Intersecting sex and American Indian identity moderates school and individual correlates of binge drinking among reservation-area adolescents.

Reservation-area American Indian (AI) youth demonstrate higher rates of binge drinking (BD) than their non-AI peers. However, individual and school-level differences in BD disparities between reservation-area AI/non-AI female and male adolescents remain unexamined. This study applies an Intersectional framework to examine risk and protective factors of BD among reservation-area youth at the intersection of their sex and AI identities. A nationally representative sample of adolescents (N = 14,769; Mage = 14.6, 49% female; 61% AI) attending 103 reservation-serving schools completed a survey between 2015 and 2019. Multilevel modeling was used to examine differences in risk and protective factors of BD between AI and non-AI male and female adolescents. Our findings indicate that the effects of student and school-level risk and protective factors on adolescents' BD are driven primarily by sex within AI and non-AI groups. Implications for future confirmatory research and tailoring school-based prevention programs are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Talking Circle For Young Adults (TC4YA) intervention: a culturally safe research exemplar.

Background: As a result of the intergenerational trauma impact and experience, Native Americans continue to exhibit trauma-related issues such as high rates of substance use. After leaving high school, the pressures and stress of continuing an education, finding work/employment, and the responsibilities related to family and tribal community obligations result in the Native American young adult being more vulnerable to substance use.Objective: The purpose of this paper is to report findings of the Talking Circle intervention impact on the outcome variables of Native-Reliance, substance use, stress, and behavioural health, depression, and cumulative trauma.Methods: Native-Reliance was the theoretical underpinning for the study, demonstrating culturally safe research. A pre-test/post-test one-group design was utilised to examine how the Talking Circle intervention influenced the outcome variables. In total, 75 Native American participants, ages 18-24, participated in the Talking Circle intervention sessions. Baseline pre-intervention measures were completed and were repeated at 6-month post-intervention.Results: At 6-month post-intervention, Native-Reliance significantly revealed an increase of 40.55 (t = 22.13, p < .001), sources of stress (SS) revealed a significant decline of 3.68 (t = -18.39, p < .001), behavioural health issues (BH) showed a significant decline of 3.63 (t = -15.36, p < .001), substance-related issues (SR) showed a significant decline of 3.57 (t = -15.24, p < .001), depression (PHQ-9) showed a significant decline of 4.85 (t = -17.02, p < .001), and cumulative trauma revealed a significant decline of 2.77 (t = -13.39, p < .001).Conclusions: The use of a culturally safe Talking Circle intervention evidenced a research approach that resulted in a positive impact on reducing substance use and increasing the well-being of young Native American young adults.Impact Statement: Culturally safer intervention environments are conducive to results in outcomes that are positive and effective.

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.

A scoping review of school-based indigenous substance use prevention in preteens (7-13 years).

BACKGROUND: Early-onset substance use is a risk factor for continued use, dependency, and poor long-term health outcomes. Indigenous youth are more likely to engage in early-onset substance use than their non-Indigenous counterparts. In Canada, culturally appropriate prevention programs are needed for Indigenous youth in elementary schools. Therefore, this scoping review aims to explore the published, international literature examining school-based substance use prevention programs for Indigenous children aged 7-13. MAIN TEXT: Methods: This scoping review followed a six-step approach: 1) identifying the research questions, 2) identifying relevant studies, 3) selecting the studies, 4) charting the data, 5) collating, summarizing, and reporting the results, and 6) consulting with experts. The review was reported using guidelines from Preferred Reporting Items for Systematic reviews and Meta-Analyses extensions for Scoping Reviews (PRISMA-ScR). RESULTS: Eleven articles (3 Canadian; 7 American and; 1 Australian) were included in the review. The prevention programs they studied were based on existing research or were adapted from existing interventions. The programs were tailored to each communities' culture by including Indigenous stakeholders in developing or adapting prevention programs to be culturally safe and responsive. The articles evaluated the programs' Effectiveness in changing student knowledge, attitudes, and behaviors using pre- and post-intervention surveys, randomized control trials, longitudinally designed analysis, and mixed methods. Mixed quantitative findings and qualitative findings highlighted the programs' value in building community capacity and fostering cultural revitalization. CONCLUSION: This review highlights best practices for developing school-based substance use prevention programs for Indigenous youth. Findings suggest that prevention programs should be culturally responsive and provide students with the knowledge and skills to prevent and manage substance use in real-life situations. Making Indigenous beliefs, values, languages, images, and worldviews central to the prevention curriculum enhanced the Effectiveness, appropriateness, and sustainability of prevention programs. Indigenous communities are best positioned to facilitate cultural tailoring without compromising the fidelity of evidence-based prevention programs.

