Pilot evaluation of a Psychological First Aid online training for COVID-19 frontline workers in American Indian/Alaska Native communities.

Introduction: The COVID-19 pandemic exacerbated mental health concerns and stress among American Indians and Alaska Natives (AI/ANs) in the United States, as well as among frontline workers responding to the pandemic. Psychological First Aid (PFA) is a promising intervention to support mental wellbeing and coping skills during and after traumatic events, such as the COVID-19 pandemic. Since PFA is often implemented rapidly in the wake of a disaster or traumatic event, evidence evaluating its impact is lacking. This paper reports pilot evaluation results from a culturally adapted PFA training designed to support COVID-19 frontline workers and the AI/AN communities they serve during the pandemic. Methods: This study was designed and implemented in partnership with a collaborative work group of public health experts and frontline workers in AI/AN communities. We conducted a pre-post, online pilot evaluation of a culturally adapted online PFA training with COVID-19 frontline workers serving AI/AN communities. Participants completed a baseline survey and two follow-up surveys 1 week and 3 months after completing the PFA training. Surveys included demographic questions and measures of anxiety, burnout, stress, positive mental health, communal mastery, coping skills, PFA knowledge, confidence in PFA skills, and satisfaction with the PFA training. Results: Participants included N = 56 COVID-19 frontline workers in AI/AN communities, 75% were AI/AN, 87% were female, and most (82%) were between the ages of 30-59. Participants reported high satisfaction with the training and knowledge of PFA skills. Pilot results showed significant increases in positive mental health and social wellbeing and reductions in burnout from baseline to 3 months after completing the PFA training among frontline workers. There were no changes in communal mastery, coping skills, stress, or anxiety symptoms during the study period. Discussion: To our knowledge, this is the first pilot evaluation of a PFA training designed and culturally adapted with and for AI/AN communities. Given that many AI/AN communities were disproportionately impacted by COVID-19 and prior mental health inequities, addressing acute and chronic stress is of crucial importance. Addressing traumatic stress through culturally adapted interventions, including Indigenous PFA, is crucial to advancing holistic wellbeing for AI/AN communities.

Developing the Feast for the Future Program through a Community Visioning Process.

BACKGROUND: Three tribal communities in the Southwestern United States have a long-standing partnership with the Johns Hopkins Center for Indigenous Health (JHCIH). OBJECTIVES: In response to community concerns about obesity, three tribal communities and Johns Hopkins Center for Indigenous Health partnered to develop culturally relevant plans for a new program. METHODS: Using a "community visioning" process, a community advisory board (CAB) from each community identified opportunities, challenges, goals, and visions for their communities. The CABs consulted with experts in pediatrics, nutrition, food distribution, agricultural restoration, and community and school gardening. RESULTS: The CABs developed seven components for Feast for the Future: 1) Edible School Gardens; 2) Traditional Food-ways Education Program; 3) Community Gardens, Orchards, and Greenhouses; 4) Farmers Markets; 5) Farmers Workshops; 6) Family Gardens; and 7) a Mobile Grocery Store. CONCLUSIONS: A community-based participatory action research (CBPAR) process was critical to developing a culturally appropriate program that built on community strengths.

Centering Community Strengths and Resisting Structural Racism to Prevent Youth Suicide: Learning from American Indian and Alaska Native Communities.

The persistence of extreme suicide disparities in American Indian and Alaska Native (AI/AN) youth signals a severe health inequity with distinct associations to a colonial experience of historical and on-going cultural, social, economic, and political oppression. To address this complex issue, we describe three AI/AN suicide prevention efforts that illustrate how strengths-based community interventions across the prevention spectrum can buffer suicide risk factors associated with structural racism. Developed and implemented in collaboration with tribal partners using participatory methods, the strategies include universal, selective, and indicated prevention elements. Their aim is to enhance systems within communities, institutions, and families by emphasizing supportive relationships, cultural values and practices, and community priorities and preferences. These efforts deploy collaborative, local approaches, that center on the importance of tribal sovereignty and self-determination, disrupting the unequal power distribution inherent in mainstream approaches to suicide prevention. The examples emphasize the centrality of Indigenous intellectual traditions in the co-creation of healthy developmental pathways for AI/AN young people. A central component across all three programs is a deep commitment to an interdependent or collective orientation, in contrast to an individual-based mental health suicide prevention model. This commitment offers novel directions for the entire field of suicide prevention and responds to calls for multilevel, community-driven public health strategies to address the complexity of suicide. Although our focus is on the social determinants of health in AI/AN communities, strategies to address the structural violence of racism as a risk factor in suicide have broad implications for all suicide prevention programming.

