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Collaborative Hubs to Reduce the Burden of Suicide among American Indian and Alaska Native (AI/AN) Youth


>> WEBINAR OPERATOR: Good day and welcome to today's Collaborative Hubs to Reduce the Burden of Suicide among American Indian and Alaska Native Youth webinar. At this time, all participants are on listen-only mode. If you like to submit a topic or a technical-related question you may do so at any time via the Q&A pod located on the right-hand side of your screen. Please note: this webinar is being recorded. I will be standing by if you should need any assistance. I will now turn the call over to Andrea Horvath Marques. Please go ahead.

>> ANDREA HORVATH MARQUES: Good afternoon everybody. I'm pleased to welcome you all to this webinar. My name is Andrea Horvath Marques. I'm the Chief of Mental Health Disparities Research Program at the Office for Research on Disparities & Global Mental Health at NIMH and this is the final in the series of two webinars in just…2007 webinar series on mental health disparities issues supported by our office.

Before I introduce the speakers, I would like to provide you with a little bit of background about this important initiative. In 2006 our office released an IFA encouraging applications to establish collaborative hubs to conduct research focused on reducing the burden of suicide and promoting resilience among American Indians and Alaskan native youth.

As of August 2017, we have the pleasure to share with you that three collaborative research hubs have been funded and they are all here with us today to share their project and their experience. Now it gives me the honor to present our first speaker and our first group to share with you.

As I see here we're gonna be first starting with the Alaskan Native Collaborative Hub for Resilience Research. Now the speakers will be Evan Peter, Vice Chancellor for Rural, Community and Native Education from the University of Alaska Fairbanks, Dr. Stacy Rasmus from University of Alaska Fairbanks, Dr. Lisa Wexler from University of Massachusetts Amherst, Dr. James Allen from University of Minnesota Medical School, and then we're gonna move on forward to the second presentation that is the Southwest Hub for American Indian Youth Suicide Prevention Research. Dr. Mary Cwik from John Hopkins Bloomberg School of Public Health will be presenting today, and will be representing is also Dr. Allison Barlow.

And finally, we're gonna go for our third hub, Preventing Suicide Among Urban American Indian Youth and Young Adults, and Dr. Spero Manson from University of Colorado and Dr. DEDRA Buchwald from Washington State University will be presenting.

So, without further ado we're gonna move forward to our first presenter Mr. Evan Peter.

>> EVAN PETER: Okay, hello. Good afternoon everyone. Sorry about that delay in the slide. My name is Evan Peter. I'm Neetsai Gwich'in and Koyukon from the community of Arctic Village, or Vashraii K'oo in my language, and it's an honor to present on the Alaska Native Collaborative Hub for Research on Resilience. I'm gonna be introducing the program broadly and then setting it in the context of the Alaskan landscape and the cultural diversity that exists within our state.

So, as you can see here on the Alaskan language map there's broadly 20 distinct Alaskan native languages across the state of Alaska. They're non-mutually intelligible although oftentimes you might hear the interior on the map is referred to as Athabascan peoples, but within those peoples there's a great deal of cultural and linguistic diversity. Among those 20 distinct groups, only five of the groups accessible by road and so the vast majority of our community and villages are quite isolated especially by continental US standards, accessible only by small plane.

For example, travelling from where we're situated at the University of Fairbanks, it can take us almost two days for us to travel to some of the communities on the western coast of Alaska. I mean sometimes just the air fare will cost us upwards of $1300 or more to ride there so it adds to some of the geographic challenges that we face in the context of Alaska, and also it demonstrates some of the remote locations and challenges in accessing healthcare and healthcare systems.

Also within the state with such a large geography, there is a lot of diversity in experiences and impacts from colonization and assimilation policies over the last several hundred years and so we're really getting a very diverse set of circumstances and social impacts from community to community and sometimes from family to family across the state that we look at as we move forward in addressing some of the issues.

One of the things that we're really excited in this project is that we're really bringing together researchers, people who've been at the community level as providers and practitioners and Alaskan native leaders from across the state to truly work together to build for Alaskan native strength and resiliency and addressing the health inequality and disparities facing our people and youth.

In this slide, you'll see that we're gonna be taking our approach with a multi-leveled oversight leadership structure, engaging with the Alaska native community through the hub. The first layer is the Alaska Native External Executive Advisory Committee which is really gonna be a smaller group of Alaska native leaders, senior Alaska native leaders from diverse backgrounds including from our tribal leadership institutions, from our tribal healthcare organizations, from non-profit and community organizations, and then cultural knowledge bearers at the community level, and that will be a smaller group that will provide a lot of the feedback and guidance as we're navigating through working on and addressing the issues that we're looking at throughout the hub. A part of the longer-term vision that we have is that the AN EAC group will also provide reflection and guidance more broadly to us within the University of Alaska Fairbanks as we address some of our forward movement in health research.

The second group is the collaborative hub. A collaborative hub is gonna be made up. It's gonna be a larger group made up largely of providers from within the different cultural organizations, really bringing together the wealth of knowledge that they've obtained over...for many of them two decades of working in attempting to prevent and preventing suicide successfully. So, we really wanna create an opportunity where we'll be learning from one another and sharing some of the best practices that may emerge.

And finally, the research steering committee is gonna be made up of Alaska native researchers and leaders within the regions where we're gonna be carrying out our research projects to provide that direct support and partnership with our group peers on the project. Thank you.

>> STACY RASMUS: Well thank you so much Evan. Well, good afternoon. This is Stacy and I'm going to present our overall ANCHRR model and specific aim.

Evan has already introduced our goal in creating an Alaska native leadership structure for our collaborative hub. During the first year of the project we will focus on establishing a research network on Alaska for suicide prevention and community resilience. We're currently in the process of identifying and recruiting membership for the three primary oversight groups that Evan has already gone over and we've selected dates for our first EAC-RSC meeting to take place in Fairbanks in the winter. So, in a shout-out to anyone on the course who's from Alaska, please give a chat to us if you're interested in attending and participating. We'll be glad to share more information about that.

The second aim of our hub lays out our plan to increase capacity across our state for Alaska natives tribally engaged in driven research. There are two main campuses at the University of Alaska. The ANCHRR's home core is at the University of Alaska Fairbanks in the College of Rural and Community development and the Institute of Arctic Biology, but we also have a core at the University of Alaska Anchorage in the Center for Behavioral Health Research and Services. The UAF core will provide administrative along with logistics and other management support with additional data and analytical support coming from the UAA core. Students will be recruited to assist with the research study in the collaborative hub meetings so we're really excited to [inaudible 00:09:30] involve our large Alaska native student base.