Recommendations from an expert panel of health professionals regarding a gestational diabetes risk reduction intervention for American Indian/Alaska Native Teens.

BACKGROUND: American Indian/Alaska Native (AI/AN) adolescents are at higher risk for gestational diabetes (GDM), type 2 diabetes, and pregnancy complications than the general population. OBJECTIVE: To inform cultural adaptation of a validated evidence-based intervention (VEBI) originally designed to deliver preconception counseling and diabetes education to non-AI/AN teens with diabetes. DESIGN: Qualitative data were collected using focus group and individual interview methods with health care professionals and experts (n = 16) in AI/AN health, GDM, adolescent health, and/or mother-daughter communication. A semistructured discussion guide elicited responses about provision of care for AI/AN girls at risk for GDM, experience with successful programs for AI/AN teens, comfort of mother/daughter dyads in talking about diabetes and reproductive health and reactions to video clips and booklet selections from the VEBI. All interviews were recorded and transcribed verbatim, and data analysis included inductive coding and identification of emergent themes. RESULTS: Providers felt teens and their moms would be comfortable talking about the VEBI topics and that teens who did not feel comfortable talking to their mom would likely rely on another adult female. Participants suggested including: AI/AN images/motifs, education with a community focus, and avoiding directive language. Concerns included: socioeconomic issues that affect AI/AN people such as: food and housing insecurity, abuse, and historical trauma. CONCLUSIONS: Perspectives from these participants have been used to guide the development of a culturally tailored GDM risk reduction program for AI/AN girls. This program will be available to health care providers who serve the AI/AN population.

Empowered by Cultural Identity and Catalyzed by Resilience: A Path to Support American Indian Nursing Student Success.

Since the early 1990s, the Institute of Medicine has identified the need to increase the number of ethnic minority nurses to improve access to care and eliminate health disparities in these populations (Institute of Medicine, 1994, 2011). American Indians (AI) and Alaska Natives endure the highest rates of poverty, depression, addiction, suicide, domestic violence, and diabetes in the United States (Sarche & Spicer, 2008). With the disadvantages AIs face, nursing schools have difficulty recruiting, retaining, and graduating AI nursing students. Based on the guidance needed by AI nursing students, a program called Niganawenimaanaanig was specifically designed to provide holistic support for these students to improve their chances of successfully completing the baccalaureate nursing program. This program, funded through a Health Resource Services Administration Nursing Workforce Diversity grant, was begun at Bemidji State University in Minnesota, proximal to three of the largest Ojibwe reservations in the state. Once enrolled in Niganawenimaanaanig, students are provided comprehensive care within a unique cultural, academic, and social support framework. Tuition scholarships and monthly stipends provide crucial financial relief to students once they are accepted into the 4-year prelicensure or RN-to-BS nursing programs. In Niganawenimaanaanig's first 2 years, the number of AI students declaring nursing as a major increased by over 600%, and the program has retained 100% of their prenursing freshmen. At the heart of Niganawenimaanaanig is a grounding in AI culture that empowers and fosters resilience among nursing students, which is a relevant and recreatable concept for schools seeking to recruit and retain ethnic minority nursing students.

Hózhó: Promoting sleep health among Navajo caregivers.