Structural violence of racism and colonization are social determinants of suicide.Collaborative and power-sharing implementation strategies can disrupt oppression.Strengths-based collectivist strategies can buffer structural suicide risk.

Evaluation of the Risk Identification for Suicide and Enhanced Care Model in a Native American Community.

Importance: There are many prognostic models of suicide risk, but few have been prospectively evaluated, and none has been developed specifically for Native American populations. Objective: To prospectively validate a statistical risk model implemented in a community setting and evaluate whether use of this model was associated with improved reach of evidence-based care and reduced subsequent suicide-related behavior among high-risk individuals. Design, Setting, and Participants: This prognostic study, done in partnership with the White Mountain Apache Tribe, used data collected by the Apache Celebrating Life program for adults aged 25 years or older identified as at risk for suicide and/or self-harm from January 1, 2017, through August 31, 2022. Data were divided into 2 cohorts: (1) individuals and suicide-related events from the period prior to suicide risk alerts being active (February 29, 2020) and (2) individuals and events from the time after alerts were activated. Main Outcomes and Measures: Aim 1 focused on a prospective validation of the risk model in cohort 1. Aim 2 compared the odds of repeated suicide-related events and the reach of brief contact interventions among high-risk cases between cohort 2 and cohort 1. Results: Across both cohorts, a total of 400 individuals identified as at risk for suicide and/or self-harm (mean [SD] age, 36.5 [10.3] years; 210 females [52.5%]) had 781 suicide-related events. Cohort 1 included 256 individuals with index events prior to active notifications. Most index events (134 [52.5%]) were for binge substance use, followed by 101 (39.6%) for suicidal ideation, 28 (11.0%) for a suicide attempt, and 10 (3.9%) for self-injury. Among these individuals, 102 (39.5%) had subsequent suicidal behaviors. In cohort 1, the majority (220 [86.3%]) were classified as low risk, and 35 individuals (13.3%) were classified as high risk for suicidal attempt or death in the 12 months after their index event. Cohort 2 included 144 individuals with index events after notifications were activated. For aim 1, those classified as high risk had a greater odds of subsequent suicide-related events compared with those classified as low risk (odds ratio [OR], 3.47; 95% CI, 1.53-7.86; P = .003; area under the receiver operating characteristic curve, 0.65). For aim 2, which included 57 individuals classified as high risk across both cohorts, during the time when alerts were inactive, high-risk individuals were more likely to have subsequent suicidal behaviors compared with when alerts were active (OR, 9.14; 95% CI, 1.85-45.29; P = .007). Before the active alerts, only 1 of 35 (2.9%) individuals classified as high risk received a wellness check; after the alerts were activated, 11 of 22 (50.0%) individuals classified as high risk received 1 or more wellness checks. Conclusions and Relevance: This study showed that a statistical model and associated care system developed in partnership with the White Mountain Apache Tribe enhanced identification of individuals at high risk for suicide and was associated with a reduced risk for subsequent suicidal behaviors and increased reach of care.

Planning for implementation and sustainability of a community-based suicide surveillance system in a Native American community.

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

Strategic Directions in Preventive Intervention Research to Advance Health Equity.

As commissioned by the Society for Prevention Research, this paper describes and illustrates strategic approaches for reducing health inequities and advancing health equity when adopting an equity-focused approach for applying prevention science evidence-based theory, methodologies, and practices. We introduce an ecosystemic framework as a guide for analyzing, designing, and planning innovative equity-focused evidence-based preventive interventions designed to attain intended health equity outcomes. To advance this process, we introduce a health equity statement for conducting integrative analyses of ecosystemic framework pathways, by describing the role of social determinants, mechanisms, and interventions as factors directly linked to specific health equity outcomes. As background, we present health equity constructs, theories, and research evidence which can inform the design and development of equity-focused intervention approaches. We also describe multi-level interventions that when coordinated can produce synergistic intervention effects across macro, meso, and micro ecological levels. Under this approach, we encourage prevention and implementation scientists to apply and extend these strategic directions in future research to increase our evidence-based knowledge and theory building. A general goal is to apply prevention science knowledge to design, widely disseminate, and implement culturally grounded interventions that incrementally attain specific HE outcomes and an intended HE goal. We conclude with recommendations for conducting equity-focused prevention science research, interventions, and training.