Now, Lisa and Kim are gonna be describing in more detail our aims to collaborate with three regions in Alaska: the Yukon-Kuskokwim region, the Bering Straits region and the Norton Sound region to conduct a research study that will be focused on systematically describing the diversity in suicide rates within each of these three regions, with the goal to identify potential mechanisms that may be contributing to community resilience in relation to suicide.

The ANCHRR's administrative core will provide support for the research study in three key areas - data and analytics support, logistics, outreach and program management support - to engage tribal leaders and other researchers and national experts in the research study, and also to provide dissemination, social marketing and communication support through multimedia, virtual, print, in-person methods to better share our successes that Evan mentioned, and the findings from the research, more broadly across the state and possibly across the Arctic as our ANCHRR grows and matures.

Our final aim, overall aim, is primarily focused on sustainability. Too often when grants come into Alaska native communities or organizations, the research and services are time-limited to the life of the grant. Once the grant ends, particularly if the grant is supporting people in our researches that were brought in from outside of our community or from remote communities, it can be very difficult to maintain services or structures supported by those grant funds. So, with research grants this often mean that communities are left not knowing the results of the research that took place there, and may not get to experience the direct benefit from the research.

So, we aim with the ANCHRR to establish translational pathways from research to practice and ideally policy change, that support long-term, community-based and collaborative research models that promote those community-level and culturally-grounded interventions that we know are better at improving Alaska native health and mental health outcomes.

So, we proposed to demonstrate that pathway through the Alaska native community resilience study that we're gonna describe to you now, and with the creation of a state-wide tool for charting community resilience. The combined overall aims for our collaborative hub and research studies seek to build capacity at multiple levels for Alaska native engagement and leadership and research across the state, and even universities, and also within our Alaska native tribes or organizations within our communities.

With the Alaska hub, we'll continue to build on our success on the prevention of suicide and the growth of resilience. So now, over to you Lisa.

>> LISA WEXLER: Great. Thanks Stacy. This is Lisa Wexler. I'm gonna tell you a little bit about the community resilience study. Youth suicide constitutes a public health crisis. It's the highest priority to the Alaska Native community, similar to the vast cultural diversity associated with the term 'Alaska Native' that Evan touched on. There are enormous differences between communities and their suicide risk. In fact, some Alaska Native regions have the lowest suicide rates, and even within regions with high rates overall some communities had little or no suicide.

Reasons for the diversity in suicide rates between communities are not yet clear, and the ways in which communities are creatively and consistently supporting wellness can provide inspiration for others to strategically do so in our community resilience study. We hope to systematically describe and investigate what's working to reduce suicide risk at the community level.

The studies are based on previous community-level research that considered the relationship between community factors and/or cultural continuity in suicide rates in indigenous communities. These studies offer a way to understand and begin to strengthen community institutions, practices and resources that are associated with reducing suicide risk. Our study will describe what communities are doing, what resources are available, and how they are reducing suicide risk. This research will provide the information needed to develop a community tool for use by village residents who want to better understand how they can strategically strengthen their communities' protective capacities.

We are confident that we can begin to describe key protective capacities within Alaska Native communities, and have done so in a pilot study. This graph shows the results of measuring eight protective factors in ten rural Alaska Native communities. These factors included tribal self-governance, local control or influence over educational, health, child welfare and emergency services, and access to cultural activities, which can simply mean that the community has a building where people can gather for traditional dancing or ceremonies. The graph illustrates the relationship between the number of community-level protective factors and the annualized community suicide rates for the period between 2005 and 2013 for ten villages.

So, what we propose to do in a similar way, we'll consider protective factors within 65 rural Alaska Native communities and go further to describe the associated mechanisms illustrating how these factors work to increase protection and resilience. We want to look at services and their cultural responsiveness in their community over essential services. Qualitative descriptions of these factors and how they work in different communities will help us describe, for instance, how schools in certain communities engage with local elders in teaching youth, or how village public safety officers collaborate with tribes to ensure reliable and respectful law enforcement.

Community development factors include the level of collaboration across village institutions, transparency in decision-making and leadership, and opportunities for community members to engage in community-level endeavors, local control in Alaska community, self-determination in the form of local option laws as well as the enforcement of those laws. The community members' narrative about their village and their sense of social justice and opportunities within it are also important considerations to local control.

Cultural continuity refers to the ways in which village communities have worked to maintain traditional practices, the language and social roles such as elders mentoring youth. Importantly this factor also includes ways in which the community is engaged in decolonizing efforts that emphasize and respect for and centering around indigenous perspectives and practices.

We expect that the greater the number of these protective factors, the mechanisms, then we're gonna work with communities to figure out exactly how to measure those to lower the rates of suicidal behaviour and associate adverse events such as alcohol-related injuries.

Soon we'll describe what we hope to learn about how these community-level factors shape community members' interactions and influence youth well-being in six communities. Take it away, James.

>> JAMES ALLEN: Thank you. So, James here. I'm gonna hold the slide for a second. One of the many exciting prospects of the proposed aim for the research study is to describe and then test the contribution of these community-level resilience factors identified here in the Phase 1 qualitative research, in terms of individual youths' protective factors' outcomes from suicide.

In a previous work we've established the relationship of several individual-level predictive variables in individual youth outcomes that are directly protective from suicide risk. In this work, we also found a very brief global measure of community-level factors accounted for the largest amount of variance in a model that also used these individual-level predictive factors.

So, to better describe factors operative in community-level resilience and to more precisely establish the magnitude of impact in youth protective outcomes, we're going to develop a measure out of this qualitative work you see proposed before you, and then using state-of-the-art Item Response Theory approaches. We're going to test this in a subset of six communities.

In this next slide you can see, condensed, the community protective factors that Lisa has just described. We're also gonna use a more generalized measure of neighborhood climate and this will allow us to actually test the additional impact of these really Alaska Native community and cultural-specific community-level factors.

Now, what we intend to do is, on the level of adults, provide them and have them complete the survey in six of these communities that will provide an assessment on the community level of these neighborhood and community-protective factors. Then we will have youth complete these individual-level protective factors that include everything from communal mastery, to the perception of positive relationships with parents, to other observable variables including their connectiveness with the community.

And then in a mixed-effect multilevel model we intend to test their impact on youth protection from suicide as well as a co-occurring alcohol use risk, essentially looking at the magnitude of the impact of community-level factors as a moderator on individual-level outcomes.

And with that I wanna turn over to Stacy for a conclusion.

>> STACY RASMUS: Okay thank you James and Lisa and Evan. And so very briefly, because I know that we're right up at that 20-minute mark, we just want to very briefly show what we had proposed in the type of tool that we're hoping to develop as an outcome from the research.