OBJECTIVES: This study explored the feasibility and acceptability of a sleep health education intervention for caregivers of children with developmental disabilities (DD). DESIGN: This mixed-methods pilot study utilized repeated measures and caregiver interviews. SETTING: The intervention occurred in the homes of caregivers who live on the Navajo Nation. PARTICIPANTS: Fifteen caregivers of children with DD aged from birth to 3 years old participated. INTERVENTION: The intervention consisted of three 1-hour home-based sessions. Educational modules were tailored to specific sleep issues of the caregiver and their child(ren), as well as the unique environmental and cultural features of Navajo families. MEASUREMENTS: Quantitative measures included a sleep habits questionnaire, pre- and postmeasures of learning, and the SF-12 HRQoL. Quantitative data were analyzed with frequencies and repeated measures analyses with p .05. Qualitative comments regarding facilitators and detractors to healthy sleep were transcribed verbatim and categorized into themes. RESULTS: Caregiver sleep duration increased by 2 hours (5.8±1.8 to 7.8±1.9, p = .005). Caregivers also reported improved physical (45.0±8.2 to 52.8+8.7 p = .001) and mental HR-QoL (41.8±8.9 to 49.3±10.9, p = .002), and enhanced knowledge of sleep disorders (13.4±4.0 to 20.7±5.6) and healthy sleep habits (15.7±4.1 to 25.4±3.4 each p = .005). Many participants reported better sleep quality in their children with earlier bedtimes and less night waking. CONCLUSIONS: Findings suggest that this tailored sleep education program is a culturally responsive approach to promoting caregiver sleep health and HR-QoL, as well as the sleep health of their children. Caregivers credited improved sleep to the support they received during visits and text messaging.

Intergenerational communication regarding Indian Residential Schools: Implications for cultural identity, perceived discrimination, and depressive symptoms.

Two studies assessed the nature of parental communication about the trauma of Indian Residential Schools (IRSs) in relation to the psychological distress of their adult offspring, and whether the link between parental communication and distress was mediated by offsprings' greater awareness of collective discrimination or sense of pride in cultural identity. In Study 1, an online survey of Indigenous participants from across Canada (N = 498) demonstrated a curvilinear relation between the extent to which parents talked about their negative IRS experiences and the severity of depressive symptoms among offspring, among whom symptoms were particularly pronounced with more frequent communication. This relation was mediated by greater perceived discrimination. A similar, but inverse, association was found when parental communications conveyed positive construals of their IRS experiences. Study 2 (N = 134) further demonstrated an association between direct communications from IRS survivors and offspring wellbeing in that, either the absence of, or especially frequent communications were related to more severe depressive symptoms among offspring. However, hearing about parental IRS experiences from someone other than the parent was not related to offsprings' depressive symptoms. Qualitative analyses indicated that direct communications from parents tended to provide excessive detail, whereas parental silence was associated with speculation and feelings of isolation or resentment among offspring of IRS survivors. Taken together, the results suggest that either insufficient or excessive parental communication about trauma might undermine offspring wellbeing, whereas moderate levels of communication that provide positive meaning and promote cultural pride or diminish perceptions of personal discrimination could be beneficial.

"We Need to Make Action NOW, to Help Keep the Language Alive": Navigating Tensions of Engaging Indigenous Educational Values in University Education.

Despite centuries of contact and conquest, Indigenous communities persist in maintaining their cultures and psychologies. Key to this success in cultural survival is the maintenance of Indigenous languages, which contain distinct worldviews. However, Indigenous languages are at risk, with fewer and fewer fluent Elder speakers. Fortunately, there remain committed groups of community educators who carry out Indigenous language education. Current mainstream teacher education programs do not typically introduce the importance of Indigenous language education to teacher candidates, who are the next generation of K-12 teachers. We view this as highly problematic, and thus carried out a proof-of-concept project in which one U.S. university's American Indian/Alaska Native teacher candidates collaborated with, and learned from, Indigenous language educators during a two-week-long summer institute at the university. In our article, we share three main findings, based on qualitative analyses of daily-written student journals collected during the two-week pilot project: (a) Indigenous language education supports the social justice vision in the American Psychological Association's Multicultural Guidelines; (b) intergenerational educational opportunities are invaluable for affirming Indigenous psychologies; and (c) Indigenous community language educators do important survivance work. Our findings provide insight into how Indigenous language education is crucial for advancing education that honors Indigenous community psychological well-being.