Measuring the effects of the COVID-19 pandemic on Diné and White Mountain Apache school personnel, families, and students: protocol for a prospective longitudinal cohort study.

BACKGROUND: This paper describes the protocol for a longitudinal cohort study, "Project SafeSchools" (PSS), which focuses on measuring the effects of COVID-19 and the return to in-person learning on Diné (Navajo) and White Mountain Apache (Apache) youth, parents, and educators. The early surges of the COVID-19 pandemic led to the closure of most reservation and border town schools serving Diné and Apache communities. This study aims to: (1) understand the barriers and facilitators to school re-opening and in-person school attendance from the perspective of multiple stakeholders in Diné and Apache communities; and (2) evaluate the educational, social, emotional, physical, and mental health impacts of returning to in-person learning for caregivers and youth ages 4-16 who reside or work on the Diné Nation and the White Mountain Apache Tribal lands. METHODS: We aim to recruit up to N = 200 primary caregivers of Diné and Apache youth ages 4-16 and up to N = 120 school personnel. In addition, up to n = 120 of these primary caregivers and their children, ages 11-16, will be selected to participate in qualitative interviews to learn more about the effects of the pandemic on their health and wellbeing. Data from caregiver and school personnel participants will be collected in three waves via self-report surveys that measure COVID-19 related behaviors and attitudes, mental health, educational attitudes, and cultural practices and beliefs for both themselves and their child (caregiver participants only). We hypothesize that an individual's engagement with a variety of cultural activities during school closures and as school re-opened will have a protective effect on adult and youth mental health as they return to in-person learning. DISCUSSION: The results of this study will inform the development or implementation of preventative interventions that may help Diné and Apache youth and their families recover from the negative impact of the COVID-19 pandemic, and positively impact their health and wellness.

Development and Cultural Adaptation of Psychological First Aid for COVID-19 Frontline Workers in American Indian/Alaska Native Communities.

The coronavirus disease 19 (COVID-19) pandemic is broadly affecting the mental health and well-being of people around the world, and disproportionately affecting some groups with already pre-existing health inequities. Two groups at greater risk of physical and/or mental health detriments from COVID-19 and more profoundly impacted by the pandemic include frontline workers and American Indian/Alaska Native (AI/AN) communities. To provide support and prevent long-term mental health problems, we culturally adapted a psychological first aid guide specifically for COVID-19 frontline workers serving AI/AN communities. We engaged a diverse, collaborative work group to steer the adaptation content and process. We also held two focus group discussions with frontline workers in AI/AN communities to incorporate their perspectives into the adapted guide. Results from the group discussions and the collaborative work group were compiled, analyzed to extract themes and suggestions, and integrated into the adapted content of the guide. Main adaptations included updating language (i.e., to be more culturally appropriate, less prescriptive, and less text heavy), framing the guide from a harm-reduction lens, incorporating cultural activities, values, and teachings common across diverse AI/AN communities (e.g., importance of being a good relative), and validating feelings and experiences of frontline workers. The resulting adapted guide includes four modules and is available as a free online training. Our adaptation process may serve as a guiding framework for future adaptations of similar resources for specific groups. The adapted guide may stand as an enduring resource to support mental well-being, the prevention of mental health problems, and reduction of health inequities during the pandemic and beyond.

Development of "CULTURE FORWARD: A strengths and culture-based tool to protect our native youth from suicide".