In the three regions, which I had originally misspoken so we will clarify those three regions in just a minute, but this is the Charting Community Resilience in Alaska tool. Essentially, we're hoping to develop maybe potentially a smartphone app - a way for communities to chart their protective factors and those community-level mechanisms that support youth protection and resilience outcomes. So, what you're seeing here on the screen is just our very proto prototype that's translated onto a digitally produced composite of a village community context where we can identify the levels of extremes, the different kinds of protective factors, and then again how community user will be able to themselves choose and assess what kind...what mechanisms are gonna be valid in their community, and the different types of strategies that will most grow out resilience and protection.

So ultimately our goal with the research study and our hub in overall is to really produce serviceable tools that can be used widely across the state to strengthen our success stories. Thank you all.

>> ANDREA HORVATH MARQUES: Thank you all. Thank you very much. We really appreciate it. It was a pleasure to hear about this project, and that this is some very...I'm just gonna ask you some questions about...that we have here, and then we'll move forward.

So, a quick question is about the regions that you were gonna be working in the project and the question is: why those regions were selected and how other regions can also be participating.

>> STACY RASMUS: Okay and I think Lisa, would you like to deal with that question?

>> LISA WEXLER: Sure. So Northwest Arctic and Bering Straits and the YK are the three regions and those are the regions where we have long-term research relationships with the PIs on the team. And so that was the reason why we're working in those three communities.

>> ANDREA HORVATH MARQUES: Good. And is there any...the question was also related there other regions could be participating later and having information about the study.

>> LISA WEXLER: Yes, absolutely. So that is where the collaborative hub will come in. So, we're really hoping to funnel what we're learning into this Charting Community Resilience in Alaska tool that will be influenced by folks from all around the regions. So, the collaborative hub will have representation across the state and we will be bringing what we're finding as we go in the research project back to that larger group to get input and to better understand how we might make that translatable across the whole of Alaska.

So, there will be absolutely an opportunity. It's starting with our collaborative hub, starting with our winter first meeting if the folks that are listening are interested to be involved in this process.

>> ANDREA HORVATH MARQUES: That great. And so finally my last question to you right for now related to how you're gonna, in your vision, disseminating this practical tool for suicide prevention around your region.

>> STACY RASMUS: Well I think...this is Stacey and that again goes back to our Alaskan Native leadership structure that I think Evan had elegantly laid out in that for the broadest reach for disseminating findings from the research study, and the tool. We got multiple levels and layers of involvement happening with the Alaskan Natives. It's like an advisory committee, research and steering committee but the collaborative hub...we will really going to get that up as our primary dissemination network and we'll use multiple strategies for getting information out. I'm not sure Evan, if you have anything else you'd like to that question.

>> EVAN PETER: No, aside from getting into the details of the partnerships that we'll have with the tribal healthcare providers across the state, where we intend to be working collaboratively with them in developing models for distinct dissemination of the information so that it goes normally to all the providers themselves and then also to the community level.


>> JAMES ALLEN: If I may add, one part of the tremendous excitement of the ANCHRR is for twenty years we had hoped to have a hub. We hoped to have the resources to bring the many people from the diversity and distances that even worth describing together to share a lot of knowledge that normally we.... we work too much in isolation and this represents a real opportunity to truly collaborate.

>> ANDREA HORVATH MARQUES: That's really nice and we are really excited to be able to leverage the effort and having this hub and the network where we can all work together. Thank you so much. It was a pleasure to hear you all. We still have a few minutes so let me know if you want to add anything before I go to the next hub.

>> STACY RASMUS: No, we will donate our minute.

>> ANDREA HORVATH MARQUES: Okay. So, thank you so much. Now it gives me the great pleasure to introduce our next hub, the Southwest Hub for American Indian Youth Suicide Prevention Research, and Dr. Mary Cwik will gonna be giving the talk. Over to you, Mary.

>> MARY CWIK: Thank you Andrea. I'm honored today to be presenting on behalf of our whole team including Allison Barlow who works here with me at the John Hopkins Center in Baltimore as well as [Noveline Goblesh] who was one of our senior Apache leaders working in Arizona.

I wanted to start by showing the model that the Apache have developed in collaboration with our team for suicide prevention in their community. This is the working model. We changed it based on all of the community knowledge that we learned about through the years in addition to the quantitative and qualitative data that the Apache have gathered. I'm not gonna go through the whole model today but I wanted you guys to be able to see it. We've been working on this model since about 2001, and I'll highlight certain areas that our hub is going to focus on further in the model.

So, one thing that the elder strongly focuses...a hub, excuse me, focuses on is traditional knowledge. You'll see later in the slide that we have an elders' curriculum as part of our study design. In addition, we really focus on capacity-building so all of our interventions are delivered by our community members and community mental health workers, and in addition we also have a focus on providing better access to care.

So, on the White Mountain Reservation there's only one mental health clinic and it can often take hours to get to. It's not quite as challenging as Alaska but it's still a barrier nonetheless. And so, in our interventions we really are going to try to use technology and home-visiting model to really improve access to care.

In addition, we really have a focus on providing case management and crisis intervention. So, our Apache colleagues and tribal stakeholders have really prioritized helping youth in the community who are already engaging in high-risk behavior, the youth who had made suicide attempts or struggling with ideation or have engaged in binge-drinking in which we know is a serious...puts more of a big risk. In addition, we also have really focused on youth resiliency as well and so the elders' curriculum that I'll discuss shortly really has a focus on strengthening youth engagement in their cultural identity, values, learning the language, becoming reattached to school.

And lastly tribal sovereignty really underpins everything that we're trying to do. So, the surveillance system that's a part of our hub that I'll describe briefly, was tribally mandated. It wasn't a research or university-wide initiative but really a tribal-wide unique mandate.

Next, I'll go a little bit about the model and where we're coming from and narrow down to some of the logistics of our hub. So here you can see our hub partners on the map, and so the Center for American Indian Health where I work is where really what we consider as the technical lead so we're gonna do a lot of the organizing for the hub. And then we have several partners that we have what we're calling research-intensive partners which are our long-standing partnership with the White Mountain Apache tribe in Arizona that I've mentioned in addition to the Navajo Nation which spans different parts of Arizona and New Mexico.

In addition, we're going to have our satellite partners which are really our practice partners - it is really the best name for them - and that is the San Carlos Apache, the Hualapai tribe and the Cherokee Nation. And so those sites will be more focused on implementing best practices that our Apache partners have tried throughout the years, that I'll describe shortly.

Just like the other hub we have sort of a structure to try to make sure that our grant is the most successful as possible. And so, as you can see I've described it a little bit already, so we have what we might call the research core and the practice core. You can see how the different partners fall into that. And we're gonna have different advisory boards from each community. So, one of the key emphasis in our grant is that there is community feedback and buy-in throughout the whole process and that we'll have different committee members from the community representing them in all of these cores.