"Let our Apache Heritage and Culture Live on Forever and Teach the Young Ones": Development of The Elders' Resilience Curriculum, an Upstream Suicide Prevention Approach for American Indian Youth.

The White Mountain Apache Tribe have developed an innovative curriculum that connects youth through Elders to their heritage, traditions, and culture, which has been proven to be a protective factor for native Americans. The development process took 4½ years and included community stakeholder buy-in, Elders' Council group formation, extensive formative work to identify content, iterative feedback between curriculum writers and Elders, and Elder training prior to implementation. Members of the Elders' Council have been visiting the local schools to teach youth about the Apache culture, language, and way of life since February 2014 reaching over 1000 youth. This approach demonstrates a promising upstream suicide prevention strategy. We discuss the process of development, implementation, and lessons learned, as this curriculum has potential for adaptation by other Indigenous communities.

Indigenizing and Decolonizing the Teaching of Psychology: Reflections on the Role of the Non-Indigenous Ally.

Canada's 2015 Truth and Reconciliation Commission published 94 Calls to Action including direction to post-secondary institutions "to integrate Indigenous knowledge and teaching methods into classrooms" as well as to "build student capacity for intercultural understanding, empathy, and mutual respect." In response, Canadian universities have rushed to "Indigenize" and are now competing to hire Indigenous faculty, from a limited pool of applicants. However, it is missing the true spirit of reconciliation for non-Indigenous faculty to continue with the status quo while assigning the sole responsibility of Indigenizing curriculum to these new hires. How can non-Indigenous psychology professors change their teaching to ensure that all students acquire an appreciation of traditional Indigenous knowledge about holistic health and healing practices, as well as an understanding of Canada's history of racist colonization practices and its intergenerational effects? Community psychologists, particularly those who have established relationships with Indigenous communities, have an important role to play. In this article, I survey the existing literature on Indigenizing and decolonizing psychological curriculum and share ways in which I have integrated Indigenous content into my psychology courses. I also reflect upon the successes, questions, and ongoing challenges that have emerged as I worked in collaboration with first Anisinaabek First Nations and then Mi'kmaw/L'nu First Nations.

Community Perceptions of Alcohol Exposed Pregnancy Prevention Program for American Indian and Alaska Native Teens.

A community needs assessment during a tribally-led Changing High-Risk Alcohol Use and Increasing Contraception Effectiveness Study (CHOICES) intervention highlighted the need to reduce the risk for alcohol exposed pregnancy (AEP) among American Indian and Alaska Native (AIAN) adolescent girls. The CHOICES for American Indian Teens (CHAT) Program aims to reduce the risk of AEP among AIAN teens in one Northern Plains tribal community. The CHAT team adopted an iterative process to modify the tribally-led CHOICES curriculum for AIAN teens. This paper describes the iterative process as well as the community perception towards AEP prevention among AIAN teens. The CHAT team conducted several levels of formative and qualitative research, including one-on-one interviews (n = 15) with community members, AIAN elders and school counsellors; and three focus groups with AIAN adolescent girls (n = 15). A qualitative data analysis identified several recommendations that centered on making the information regarding alcohol and birth control appealing to teens; ensuring the confidentiality of the participants; making the program culturally relevant; and including boys in the program. This study outlines various components prioritized by community members in creating a culturally-relevant and age-appropriate AEP prevention program and provides community perceptions of AEP prevention for the teens in this community.

My Journey: Development and Practice-Based Evidence of a Culturally Attuned Teen Pregnancy Prevention Program for Native Youth.