OBJECTIVE: Indigenous knowledge and practices promote American Indian/Alaska Native (AI/AN; Native) communities' health and well-being. Historical losses and continued oppression have resulted in disproportionately higher AI/AN youth suicide rates. This article describes the development of a new national resource guide titled "CULTURE FORWARD" for tribal leaders and stakeholders to support youth suicide prevention efforts through cultural strengths. METHOD: The CULTURE FORWARD guide was developed over 6 months through a community-engaged process. We conducted nine roundtables and eight interviews with a wide variety of community members, leaders, and providers representing 36 diverse tribal communities and geographic regions. Participants discussed AI/AN youth risk and protective factors, successful community efforts to prevent suicide, and content and dissemination ideas. A comprehensive literature review complemented qualitative findings. A diverse and representative National Advisory Editorial Board guided content and design throughout development. RESULTS: Qualitative data were analyzed iteratively and thematically. Across all listening sessions, culture was identified as a key protective factor against AI/AN youth suicide. Five themes related to cultural strengths informed guide chapters. Each chapter includes an introduction; how that theme helps prevent Native youth suicide; a review of academic literature, community stories and programs; action steps; and additional resources. CONCLUSIONS: CULTURE FORWARD honors and empowers communities by weaving strands of knowledge, stories, and practical resources highlighting Native communities' strengths to protect against Native youth suicide. The guide is free online and print copies are being distributed nationally. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Centering Indigenous Knowledges and Worldviews: Applying the Indigenist Ecological Systems Model to Youth Mental Health and Wellness Research and Programs.

Globally, Indigenous communities, leaders, mental health providers, and scholars have called for strengths-based approaches to mental health that align with Indigenous and holistic concepts of health and wellness. We applied the Indigenist Ecological Systems Model to strengths-based case examples of Indigenous youth mental health and wellness work occurring in CANZUS (Canada, Australia, New Zealand, and United States). The case examples include research, community-led programs, and national advocacy. Indigenous youth development and well-being occur through strengths-based relationships across interconnected environmental levels. This approach promotes Indigenous youth and communities considering complete ecologies of Indigenous youth to foster their whole health, including mental health. Future research and programming will benefit from understanding and identifying common, strengths-based solutions beyond narrow intervention targets. This approach not only promotes Indigenous youth health and mental health, but ripples out across the entire ecosystem to promote community well-being.

Balancing cultural specificity and generalizability: Brief qualitative methods for selecting, adapting, and developing measures for research with American Indian communities.

Culturally appropriate, valid and reliable measures are critical to assessing how interventions impact health. There is a tension between measures for specific cultural settings versus more general measures that permit comparisons across samples. We illustrate a feasible approach to measurement selection, adaptation and testing for a study of brief interventions to prevent suicide among American Indian youth ages 10-24. We used a modified Nominal Group Technique (NGT) with N = 7 Apache Community Mental Health Specialists (CMHS') to elicit priority impacts of interventions under study. We then tested the reliability and validity in N = 93 youth at baseline. The NGT results included selection of alternative measures, item removal and addition, and creation of a local well-being index. Measurement testing indicated excellent to good internal consistency (α: 0.82-0.96) and strong construct validity. Study results demonstrate a feasible approach to balancing cultural specificity and generalizability while producing valid and reliable measures to use in an intervention trial. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Wakȟáŋyeza (Little Holy One) - an intergenerational intervention for Native American parents and children: a protocol for a randomized controlled trial with embedded single-case experimental design.

BACKGROUND: Trauma within Native American communities compromises parents' parenting capacity; thus, increasing childrens' risk for substance use and suicide over the lifespan. The objective of this manuscript is to describe the Wakȟáŋyeza (Little Holy One) intervention and evaluation protocol, that is designed to break cycles of intergenerational trauma, suicide, and substance use among Fort Peck Assiniboine and Sioux parents and their children. METHODS: A randomized controlled trial with an embedded single-case experimental design will be used to determine effectiveness of the modular prevention intervention on parent-child outcomes and the added impact of unique cultural lesson-components. Participants include 1) Fort Peck Assiniboine and Sioux parents who have had adverse childhood experiences, and 2) their children (3-5 years). Parent-child dyads are randomized (1:1) to Little Holy One or a control group that consists of 12 lessons taught by Indigenous community health workers. Lessons were developed from elements of 1) the Common Elements Treatment Approach and Family Spirit, both evidence-based interventions, and 2) newly created cultural (intervention) and nutrition (control group only) lessons. Primary outcomes are parent (primary caregiver) trauma symptoms and stress. Secondary outcomes include: Parent depression symptoms, parenting practices, parental control, family routines, substance use, historical loss, communal mastery, tribal identity, historical trauma. Child outcomes include, externalizing and internalizing behavior and school attendance. Primary analysis will follow an intent-to-treat approach, and secondary analysis will include examination of change trajectories to determine impact of cultural lessons and exploration of overall effect moderation by age and gender of child and type of caregiver (e.g., parent, grandparent). DISCUSSION: Many Native American parents have endured adverse childhood experiences and traumas that can negatively impact capacity for positive parenting. Study results will provide insights about the potential of a culturally-based intervention to reduce parental distress - an upstream approach to reducing risk for childrens' later substance misuse and suicidality. Intervention design features, including use of community health workers, cultural grounding, and administration in Head Start settings lend potential for feasibility, acceptability, sustainability, and scalability. TRIAL REGISTRATION: ClinicalTrials.gov: NCT04201184 . Registered 11 December 2019.