In addition, we're gonna have cross-site collaboration, so in addition to each of the tribes implementing their theories of activities we're gonna have time for us to come together and have webinars and really learn from each other. And I think really by having different communities and different tribes learn from each other we'll really be able to advance the field.

So, in our administrative or practice core you can see here are some of our aims and activities and so I will do my best to summarize this here for you. So, our first aim is really again for that to really sort of provide oversight and coordination of all the activities because we know that can take a lot of time for the different tribal communities and their partners who are just trying to implement the best practices.

So, we're gonna really work with all of them to develop a five-year plan - that's the length of the grant - so that they can really come up with a vision for what they hope to accomplish over the time of the hub. We're gonna be available to provide ongoing technical assistance to them, including on problem-solving barriers if they've started implementing suicide prevention practices. And then we're gonna help them to monitor their progress because we know that a lot of the time the folks are doing great things out there in their communities and they often just don't...might not have the time to document them in all the different kinds of the ways that are in NIMH and that the research field might like, and so we're gonna try to help them with that in the way that they would like to do.

Then for our second aim, again we really wanna have...we really believe that communication is key and so our second aim is really about the communication. And so, we're gonna have sort of regular call schedules and hub meetings including one in person per year where everyone from our different hub site can come together to share what they're doing, share their challenges, learn from each other, have them guest speakers. So, I think that's one of the parts I'm most excited about. In addition, we will be available to kind of help any sites if they need it to...if they want to share what they're doing at their site or at different conferences or in different kinds of publications to help provide the poor to do that.

Our third aim for the practice or administrative core is really to do more outreach and dissemination. We know that that has been a challenge for us in the past, and it's true for other research groups as well, that we might do this great study and then we put them in journals and the community knows about them but we don't always do a great job making sure others know about our findings or making them be user-friendly. So, we're gonna have...we have a communications director here at our center and she is gonna really help us with outreach to media outlets, providers, service organizations, to hosts of webinars, and have newsletters that will go across the hub, but after that we'll go out nationally as well.

I have mentioned before that the cornerstone of our hub is that each community will have a community advisory board informing their activity. So here you can see a little bit of the details about the advisory board and how we have asked them to structure it, so we'll really try to have broad representation across different stakeholder groups. And we also really want those advisory boards to help us plan what we're gonna do over the five years, help with interpreting any findings that come in so they'll really have a key role.

The next part of our grant that we think will really help with making it a success is we are gonna utilize an idea of paired teams. And so, we have used this before locally with Baltimore Hopkins in our Apache partnership, and you can see here some of my Apache colleagues on the slide, and you'll see [Noveline Goblesh, who’s a] key team member is on the left-hand side. What we're really gonna do is make sure that everybody has a point person in the grant so folks don't get locked in the shopper lot. So, there might be a university-based partner or research-intensive partner who paired with someone from one of the communities, so that way if they have a question or issues they can go right to that person and not feel lost about knowing who to email or where to get resources.

In addition, what we're going to try to do is try to use technology. So, we have two key technologies that we're featuring. So, one is called Basecamp and some folks may be familiar with it, and it's really a team management communication tool. So, it really helps all our teams to be together and organized so we can have calendars, weekend post resources, they'll be able to talk across teams. So, we're gonna use that to make sure we have great communication.

And then we're going to utilize a program called COMM Care which will allow us to switch our paper-based surveillance system into a tablet-friendly version. So, I have indicated a little bit that surveillance is one of the key cornerstones. The Cherokee and Apache have decided to mandate suicide surveillance in their community and it has really allowed them to gather great community-specific data on trends and patterns and how that changes over time in the community to be able to get more resources and better target their program, and you can read about the surveillance here on the slide.

In addition to what it has done, it is not just about data gathering. What happens with the surveillance is that a community mental health worker then goes out and makes an in-person connection with the at-risk individual, listen to their story, then gather some data, and make sure they get connected to care. In addition, if they seem to need more than a one-time visit the community health workers will follow up with them over time.

And so here you can see the process that I've just laid out and the tribes are readily sharing sort of the form, that we have a couple of papers about the process that folks would like to read more about it. And then this process is where a lot of our practice partners are really wanting our help. They're interested and that's why they decided to partner with us on this grant, if they're interested in implementing surveillance and follow-up in their community taking our model and modifying it.

So here, for those of you that are interested you can see the steps. So, the one thing is we have lots of paper forms from that surveillance overview. It was all paper-based. And so, our staff, which is why we're gonna talk about COMM Care next...we're really spending a lot of time doing data entry and then validate that data, because with any data we want to really make sure it's rigorous and with the evaluation especially sensitive.

And so, we were really realizing that they would much rather be out in the field helping their community members and so that's why we're switching to this COMM Care system which is a big part of our grant here. It will also us to do different things where we can sort their case management list by risk, geographic area, give them real-time reports, and I think it will really help them to prioritize and really be efficient and help the community in the best way possible.

Then here in the next list for last few minute I'll talk about the research project that we're conducting, and here it's really built on the long-term partnership over twenty years that Apache and John Hopkins University has been working together. And through some of our different multi-tiered efforts they have been able to see, for different of slices of time, decreases in the suicide rate up to 38 percent. However, there still is suicide in the community. We haven't been able to reach zero suicide. And so, we really felt that we were in need of cultural healing modalities to really bridge the gap by some of the Western models that were currently being used.

And what we're doing is we're combining two different interventions, and here you can see our age group that we're targeting. And so, one is called New Hope and it reduces imminent suicide risk. It teaches things like safety planning, emotion regulation, and it facilitates connection to care. And then our newer intervention is an Elders' resiliency curriculum, which we really view as a long-term strategy to promote resilience in these at-risk youth by increasing their connectedness, their self-esteem and their cultural identity and values.

Just to give you a sense we did a little bit of pilot data on both interventions. So, for New Hope we've seen some decreases in depression for, then the pilot study, in addition to decreases in the negative cognitive thinking. And then this slide will show you there have been some decreases in suicidal ideation as well as increases in service utilization, which is one of the goals of that intervention.

For our Elders' curriculum, the results are in a different form but to me they're even more exciting to look at. And so here we can see that the students who's done a version of our Elder's curriculum were really enjoying that and were learning things about their culture and their language and their values.

And here you can see some quotes from some of the youths that participated in our Elders' curriculum and they were just really inspiring. Our Elders' are just one of our real strengths of our program.

So, what we're gonna do I don't have probably the time to go through every single thing, but probably you can see here our hypotheses...and they're letting me know that our time is up so Andrea, I don't know if you want me to take a minute or two for question time or just pause here.