A clear need exists for teen pregnancy prevention programs that are responsive to the specific needs and cultural contexts of Native American communities. Recent data indicates that the birth rate for Native teens is nearly two and a half times the rate for White teens (32.9 versus 13.2). To address this disparity, we conducted formative research with Northern Plains Native American community members, resulting in My Journey, a culturally attuned curriculum for 6⁻8th graders. My Journey is grounded in traditional values and teachings to promote self-efficacy in sexual health decision-making and engagement in prosocial behaviors. We conducted a pilot study with 6⁻8th grade students (n = 45), aged 11⁻14 years (22 females, 23 males). Pilot study findings confirm program feasibility and acceptability. The process evaluation revealed that teachers liked the curriculum, particularly its adaptability of cultural components and ease of student engagement. The outcome evaluation demonstrated that My Journey provided an avenue for NA youth to increase their sex refusal self-efficacy. Application of the culture cube framework revealed My Journey has made a meaningful practice-based evidence contribution as a community-defined, culturally integrated curriculum that is effective. Future directions include broader implementation of My Journey, including adaption for additional populations.

How can an Education Workshop Serve as an Intervention for American Indian Screening Participation.

American Indians (AIs) continue to have elevated cancer incidence and mortality, and most have issues accessing cancer screening services. During 2013-2014, Mayo and its partners created Native Cancer 101 Module 10 "Prevention and Early Cancer Detection" education workshop. A community-based AI organization implemented nine of these workshops during 2014-2015 via diverse venues. Nearly all participants eligible for at least one type of cancer screening participated in a workshop and consented to follow-up within 3 to 6 months to determine if screenings had been completed or scheduled. Native Cancer 101 Module 10 workshops were conducted with 150 community members of whom 6 had recently completed cancer screening (n = 144). The workshops had a 25.20% increase in knowledge, and 97.1% of subjects responded that they would recommend the workshop to their friends and family. Most (136 of 144) submitted a consent form to be contacted 3 to 6 months following the workshop. Patient navigators reached 86 (63.2%) of the consented participants in the follow-up calls after the workshop, and 63 (46.3%) self-reported that they had completed at least one cancer screening test for which they were eligible. The single implementation of the workshop influenced community participants' completion of cancer screening.

The essential role of cultural safety in developing culturally-relevant prevention programming in First Nations communities: Lessons learned from a national evaluation of Mental Health First Aid First Nations.

Mental Health First Aid is a population health approach that educates people to recognize and respond to mental health challenges. Since 2012, the Mental Health Commission of Canada has worked with six First Nations communities to develop a culturally-relevant version of the program called Mental Health First Aid First Nations (MHFAFN). This paper presents mixed methods, multi-informant data from a national evaluation to assess the extent to which the course was experienced as culturally safe by Indigenous participants, factors that contributed to these experiences, and ways in which cultural relevancy of MHFAFN can be improved. Our evaluation team conducted participant interviews and surveys, as well as facilitator interviews. Nearly all Indigenous participants (94.6%) experienced the course as safe. Participants and facilitators identified a range of factors that promoted cultural safety, including the knowledge and skills of the facilitators and the cultural components of the course. Participants that did not experience safety identified trauma-related factors and facilitation style. The findings suggest that MHFAFN may be situated in a way where shared cultural backgrounds are imperative to the success of the course. Further evaluation of the MHFAFN curriculum, with the goal of continual improvement, may help to further enhance participants' experiences in taking the course.

Developing a Tribal Health Sovereignty Model for Obesity Prevention.

BACKGROUND: Few models for effective health interventions exist for stemming the tide of American Indian (AI) childhood obesity rates; they are among the highest in the United States and are increasing. Obesity-related chronic diseases (i.e., diabetes type II and cardiovascular disease) rates far exceed other U.S. racial groups. Some studies show success with health interventions that center within an AI worldview and approach, rather than those that center on an individualistic Western worldview. The Tribal Health Sovereignty (THS) model presented here defines health through an AI perspective and applicably to food and exercise intervention. The model discussed in this paper is grounded in a study, which used a community-based participatory research (CBPR) photovoice methodology and can be used to design effective health interventions. METHODS: Development of the THS model was guided by Earp and Ennett's representation of concept model development for health education research and intervention. Findings from a CBPR study that used photovoice methodology informed the model. Differences between AI and Western models of health are explored and illuminate how an interventions shaped by Indigenous culture and worldview can lead to better health outcomes among AI people. RESULTS: A THS model was developed to guide future AI interventions embedded within tribal culture. CONCLUSIONS: By using a THS model, tribal communities can engage in identifying barriers and facilitators for health to lower childhood obesity.