Diné (Navajo) female perspectives on mother-daughter communication and cultural assets around the transition to womanhood: a cross-sectional survey.

BACKGROUND: The inclusion of protective factors ("assets") are increasingly supported in developing culturally grounded interventions for American Indian (AI) populations. This study sought to explore AI women's cultural assets, perspectives, and teachings to inform the development of a culturally grounded, intergenerational intervention to prevent substance abuse and teenage pregnancy among AI females. METHODS: Adult self-identified AI women (N = 201) who reside on the Navajo Nation completed a cross-sectional survey between May and October 2018. The 21-question survey explored health communication around the transition to womanhood, cultural assets, perceptions of mother-daughter reproductive health communication, and intervention health topics. Univariate descriptive analyses, chi squared, and fisher's exact tests were conducted. RESULTS: Respondents ranged in age from 18 to 82 years, with a mean age of 44 ± 15.5 years. Women self-identified as mothers (95; 48%), aunts (59; 30%), older sisters (55; 28%), grandmothers (37; 19%), and/or all of the aforementioned (50; 25%). 66% (N = 95) of women admired their mother/grandmother most during puberty; 29% (N = 58) of women were 10-11 years old when someone first spoke to them about menarche; and 86% (N=172) felt their culture was a source of strength. 70% (N = 139) would have liked to learn more about reproductive health when they were a teenager; 67% (N = 134) felt Diné mothers are able to provide reproductive health education; 51% (N = 101) reported having a rite of passage event, with younger women desiring an event significantly more than older women. Responses also indicate a disruption of cultural practices due to government assimilation policies, as well as the support of male relatives during puberty. CONCLUSIONS: Results informed intervention content and delivery, including target age group, expanded caregiver eligibility criteria, lesson delivery structure and format, and protective cultural teachings. Other implications include the development of a complementary fatherhood and/or family-based intervention to prevent Native girls' substance use and teen pregnancy.

Designing a Clinical Decision Support Tool That Leverages Machine Learning for Suicide Risk Prediction: Development Study in Partnership With Native American Care Providers.

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

Suicide and the opioid overdose crisis among American Indian and Alaska Natives: a storm on two fronts demanding swift action.

The opioid crisis in the United States has received national attention and critical resources in the past decade. However, what has been overlooked is the effect the opioid crisis may be having on a three-decade suicide crisis among American Indian and Alaska Native (AIAN) communities that already have too few resources to address behavioral and mental health issues. This paper describes recent epidemiological trends associated with both opioid overdose and suicide at a national level for AIANs and the rest of the United States. We used data reported by the Centers for Disease Control and Prevention to report historical trends of opioid overdose and suicide for AIAN and non-AIAN populations. We found alarming and potentially correlated trends of opioid use and suicidality among AIAN populations. We highlight both current and future research that will be essential to understanding and addressing the unique intersection between opioid and suicide risk and protective factors to inform dual prevention and intervention efforts among AIAN populations with potential relevance to public health response among other at-risk populations.

Feasibility, Acceptability, and Preliminary Impact of Asdzáán Be'eená: An Intergenerational, Strength-Based, and Culturally Grounded Program to Improve the Health of Navajo Families.

