Adaption of a culturally informed stress reduction intervention for Native American Head Start Teachers using ADAPT-ITT and CBPR methodologies

doi:10.21203/rs.3.rs-1727821/v1

PDF

Research

Adaption of a culturally informed stress reduction intervention for Native American Head Start Teachers using ADAPT-ITT and CBPR methodologies

https://doi.org/10.21203/rs.3.rs-1727821/v1

This work is licensed under a CC BY 4.0 License

Version 1

posted 23 Jun, 2022

You are reading this latest preprint version

Background

Higher rates of adverse childhood experiences (ACEs) among Native American populations can be attributed to historical and contemporary traumas stemming from colonization and ongoing discrimination. On the Fort Peck Reservation, six Head Start centers serve over 300 children. Head Start is a federally funded program promoting school readiness for preschool children from low-income families. Tribal Head Start teachers report high levels of stress and depression as they work with children scoring high in ACEs. Teachers have requested support in managing their psychological health and well-being.

Methods

A community-based participatory research framework was employed to ensure culturally safe research practices in entirety to adopt and adapt a psychological health intervention for Head Start teachers. The eight step ADAPT-ITT methodology was utilized to guide the adaption process: 1) assessment, 2) decision, 3) adaptation 4) production, 5) topical experts, 6) integration 7) training and 8) testing. Teacher interest and needs were assessed through focus groups and in-depth interviews. Based on formative feedback, a culturally informed intervention, Little Holy One, was then adapted for Head Start teachers using ADAPT-ITT. Little Holy One is a 12-lesson intergenerational curriculum intervention designed to reduce parental stress and trauma-related symptoms among parent-child dyads.

Results

From the qualitative assessments teachers described experience of stress, depression, and post-traumatic stress disorder. Based on teacher preferences for content and perceived needs a culturally informed format and content educating about stress were integrated into the intervention. Assessment of community capacity to help adapt and adopt the intervention revealed their ability to implement the intervention. Iterative feedback with a tribal advisory board and designers of the original intervention led to final selection of five lessons. Using theater testing (step 4 of ADAPT-ITT) these lessons were adapted for implementation with Fort Peck Head Start teachers.

Conclusion

The adaptation and evaluation process of the Little Holy One lessons contribute critical considerations that must be taken in adapting psychological health interventions to decrease stress and improve well-being. Results outlined in this paper provide a framework to adapt interventions to be culturally and context specific and meet the needs of the people it serves.

CBPR

Native American

stress

cultural adaptation

process evaluation

ACEs

well-being

ADAPT-ITT

Using a community-based participatory research framework demonstrates a strength based, community focused process that ensures culturally safe research practices in vulnerable communities.
Utilization of ADAPT-ITT methodology provides a process for adapting an intervention prior to implementation to increase feasibility, acceptability, and long-term sustainability
Culturally informed psychological health care and even “culture as treatment” holds promise of carrying cultural strengths forward for generations to come

Adverse childhood experiences

Native Americans residing in remote reservation-based settings benefit from being connected to place, culture, community, and tribal sovereignty (1). However, many still struggle with poverty, high crime rates, poor performing schools, and lack of access to health care services and job opportunities (1–3). Compounding less than optimal Social Determinants of Health is the prevalence of adverse childhood experiences (ACEs)— stressful or traumatic events in early life—which have shown to last into adulthood and contribute to increased morbidity and mortality across the lifespan (4). ACEs include emotional, physical, and sexual abuse, witnessing intimate partner violence (IPV), parental separation, neglect, having incarcerated relative(s), community poverty and violence (4, 5). Greater number of ACEs experienced in childhood can equate to higher risk of developing chronic disease (e.g., diabetes, hypertension, and cardiovascular disease), depression, behavioral challenges, alcoholism, poor school performance, unemployment, high-risk substance use, and suicide (5, 6). One way the effects of ACEs can occur is through prolonged activation of the stress response, leading to epigenetic changes that negatively impact short- and long-term health outcomes (3).

National surveillance data shows ACE scores among Native Americans are 2.36 times higher than those of White individuals (7). Further, Native American children who are exposed to or witness traumatic events such as IPV and/or physical and sexual abuse and neglect experience post-traumatic stress disorder (PTSD) twice as much as the general United States (U.S.) population (8). A prior study with Fort Peck youth, ages 15–24, found 78% of the sample experienced at least one ACE (8). After controlling for demographics, each additional ACE increased the odds of PTSD by 55%, depression by 57%, suicide attempts (37%), and high-risk substance use (51%) (8). While this study did not find a statistically significant relationship between historical trauma and discrimination and suicide ideation and attempts, other studies have found positive statistically significant associations between suicide attempts and familial attendance at residential boarding schools (9, 10).