>> ANDREA HORVATH MARQUES: If you wanna I can give you one more minute to finalize them. Then I can go over onto the questions.

>> MARY CWIK: Perfect. So, I'll just let you guys know that our primary and secondary outcomes, we're looking at changes in suicidal ideation. So, we're hoping to decrease that and increase resilience with these interventions, and we're gonna do it using a smart design study. And you're not meant to understand everything about this design.

We have some experts on our team. They're helping us with it and they'll really allow us to put these interventions in different orders and have youth get different sequences so we can really understand the true impact over time and to notice that we get to follow the youth over time so we'll have a flexible time point.

And here you can see that we're gonna be able to understand some mediators and moderators. And lastly, we're gonna talk all of our hub partners about which parts of these interventions they like and they think are feasible in their community, and try to disseminate these strategies to our partners. And I'll go ahead and stop there. Thanks Andrea for the extra minute.

>> ANDREA HORVATH MARQUES: Thank you so much Dr. Cwik. It was a pleasure to hear about the project and we're really excited also to work together. I'm gonna ask maybe the more general questions that I'm gonna put for the end and then I'm gonna ask you a question about of how...if there is any vision to expand this surveillance system that you're using in all the regions.

>> MARY CWIK: Yes, we definitely do. We get interests from all over, not just the Southwest. For sure we have some groups in Washington State that are in various stages of implementing the surveillance system and I think the COMM Care new application will really help with that. So, the folks are always welcomed to reach out to us even if they're not in the Southwest.

>> ANDREA HORVATH MARQUES: Great, and for all the speakers people are also asking about sharing your contact information. They are willing to ask some questions if they're not here today and I'll ask them if they'll be able to share with us any new information on site.

And so, thank you so much Mary. I'll leave out the other questions for later so then we can move on to our next speakers and our next project. We're gonna be presenting the Preventing Suicide Among Urban American Indian Youth and Young Adults, and Dr. Spero Manson is gonna be starting. So over to you Dr. Spero.

>> SPERO MANSON: Thank you Andrea, and Dedra and I will be sharing the presentation. And a good day to all of our colleagues and each of those of you in the audience in general for the opportunity to share. I think this is important work that's been a long time in coming.

So, our particular hook focuses on the urban American and Alaskan native youth and young adults on suicide and its prevention. So, we'll begin with a quote that I think probably captures the experience of many of the providers and our respective healthcare facilities, not just in urban and suburban America but also in rural and reservation communities as well, which really underscores the enormous burden, frustration and sense of helplessness that many of our clinicians and other providers experienced when presented with suicide and its consequences in our respective communities.

The previous presenter hinted at the extent of the nature—the extent of suicides and its causes in our community. You can see it from this slide in fact. It’s more than six times higher than the white counterparts in our respective communities, and our youth and young adults bear a disproportionate burden of the risks associated with that.

However, we really know that these statistics which derived largely from research in rural and reservation communities do not give us a sense of what the circumstances are in our urban and suburban communities in which that original quote anticipated. They became known as the 'invisible tribes' and the enormous burden and challenges that they face in day-to-day life.

We know from this that suicide also occurs with alarming frequency in urban areas as it does in the rural and reservation communities, and of course our cities are home to over 72 percent of all American and Alaskan natives so it's an enormous segment of our population, and that the youth and young adults living in urban or suburban America face notably higher risks of attempted suicide in comparison to their non-native counterparts.

There is available evidence that suggests that there are a number of contributors in fact are echoes in terms of the risk profiles of those who were guided in rural and reservation communities.

Importantly here too is that more than one-third of American and Alaskan native dwellers are served by 34 urban Indian health organizations, UIHOs, that are located in 19 states, but these urban Indian health organizations by and large are poorly equipped to address these kinds of concerns. And then it was that sort of circumstances that has driven the particular aims of our urban hub, and the first is to engage this large, sophisticated pre-existing research network of academic institutions in our urban Indian health organization partners to conduct highly relevant, scientifically meritorious work that advances the state of the art in suicide prevention in this particular population.

It begins, as we'll talk about in a little greater detail in a few moments, with us evaluating the screening and bringing interventions to probe for treatments as be by our SBIRT program that is coming on two of our largest urban Indian health organizations in the United States. So specifically, [inaudible 00:48:14] help for the First Nations community help source to identify and address factors that affect the implementation and subsequent prevention of suicide among our youth and young adults. Then based on that, marrying it with a randomized, controlled trial of the effectiveness of enhancing these efforts by sending caring text messages to increase resilience through social connectedness and engagement and thereby reduce suicidal ideation, attempts and hospitalizations.

Specifically, for us is promoting a systematic economic evaluation of these two adapted versions of the SBIRT model that will be examined carefully within the context of our urban Indian health partners, and ultimately to expand the research capacity of our partners through the urban Indian health organization network.

For organizing home for this work is in two major studies. First is at the Centers for American and Alaskan Native Health located at the University of Colorado and [inaudible 00:49:17] campus which I have the honor directing. They have a large variety of national centers that provide the platform from which much of our work springs and you can see here the nature and extent of that collaboration in terms of its resources and historic collaboration with many of our tribal partners.
The second major partner here is the Partnerships for Native Health with [inaudible 00:49:39] direct out of Washington State University. It too had a large array of resources and a long history of collaboration particularly within the context of participatory research models with an array of different kinds of tribal healthcare and even agencies across the country.

This is basically our team and myself. There's a medical anthropologist, there's the PIs joined by Denver in the internet. As with the other principal investigators, we have a very skilled and experienced biostatistics, and the epidemiologist Carmen Miller who directs the methods core. We have a health economist John Murphy from Cornell University who directs the economic analysis for us and of course is joined by Tasey Parker from the University of New Mexico, with the professor and vice chancellor is there. She herself is Seneca served as the President of the board for First Nation’s Community Health Source.

Linda Son-Stone the CEO for that agency. We're also joined by our partners of the Seattle Indian Health Board Ester Lucero [inaudible 00:50:47] administration of [inaudible 00:50:51], and [inaudible 00:50:53] MQ who's [inaudible 00:50:54] who's our local project coordinator at [inaudible 00:50:57] traditional healing program. And then we have two research scientists U. Tsosie and Laurie Moore who are the essential coordinators for this.

We're joined as well by Dr. Novins who's the [inaudible 00:51:12] psychiatrist and professor at the University of Colorado. I think he's already well-known for all of you [inaudible 00:51:17] in this regard. And of course, Denise Dillard [inaudible 00:51:20] and Jody Trojan and in a few moments, we'll talk a little bit about the nature of their work and how it contributes to the efforts, and Dr. Dillard is of course the Inupiaq and directs the research department at the [inaudible 00:51:34] at the Alaska Native Medical Center.