Native American youth endure a complex interplay of factors that portend greater risk-taking behaviors and contribute to marked health disparities experienced in adolescence. The Asdzáán Be'eená ("Female Pathways" in Navajo) program was developed as a primary prevention program to prevent substance use and teen pregnancy among Navajo girls. The Asdzáán Be'eená program consists of 11 lessons delivered to dyads of girls ages 8 to 11 years and their female caregivers. Feasibility, acceptability, and preliminary impact on risk and protective factors were assessed through a pre-/post study design. Data were collected from girls and their female caregivers at baseline, immediate, and 3 months postprogram completion. Forty-seven dyads enrolled in the study, and 36 completed the 3-month evaluation. At 3 months postprogram, girls reported significant increases in self-esteem, self-efficacy, parent-child relationship, social support, cultural, and sexual health knowledge. Caregivers reported increased family engagement in Navajo culture and parent-child communication and improved child functioning (fewer internalizing and externalizing behaviors). Findings suggest Asdzáán Be'eená has potential to break the cycle of substance use and teen pregnancy in Native communities by improving protective and reducing risk factors associated with these adverse health outcomes. Additional rigorous efficacy trials are necessary to establish program effectiveness.

Development and Dissemination of a Strengths-Based Indigenous Children's Storybook: "Our Smallest Warriors, Our Strongest Medicine: Overcoming COVID-19".

The traditions, strengths, and resilience of communities have carried Indigenous peoples for generations. However, collective traumatic memories of past infectious diseases and the current impact of the coronavirus disease 2019 (COVID-19) pandemic in many Indigenous communities point to the need for Indigenous strengths-based public health resources. Further, recent data suggest that COVID-19 is escalating mental health and psychosocial health inequities for Indigenous communities. To align with the intergenerational strengths of Indigenous communities in the face of the pandemic, we developed a strengths- and culturally-based public health education and mental health coping resource for Indigenous children and families. Using a community-engaged process, the Johns Hopkins Center for American Indian Health collaborated with 14 Indigenous and allied child development, mental health, health communications experts and public health professionals, as well as a Native American youth artist. Indigenous collaborators and Indigenous Johns Hopkins project team members collectively represented 12 tribes, and reservation-based, off-reservation, and urban geographies. This group shared responsibility for culturally adapting the children's book "My Hero is You: How Kids Can Fight COVID-19!" developed by the Inter-Agency Standing Committee Reference Group on Mental Health and Psychosocial Support in Emergency Settings and developing ancillary materials. Through an iterative process, we produced the storybook titled "Our Smallest Warriors, Our Strongest Medicine: Overcoming COVID-19" with content and illustrations representing Indigenous values, experiences with COVID-19, and strengths to persevere. In addition, parent resource materials, children's activities, and corresponding coloring pages were created. The book has been disseminated online for free, and 42,364 printed copies were distributed to early childhood home visiting and tribal head start programs, Indian Health Service units, tribal health departments, intertribal, and urban Indigenous health organizations, Johns Hopkins Center for American Indian Health project sites in partnering communities, schools, and libraries. The demand for and response to "Our Smallest Warriors, Our Strongest Medicine: Overcoming COVID-19" demonstrates the desire for Indigenous storytelling and the elevation of cultural strengths to maintain physical, mental, emotional, and spiritual health during the COVID-19 pandemic.

Our Collective Needs and Strengths: Urban AI/ANs and the COVID-19 Pandemic.

The COVID-19 pandemic has raised national consciousness about health inequities that disproportionately impact American Indian/Alaska Native (AI/AN) communities, yet urban AI/AN communities continue to remain a blind spot for health leaders and policymakers. While all United States cities have been the traditional homelands of AI/AN peoples since time immemorial, urban AI/ANs are consistently excluded in local and national health assessments, including recent reports pertaining to COVID-19. Today the majority of AI/ANs (71%) live in urban areas, and many cities have strong Urban Indian Health Programs (UIHPs) that provide space for medical care, community gatherings, cultural activities, and traditional healing. Many of these UIHPs are currently scrambling to meet the needs of their AI/AN service communities during the pandemic. While the COVID-19 pandemic brought new sources of funding to UIHPs, the lack of local AI/AN data and arbitrary funding restrictions precluded some UIHPs from addressing their communities' most immediate challenges such as food and economic insecurities. Despite these challenges, urban AI/AN communities carry the historical resilience of their ancestors as they weave strong community networks, establish contemporary traditions, and innovate to meet community needs. This article focuses on the experiences of one UIHP in Baltimore City during the COVID-19 pandemic to illustrate present-day challenges and strengths, as well as illuminate the urgency for tailored, local data-driven public health approaches to urban AI/AN health.