Prevalence of ACEs vary by region primarily due to the impact of social determinants of health; however, the overall picture for Native Americans is alarming. Substantive evidence suggests that higher rates of ACEs among Native American populations can be attributed to historical traumas they have experienced as direct result of colonization i.e., the outlawing of language and culture—until 1972, genocide, forced relocation to reservations, child abuse in the boarding school system, and contemporary traumas stemming from ongoing discrimination (1, 7, 8). This has spurred intergenerational trauma, or the experience of severe traumas transmitted to offspring through epigenetic changes affecting childrens’ physical and psychological health and well-being for generations (3, 11, 12). However, factors that can help children experiencing ACEs overcome adversity include education and positive childhood experiences (13). Safe, stable, and nurturing relationships can also be protective against mental health challenges and risk behaviors as children grow into adulthood (13, 14).

Tribal Head Start teacher stress

Despite a high level of job satisfaction reported by Head Start teachers, especially in their ability to make a difference in their students’ lives (15, 16), early childhood education teaching remains one of the most stressful occupations in the U.S., with 46% of teachers reporting increased daily stress during the school year (17). Burnout, anxiety, depression, sleep disorders, job dissatisfaction, poor performance and a high turnover rate have all been attributed to teacher stress. Secondary traumatic stress, or compassion fatigue, also contributes to teachers’ strain as they work to support children and families that have suffered multiple adverse experiences(18, 19). In poverty-stricken areas, early childhood education teachers are likely to come from the same community as their students, and thus have dealt with similar ACEs and stressors as the children they teach. These ACEs can influence teachers’ levels of stress and hinder their well-being (20).

Pre-school and Head Start teachers, particularly those working in rural, low-income communities, are well positioned to help mitigate negative and/or long-term effects of ACEs. Teachers provide positive interactions, emotional and instructional support, are sensitive and responsive, and stimulate childrens’ development. They are often trusted, can effectively communicate, and develop relationships with parents, and often serve as first responders for students in times of crisis (14). As such, expanding teachers’ resilience skills—providing them with tools to cope with their own stress and trauma—can potentially have a lasting impact on their personal well-being, as well as that of the students, schools, and communities (14, 21).

Reservation community needs assessment

The Fort Peck Reservation, home to the Assiniboine and Sioux Tribes, located in rural, northeastern Montana has experienced disproportionate health inequities and collective traumas. A community health assessment conducted in 2015 showed medium household income in Fort Peck was $12,000 lower than the rest of the state and 36% of children live in poverty (22). While Fort Peck youth report less alcohol use (54% compared to 70% for Montana), substance use—particularly use of hard drugs such as methamphetamine—is higher (5% compared to 3% for Montana) (22). In the Fort Peck suicide study, however, youth with high scores of ACES (4–6) had four times the odds of poly-drug use (alcohol, marijuana, methamphetamine, and/ or prescription drugs) (8). Visits to the emergency room involving intentional self-injury are three times higher in Fort Peck than the rest of Montana (22). The percent of driving fatalities that are alcohol impaired are significantly higher for Roosevelt County, of which Fort Peck is part, 71% compared to 47% for Montana (22). Adults in Fort Peck average 4.4 mental health days compared to 3.4 among other Montanans; compounded by the ratio of mental health providers to patients being 1 to 1,030 in Fort Peck versus 1 to 399 across the rest of the state. Further, access to primary health care is difficult, with a ratio 1 provider to 5563 patients versus 1 to 1,312, respectively (22). In recent decades, Fort Peck community leaders have expressed greater interest in finding solutions to these complex health challenges experienced by their People. Fort Peck’s tribal Head Start administration reports that teachers need enhanced support given they work in a challenging environment with a population experiencing heightened stress, all while receiving minimal assistance for managing their personal health and well-being. Despite the resilience and commitment demonstrated by Head Start teachers, it is imperative their psychological health and well-being is not overlooked.

In Fort Peck, there is critical need for sustainable psychological and behavioral health support (23). However, provision of these services is hampered by the remote location of reservations, wait time of up to 3 months, lack of private or employment-based health insurance, reluctance to utilize existing health services due to structural and institutional racism (1, 24), and the primary health care provider on reservations, the Indian Health Service, being chronically underfunded and understaffed, particularly in rural and remote settings (25). As a result, access to quality, culturally sensitive psychological and behavioral health care is lacking (26).

