Alaska Native adolescents were recruited via flyers and community events for an observational cohort study in California. Baseline assessments were conducted among 142 adolescents from March 1, 2018, to March 31, 2020, and follow-ups were conducted among 114 adolescents from December 1, 2020, to June 30, 2022. Exposures Baseline actigraphy-assessed sleep duration and efficiency and self-reported sleep disturbances and social jet lag (absolute value of the difference in sleep midpoint on weekends vs weekdays; indicator of circadian misalignment). Main Outcomes and Measures Main outcome measures included self-reported depression (measured using the Patient Health Questionnaire), anxiety (measured using the Generalized Anxiety Disorder 7-item scale), past year alcohol and cannabis use, body mass index, systolic blood pressure (SBP) and diastolic blood pressure (DBP), waist circumference, and glycosylated hemoglobin (HbA 1c ). Analyses examined whether baseline sleep was associated with health outcomes at follow-up, controlling for age, sex, and baseline outcome measures. Results The baseline sample included 142 urban American Indian and Alaska Native adolescents (mean [SD] age, 14.0 [1.4] years; 84 girls [59%]), 80% of whom (n = 114; mean [SD] age, 14.1 [1.3] years; 71 girls [62%]) completed follow-ups. Linear or logistic regressions showed significant negative associations between shorter sleep duration and depression (β = −1.21 [95% CI, −2.19 to −0.24]), anxiety (β = −0.89 [95% CI, −1.76 to −0.03]), DBP (β = −2.03 [95% CI, −3.79 to −0.28]), and HbA 1c level (β = −0.15 [95% CI, −0.26 to −0.04]) and likelihood of alcohol (odds ratio [OR], 0.57 [95% CI, 0.36-0.91]) and cannabis use (full week: OR, 0.59 [95% CI, 0.35-0.99]) at follow-up. Greater social jet lag was associated with significantly higher SBP (β = 0.06 [95% CI, 0.01-0.11]) at follow-up. Conclusions and Relevance This cohort study found significant associations between poor sleep and adverse changes in health outcomes. Findings highlight the importance of developing culturally responsive interventions that target sleep as a key modifiable risk factor to improve the health of American Indian and Alaska Native adolescents.