Jody Trojan has for twenty years worked with Alaskan native organizations and communities around a broad range of projects, not the least of which are the current [inaudible 00:51:47] efforts. We are also by joined by K. Comtois who is particularly experienced in the extension of this kind of approach of using mobile technology, particularly carrying texts to a variety of different populations. And then last but least Abigail Echo-Hawk that's recently appointed director of the Urban Indian Health Institute which is the tribal epidemiology center for all the urban heath organizations in the country.

Speaking of which you may not realize this but there are 33 urban Indian health organizations across the country that range in terms of the nature and extent of services that they provide to their constituents all the way from a comprehensive clinic to a limited-access clinic and ultimately those that provide basic outreach and referral. The [inaudible 00:52:40] and First Nations are two of the most comprehensive and largest of these, and are at the leadership level with respect to setting the tone and providing examples of what can be done to this particular effort.

So just recently First Nations Community Healthsource is located in Albuquerque, New Mexico. It has a very extensive program that provides medical care to over four thousand primary care patients between 12 and 13 and 34 years of age which is our basic target population. They currently employ SBIRT for alcohol abuse in 2010. We'll be elaborating on that with respect to suicidality

The Seattle Indian Health Board located in Seattle in King County of Washington State of course serves a very large population of 35,000 American and Alaskan eligible consumers who are at risk for suicide for a variety of different reasons including poverty and unemployment, or dropped out and et cetera, et cetera. They too provide medical care for well over three thousand patients aged 12 to 34 in each year, and they've just begun using the SBIRT model in primary care. We'll be enhancing that to include suicide screening.

So, let me turn to the intervention itself which we call SPUNKY and some of the background and methods. The first set of aims set of our intervention has a focus on the screening for [inaudible 00:54:07] treatment SBIRT. SBIRT has become an accepted evidence-based practice for preventing or ameliorating alcohol abuse and dependence, especially in primary care settings. And indeed, the national strategy for suicide prevention action plan that came out that I had the privilege of contributing to, recommends that SBIRT be considered for early detection, triage and management of young people at high risk for suicide and that's in fact what we're doing in our specific aim.

The next slide is a little complicated but I understand the presentations will be available to you. It basically shows you the structure and process for the screening and the management and triage of individuals to identify their risks for suicidality. The rectangular box indicates patients' status in that aspect, the red arrows highlight points in the process that risks for drop-out, and complications in terms of reducing coverage and effect this unfit. And we will be using that SBIRT screening process to identify the individuals who will be targeted for assignment to the various conditions of those same types [inaudible 00:55:23] randomized controlled trial. So Dedra [inaudible 00:55:27] in detail.

>> DEDRA BUCHWALD: Thank you. So, our intervention is based on something called Caring Contacts, and Caring Contacts is the only intervention that is actually being shown in a randomized controlled trial to prevent suicide. In the original study, there was 843 patients discharged from an impatient unit for depression or suicidality and then were randomized to basically care as usual versus contact with a brief non-demanding letter for four years. And the study found a great benefit in the first two years when suicide risk was highest. As you can see it reduced suicide deaths by about half.

Interestingly 75 percent of patients - and this was in the time of letters - sent back grateful messages to the investigators. Subsequent studies have been conducted worldwide in multiple cultures with various intervention periods, various contact intervals and various delivery methods, so postcards, letters, calls, but not text messages. We decided to use text messages because as Dr. [inaudible 00:56:48] experienced with the military where she is implementing a very similar trial using text messaging to reduce suicide and it's been very successfully accepted so far.

So, a little bit about text messaging and suicide intervention, first of all most American Indian and Alaskan natives own a mobile phone and the vast majority often use it for texting, and this comes from various surveys that we've done in various sites across the United States. Mobile phones are increasingly used to treat addictive and psychiatric disorders, and there are small ongoing studies in Asia, Europe and the US which are pilot texting to prevent suicide.

So, our specific aims related to the RCT are two-fold. One is to conduct a randomized controlled trial of the effectiveness of this enhanced SBIRT intervention by sending caring text messages to increase resilience through social connectiveness which is the key construct for this intervention and engagement and thereby reduce suicidal ideation attempts and hospitalization. And then as Spero mentioned we're gonna perform a systematic economic evaluation of SBIRT and the SBIRT-enhanced intervention.

So, our conceptual model is based on the Interpersonal Theory of Suicide and you can see a brief schematic here in which suicidality is reduced by improving retention in SBIRT which promotes resilience by increasing connectedness and that's through texting. As you can see, we look at social connectedness as a possible mediator. And prior research has actually validated this theory among the native population.

So, eligibility for that Spero mentioned we're focused on adolescents and young adults. They will need to complete the brief intervention component of SBIRT and screen positive for risks of suicidality but be hospitalized or in danger of imminent self-harm. And of course, they must have a text-enabled mobile phone and be willing to receive the texts that are part of the intervention, and of course not be cognitively impaired, and for minors we need parental consent.

So, the actual intervention is actually two interventions. We have two versions of SBIRT+ text messaging. One is a 6-month intervention and one is 12 months, again versus SBIRT as it's just simply implemented at the site. The message content and frequency for both groups will need to be finalized during our adaptation process. In the actual intervention in the first six months both groups will receive about eight caring texts, again depending what were informed by the site, within 24 hours of enrolment or a week after enrolment and as you see over several months and then with a message on the person's birthday.

In the out-months the participant in the SBIRT+ 12 group will also receive text messages monthly and again on their birthday. Of course, we're going to provide a number for them to contact if there's some immediate concerns about their self-harm.

The procedures: we need to develop the text messages, finalize the LifeWIRE process which is the automated interactive platform that sends messages, we'll have a backup where we'll send letters to participants' homes if we can't find them by text messaging, we have to train our coordinators and our supervisors that are to sites, we need to set up an enrolment site so we can collect data in a private area, and then individuals will be randomized after the baseline visit in equal proportions to these two groups, and then of course we'll collect follow-up data at the appropriate interval.

This is an actual cartoon of the design and you can see at the top they're seen by an expert clinician, they are randomized to these three groups, they get different intervals with the text messaging, and then there's the 6 and the 12-months follow-up.

So, our primary outcomes are suicidal ideation, self-reported suicide attempts and actual treatment-seeking primarily hospitalization. We use some measures for all of these that have been validated in native populations. We also have secondary outcomes - retention and social connectedness - which as you saw were the main component in our conceptual model.

We have some other measures that we're using. Again, most of these have been selected because of their prior use in native communities. We have a resilience measure, we have mortality outcomes, substance abuse, depressive symptoms. Obviously, we get demographics. And then we're going to look at intervention dose in terms of how many texts received and do a reception survey.