Cultural and community strengths

Native American communities demonstrate immense cultural and community strengths despite ongoing disparities. There is growing recognition that physical and psychological health challenges afflicting Native American communities are connected to settler colonialism. This has led to an emergence of behavioral health interventions that emphasize cultural buffers (e.g., positive tribal identity and communal mastery) to promote well-being and bolster individual and collective strengths as means of regaining connection to cultural heritage and ways of being (27, 28). Furthermore, culturally informed psychological health care and even “culture as treatment” holds promise of carrying cultural strengths forward for generations to come (1, 29).

Study Purpose, Community-Based Participatory Research and ADAPT-ITT methodology

To our knowledge, there is little or no implementation research to support the psychological health and well-being of tribal Head Start teachers. Therefore, the purpose of this paper is to, 1) describe our study methodology using the principles of Community-Based Participatory Research (CBPR), and ADAPT-ITT methodology, within an existing academic-community partnership used to frame this work, and 2) outline the process of finding, adapting, and preparing an intervention for testing that will support tribal Head Start teachers by reducing stress and depression, improving well-being, and strengthening resilience.

CBPR is the gold standard for research with Native American communities (30, 31), as it emphasizes development of academic-community partnerships, addressing public health concerns identified by the community of interest, and centering co-learning as the outcome (32). In turn, these actions enhance trust, eliminate power imbalances, and bolster community capacity to reduce health disparities (33). The ADAPT-ITT methodology has been successfully used in Native American contexts and was utilized for this study due to its pragmatic focus on adapting evidence-based interventions for culturally diverse populations (34, 35). It helped ensure that the adapted intervention would remain true to the core elements of the original intervention, and be relevant, sustainable, and acceptable to the new target population (34). Thus, this paper can serve as a model for future adoption and adaption of interventions in this population.

Study design and population

This study incorporates observational and qualitative data from interviews and focus groups into the adaptation and creation of a psychological health intervention using the ADAPT-ITT process within a CBPR framework for Native American Head Start teachers on the Fort Peck Reservation. The TIDieR (Template for Intervention Description and Replication) checklist (36) describes the adaptation process (additional file 1) and the COREQ (Consolidated criteria for reporting qualitative research (37) (additional file 2) describes the process for the interviews and focus groups.

Spanning 180 miles and encompassing 3,200 square miles, the Fort Peck Reservation is home to the Assiniboine and Sioux Tribes—approximately 12,000 tribal members (38). There are six Head Start schools across the Fort Peck reservation serving over 300 children between three to five years old. Those also eligible for services include pregnant women and children from birth to three years of age, and children and families who are homeless, in foster care, or receiving Temporary Assistance for Native Families or Supplemental Security Income (38). Tribal Head Start Administration reports that most children come from single-parent homes, and 80% are below the Federal Poverty Level (Personal communication V. Wood, July10, 2020). There are 21 Head Start teachers and teachers’ assistants; all are women and identify as Native American, with the majority identifying as Assiniboine or Sioux. More than half of these teachers have worked for Head Start for over 20 years. Administration reports that these teachers receive little to no mental health support despite the stresses of their job, personal life, and community (drug addiction, high crime, and suicide rates) (Personal communication V. Wood, July10, 2020).

CBPR framework

The decision to use a selected CBPR framework arose from recognition of the distrust Native American communities have towards academic institutions and researchers, which stems from colonization and experience of unethical research practices with their Peoples (39). Table 1 outlines how CBPR steps and principles were employed throughout the study to enhance the rigor, relevance, and reach of study findings. Team engagement within the community involved 1) access to guidance from a Native American researcher familiar with the community; 2) attending workshops led by Native American Elders and Native academic researchers on how to work with Native populations; and 3) collaboration with other Native and non-Native researchers to conduct a literature review on best practices for culturally safe research with Native American populations (39).

Table 1

CBPR links to study aims
Steps of CBPR (54)	Principles of CBPR(32)	Relation to Study Aims	Strengthens the science by… (55)
Defining, engaging community; identifying community needs and research	Recognition of the community as a unit of identity; recognize tribal sovereignty; building on strengths and resources within community; collaborative partnerships; integration of knowledge and action for mutual benefit of all partners.	Tribal IRB; formation of Tribal Advisory Board (TAB); background research; stakeholder interviews, focus groups; building and maintaining trust; consensus of research goal and development of questions; oversight of research by Native American scholar and TAB.	Ensures Relevance
Design/Hypothesis testing; responsible conduct of research	Promotion of co-learning and an empowering process that encourages social equality; cyclical and interactive process	Community relevant outcome measures; adapting modules of Wakȟáŋyeža, through iterative work with TAB; Implement with ongoing oversight and problem solving with TAB.	Enhances Rigor
Analysis; interpretation of results; dissemination; action	Focus on health from strengths-based perspectives; dissemination of findings and knowledge to all partners	Refinement based on new understandings; review and interpretation by all members of team; joint publications; collaborative conference presentations; community presentation	Extends Reach