Enhancing medical student diversity through a premedical program: A Caribbean school case study.

Background: Physicians with backgrounds underrepresented in medicine (URiM) are more likely to practice in underserved communities. Recruitment into and assistance during medical education has the potential to increase the number of URiM physicians. This study analyzes URiM students' academic performance at a well-established Caribbean school with and without prior successful completion of the Medical Education Readiness Program (MERP). Methods: A retrospective analysis of premedical school requirements and achievements in medical school were performed for URiM students enrolled in Ross University School of Medicine between 2006 and 2012, through either MERP or direct admission. For MERP and non-MERP students, an independent sample two-tailed Student t-test was used to compare prerequisite Grade Point Average (p GPA), Medical College Admission Test (MCAT), and The United States Medical Licensing Examination (USMLE) Step 1 scores. Chi-square analysis was performed to compare the attrition rates for MERP and non-MERP URiM students in the first years of medical schools well as USMLE Step 1 pass rates. Results: A total of 1299 students entering medical school directly (n = 981) or through MERP (n = 318) were evaluated. The mean MCAT (19.6 for MERP vs. 21.6 for non-MERP, P < 0.001) and prerequisite GPA (2.8 for MERP vs. 3.1 for non-MERP, P < 0.001) were significantly lower for the MERP students. A similar percentage of MERP and non-MERP students reached the 2nd year (83.0% and 80.9% respectively, P = 0.407) and 3rd year (80.5% and 79.0% respectively, P = 0.565) of medical school. USMLE Step 1 pass rates for MERP (90.6%) and non-MERP (92.3%) as well as USMLE Step 1 mean scores (208.9 and 210.0 for MERP and non-MERP, respectively) were also comparable. Discussion: MERP-like programs can help URiM students with lower undergraduate scores succeed in medical school.

Commentary: Indigenous Nursing - Learning from the Past to Strengthen the Future of Healthcare.

Nurse leaders, educators and employers work to address the challenges of providing optimal care to Indigenous people and communities in Canada, which is often further complicated by geography and isolation. The Canadian Indigenous Nurses Association (CINA) has responded to the Calls to Action of the Truth and Reconciliation Commission of Canada through partnerships with various levels of government, including the First Nations and Inuit Health Branch of the new federal department of Indigenous Services Canada, to increase and better support Indigenous nurses in the healthcare system. Grounding nursing practice with the wisdom and strength of Indigenous knowledge, balanced with the perspectives of western ways of knowing is further facilitated when nursing students can be educated and supported closer to home. Learning in a supportive way, closer to where one lives, can allow for important family ties, cultural supports and practices to improve experiences and outcomes for students.

Findings from American Indian Needs Assessments.

Because of decreased access and dismal survival rates, strategies need to be developed to increase cancer awareness and facilitate cancer prevention, early detection, and screening activities within American Indian (AI) populations. The purpose of this study was to develop a locally tailored needs assessment to collect cancer prevention, control, and risk factor information and knowledge, attitude, and perceived behavior (hereafter referred to as "needs assessment") data from 500 community members living in 3 geographically diverse settings: the Southeastern USA, the Rocky Mountain region, and the Northern Plains. Needs assessment data helped identify local health priorities and create a pilot cancer prevention and early detection education intervention. There were two versions of common items of the instrument: short (~35 items) and long (55 items), and each partner added items that were recommended by their local AI Advisory Committee. Each partner collaborated with local AI organizations to identify and recruit participants at community venues. During the sessions, facilitators used Power Point® slides and ARS equipment and software to anonymously collect participants' responses. The partners collected needs assessment data from 677 community members over a 4-year period. Cancer education knowledge was low, barriers to accessing timely cancer screening and care services were excessive, tobacco use was excessive, and daily physical activity was insufficient for most participants. ARS was an effective way to collect needs assessment information. During discussions following the data collection, community members requested more cancer education opportunities, access to patient navigation services, and cultural competency training for healthcare providers.