So, we have a sophisticated data analysis component. We use a multi-step approach to evaluate actual mechanisms. Just briefly, retention is as I mentioned one of our primary outcomes. We use ordinal logistic regression to estimate SPUNKY's effect on retention: full, partial or no retention. For social connectedness, we use linear regression to examine the association connectedness and suicidal ideation.

And then we use generalized estimating equations to estimate the effect on connectedness over the follow-up period, both 6 and 12 months to determine whether SPUNKY increases actual social connectedness. And then we're looking at within-person change in connectedness and suicidality at follow-up to see whether social connectedness is associated with improved outcomes regardless of any of the three group assignments.

So that's the brief overview of the randomized controlled trial portion. Thank you for your attention. I'm happy to answer any questions.

>> ANDREA HORVATH MARQUES: Thank you so much and it was an honor to hear about your project. We're already excited about it. I'm gonna go and start asking some questions now that are coming.

The question is how you make sure the form...they not get disconnected towards the end of the month.


>> SPERO MANSON: I'm sorry. This is breaking up. I couldn't hear the question.

>> DEDRA BUCHWALD: Yeah, I couldn't hear it either.

>> ANDREA HORVATH MARQUES: I'm sorry. Can you hear me now?



>> ANDREA HORVATH MARQUES: The question is about how you're gonna ensure the...about the form...whenever you're sending the message you gonna be sure that people are receiving the message and how does it work in this process.

>> DEDRA BUCHWALD: So LifeWIRE tells you whether the message was received, and of course the individual can respond. If the message is not received or we get the message and the phone has been disabled or something, or any other indication that the recipients are not getting the message, we have three or four different ways to connect with the patient or individual.

So, we're able to send letters. That's why we have the backup letters to their guarantor which is recorded in their clinic chart - parents, spouses. So, we have a number of different backup addresses that we can use. We also did surveys to find out how many people have had the same phone number for what period of time, and contrary to what we perhaps thought the vary majority of people have had the same phone for at least a year or two, so the numbers are stable.


>> ANDREA HORVATH MARQUES: Yeah and just like that was a question regarding to that about people changing phone number and how you're gonna be addressing that.

>> SPERO MANSON: And I think that answers that. Right, Dedra?

>> DEDRA BUCHWALD: Yeah, I think-

>> ANDREA HORVATH MARQUES: Yes, sure. So, another question the text messages people are gonna be receiving from somebody they already talked with, or it's gonna be an automated system?

>> DEDRA BUCHWALD: It's an automated system but it can be programmed to reflect who the person talks to, or it can be programmed to reflect other standard elders in the community. I think some of that is going to need to be refined in the adaptation process. In some of these communities it may be preferable to have messages from different types of people but it can be programmed.

But let me say they're not individualized in the sense that "I saw you on Thursday" and such and such and "You said this and that". The messages are a tweet of messages that have been reviewed and approved by the communities and they are sort of standard messages, so we don't have the capacity to send everyone individualized messages.

>> SPERO MANSON: I think it's important to remember too that this is an enhancement of tiers of various degrees of the screening brief intervention referral for treatment model which underpins the entire study, so it's the clinician that will go help and consult them. Here she is called in those...attached in those primary care themes. It's the principal point of contact and if we use [inaudible 01:08:01] who we use for that [inaudible 01:08:05] but they are also one of the principal components of the safety net with respect of those individuals. So, this doesn't replace the SBIRT intervention. It enhances it.

>> ANDREA HORVATH MARQUES: That's perfect. That's great. And so, another question is that maybe you share a little bit with us. Spero you mentioned about the systematic economic evaluation that's gonna be the form. And then I'll like you to say some more about why is that important.

>> SPERO MANSON: Well that's a great question. This work we began in 2001 with Dr. Dillard in the Southcentral Foundation, funded initially by Sampson something called the Depression Collaborative where we built into their primary care teams, introduced for them what we call behavioral health consultants - master-level clinicians who are equipped to screen initially then for major depression and based upon how the [inaudible 00:60:05] is screened, and during that primary care encounter were then referred by the PCP, the primary care provider, to the behavioral health consult for a complete assessment and intervention which was tiered then upon the levels of severity

That particular process identified that with each of the years, following with that approximately 27 percent of the total patient population seen in the primary care center there in the Southcentral Foundation was qualified at a high risk for serious depression and 91 percent of that 27 percent had never actually disclosed to anyone else of their depressive symptoms. And it had a very remarkable penetration as well as subsequent follow-ups and increased treatment in this with those individuals.

Based on that the state of Alaska revised the PCP codes so that Medicaid reimbursement became possible and Southcentral Foundation now have 36 behavioral health consultants, one attached to every single primary care team. They have expanded through Medicaid so it has become totally self-sustaining.

That has now expanded to Chief Andrew Isaac's clinic in Fairbanks, Alaska, and we believe that the economic evaluation of the impact of this kind of an intervention is absolutely critical to being able to document the cost-effectiveness of it and to quality urban Indian health organizations to seek reimbursement for the provision of these services and towards sustaining this platform as well.

So that's why we believe that a cost analysis and an economic evaluation is absolutely critical to what they've done in terms of its financing policy or potential.

>> DEDRA BUCHWALD: And I think the other piece of this...that's the implementation piece but there's another part of this which looks at lives lost, qualities and dollies and the kinds of metrics that health economists use, and youth suicide obviously had an enormous impact on the community.

>> ANDREA HORVATH MARQUES: That's great. Thank you. So just one last question for you and then I'm gonna open it also for everybody. There are some general questions that everybody can help us to answer, but regarding the text message, one more question related is that going to be a link to a crisis line in the text message?

>> DEDRA BUCHWALD: No. There is information that participants can access. The models that I am aware of that have been used, they don't have necessarily a link. They may have a phone number that people can call but they don't have a link like to a website or anything like that.

>> ANDREA HORVATH MARQUES: Great. So now I'm going to open also for general questions and then I'm going to summarize. One of the questions that was at the beginning and then probably one of the questions are also for the all the hubs, but one of them is how people can get access to a specific village's suicide rate. If your expertise is on the network then that's also something that we're gonna help. How can we help people to have a specific village's suicide rate? Anybody can answer please?

>> MARY CWIK: Can you repeat that?

>> ANDREA HORVATH MARQUES: The question was how can [inaudible 01:13:03] a way to get access to the data regarding a specific village or a specific community about suicide rates.

>> LISA WEXLER: This is Lisa.


>> LISA WEXLER: The Alaska death Violent Death Reporting System keeps track of that. As far as specific names of villages and their specific suicide rates, that's a little bit tricky because of confidentiality and the importance of protecting that for individual villages but there is. You can...yeah, so you can request the identified group of villages and see the differences there.

>> SPERO MANSON: From this is Spero and with respect to the urban Indian community, Abigail Echo-Hawk who directed the Urban Indian Health Institute, the tribal epidemiology center for urban community, is the principal contact in that she receives every nine months a download from the National Data Warehouse with that kind of information about where attempts and completions are located but again as with Lisa's, of concerns and constraints of they will not identify by region. It's only in terms of the national aggregate.

>> ANDREA HORVATH MARQUES: Thank you. Anybody else wanna mention anything? I think we have a good answer but if anybody wants to say anything just let me know. Okay. So, I'm going to the next question. It's saying that all the information about this webinar is being recorded and will be in our website so people can have access to that later on. Also in the website, we have more information about every speaker. We have a curriculum, a summary of everybody. So, we...but we don't have too much time here. I wasn't able to share with you all the expertise our speakers have but you're gonna be able to see and check this online. And let me see if there is any more we have for the questions here.
And then one more question is that by the end if anybody wants to share their content and how the community and get in touch with you all, to get more information how to participate or how to get more information about the study.
We want to remind you that we also have an online NIH. The summary of the studies, the public have access to that and we can provide you the link but all the PIs also. The speakers and provide some contacts for you all.

>> SPERO MANSON: For those interested in regard to the SBIRT effort and experiences in Southcentral Foundation I think you can start at this. In NIMH PubMed you'll find probably a half a dozen or more articles specifically wrote by [inaudible 01:16:42] and colleagues describing that in detail and much of the evidence behind its impact.

>> DEDRA BUCHWALD: And yet not a lot has being published on the text messaging studies that I'm aware of. We have a couple of smaller ones but the big studies out of the military that [inaudible 01:17:02] I don't believe has any publication yet.

>> ANDREA HORVATH MARQUES: Great, thank you. So, as we do have a few minutes left, I will ask one of each group if you want to give a final word. And then I'm gonna give you a little summary of our webinar. So, if we can start with the Alaska Native Collaborative Hub, if one of you can just give us a little last word about it?

>> STACY RASMUS: I'm gonna turn that over to Evan.

>> EVAN PETER: Yeah. So, before I jump in to the last word on ANCHRR I do want to announce that UAF has co-produced a film called We Breathe Again which followed the lives of four Alaskan native people over a two-year period, one of them longer than that, documenting the impacts of inter-generational trauma and suicide, and the film was picked up by America Reframed for national public television broadcast so it will be broadcast nationwide on September 26th at 8pm Eastern Time. Probably you can look at it through local PBS stations if it will be broadcast locally there. So, I wanted to share about that announcement on that film.
But beyond that our team is very excited about ANCHRR taking root and outreaching throughout the state Alaska to really being together the many leaders, researchers and practitioners that have been doing work and have been focusing on addressing this issue so that we can really expand and learn and grow with one another and also appreciate the connection more broadly to the other hubs across the nation, so we thank you.

>> ANDREA HORVATH MARQUES: Thank you. Then I'll pass over to Southwest Hub. Mary Cwik, please?

>> MARY CWIK: Oh, yes. I just wanna echo what Evan said and also to acknowledge and thank NIMH for having the vision to put these hubs together. I think the way it's designed is really great If there's practice components, research components, so that we can really all learn across tribes and from each other. I think it's really gonna take field forward and I think even non-tribal groups, I think, can learn a lot from the research and the practices being done in tribal communities.

>> ANDREA HORVATH MARQUES: Thank you so much Mary. Now I'm gonna pass to the Preventing Suicide Among Urban American Indian Youth and Young Adults.

>> SPERO MANSON: Well let me echo my colleagues. I'm also delighted to have the collaborative nature of this initiative. Let me also underscore the fact, something that hasn't been mentioned, that this in fact isn't an initiate that's led by the National Institute of Mental Health. It involves the National Institute of Minority Health and Health Disparity which has been setting the tone and stage for the pursuits of minority health and health disparities research across the national institutes of health.
So, to see these two sister institutes work together leads me to encourage that our nature's agenda in this regard will be much more aggressive and in point than it has been prior to your arrival, Andrea. So, thank you for your leadership in that regard and thank you too to NIMHD.

>> ANDREA HORVATH MARQUES: Thank you and thank you for bringing that up. I was going to address this because we also...I want to let everybody know that NIMHD is also supporting this initiative. It's part of NIMH but NIMHD is also financially supporting this effort and we got working together on that. So, thank you for bringing this up. I was going to mention that in my final, but thank you.

And so just to finalize now, I would like to thank you all. We are very excited and honored to have you all to fund these three projects. We're gonna be five-year projects here, that we're all gonna be working together, and we are very honored to have all three here in our webinar. I want also to remind you all that we are transferring the health model from our office's experience in global mental health, bringing back to US to address a major public health issue. It's that suicide among American Indians and Alaskan natives.

So, we're very happy to be able to leverage and move on in this project, and I would like to finalize saying to remind you that with a collaborative hub we will address research to develop and test culturally relevant preventive strategies and interventions that could reduce suicide and increase resilience among American Indians and Alaskan natives.

And thus, finally we want to remind everybody who are seeing the hub. We serve as a network of investigators and partners whose activities will aim to reduce the burden of American Indians and Alaskan natives. I would like to thank you all to participating in this webinar, and if you have a question with you and it was not able to be answered right now, I'm going to also send it to the presenters and they will answer you if possible. And then I would like to remind you that everything is gonna be recorded and we gonna be having that on our website.

Mental Health Disparities
August 29, 2017

Q&A Log

1. Sue: I am a mental health consultant for Head Start with many communities in the Bethel area. Is there a way to get access to the data regarding specific villages regarding suicide rates?

2. B LaFromboise: Will you be including adolescent focus groups and individual responses?

3. C Lemieux: How can we get access to the curriculum?

4. Irene Cho: Will the slides be available after the meeting?

5. Dustin Richardson: Would it be possible for Mary to share her contact information if we have additional questions?

6. Carolyn Coley: What are the components of the text message?

7. Patricia Henderson: Dr. Buchwald, how will you ensure the phone do not get disconnected towards the end of the month?

8. Stephanie Gregory: Will the text messages be from people that the text receivers know? Or will they come from strangers?

9. Roberta Moto: Cell phone numbers change might be a problem.

10. Stan: Are the text messages unique and personal or they automated?

11. Roberta Moto: Is there a link to a crisis line in the text?

12. Patricia Henderson: Will the intervention take place in urban communities??

13. Stan: Is part of your system include advisor consultant and Elder self-care in case of suicide loss? Do you provide care for your system providers that are directly affected by a suicide?