ADAPT-ITT methodology

ADAPT-ITT methodology was originally developed to ensure a systematic framework for adapting, implementing, and evaluating evidence-based HIV prevention interventions (34). Using an iterative process and repeated applications Drs. Wingood and DiClemente developed the ADAPT-ITT model considering the need to be cost effective, attentive to cultural context, adhering to core intervention elements, and producing an adapted intervention that is relevant, sustainable, and acceptable for the target population (34). Utilized in domestic and international settings, with diverse populations ADAPT-ITT involves the community and target population throughout the adaption process, uses qualitative data (interviews, focus groups, observation) and quantitative assessments (theater testing, feasibility testing and pretest posttest surveys) to ensure a systematic process to efficiently create an adapted intervention (34). The ADAPT-ITT method consists of eight sequential steps that guide researchers through the adaptation process. For this study we applied each step using the following qualitative and quantitative assessments and tools:

1) Assessment: literature review; focus groups and interviews.

2) Decision: identified and selected an evidence-based intervention to adapt.

3) Adaptation: original intervention reviewed and tested by target audience using theater testing methodology.

4) Production: iterative process with Tribal Advisory Board (TAB) and original intervention designers to develop a draft of the adapted intervention.

5) Topical experts: draft reviewed by TAB, and proposed survey measures piloted with TAB.

6) Integration: feedback from experts incorporated into draft and pretest-posttest survey,

7) Training: a community health worker (CHW) will be trained in recruitment and implementation of adapted intervention and

8) Testing: a feasibility/acceptability study will be conducted in the future.

Figure 1 summarizes processes implemented by the team, which correspond to each step of the ADAPT-ITT model. Of note, the final two steps (7. training and 8. testing) will be reported in a future publication.

Ethics approval

The Fort Peck Head Start administration had interest in exploring and implementing a sustainable intervention to promote their teachers’ well-being, which was solidified in a meeting with the Tribal Executive Board—consisting of Assiniboine and Sioux tribal leaders. We discussed our intent, and a Tribal Resolution (Resolution #30-348-2020-03) authorized this research, which gave permission to apply for funding and conduct a study on the reservation with Fort Peck Head Start teachers. Additionally, the resolution includes a section on the tribe rights to protect intellectual property and Indigenous knowledge including, pictures, songs, or stories and requires that any manuscripts be reviewed by the council prior to publication. Institutional Review Board (IRB) approval was granted by both the XXXX (Blinded for review) and Fort Peck IRBs.

Tribal Advisory Board

With permissions, formal IRB approvals, and training completed a TAB was then established. A TAB is made up of community members who share a common identity, history, symbols, language, and culture (39). They advise researchers on culturally safe research practices with the community and help their communities understand research rationale, impact, and consent processes (39). The TAB for this study consisted of a Head Start supervisor, Head Start teacher, Head Start parent, a cultural advisor, a public-school educator (and Head Start parent), and a Head Start grandparent. TAB members receive an honorarium for attending meetings. Using an iterative process, the researchers worked with the TAB, to develop a logic model that outlines the research process of this study (Fig. 2).

Data Collection

Step 1– Assessment

A comprehensive literature search for studies that have implemented interventions with for Head Start teachers across the U.S. to decrease stress or promote well-being was conducted. We also searched for studies that included Native American Head Start teachers or the use cultural adaptations with the Head Start population.

The next step comprised focus groups and interviews with Head Start teachers, parents, and community members to assess psychological risks such as stress, depression and PTSD, preferences for intervention content, perceived need(s), and an assessment of capacity within the community to help adapt and adopt the chosen intervention. Prior to collecting qualitative data, our TAB reviewed the semi-structured focus group and in-depth interview guides (available upon request). They conveyed culturally appropriate ways of ordering the questions and how to ask difficult questions, and ensured we were taking a strengths-based approach to understanding stressors and coping mechanisms among Fort Peck Head Start teachers. Recruitment was conducted using flyers, email and a presentation describing study purpose at a Head Start staff meeting. Eligibility criteria included being older than 18 years, currently or previously worked for Fort Peck Head Start as a teacher, teachers assistant, supervisor, or ancillary staff, or be parents of children that have or had attended Head Start. Teacher needs, comments and concerns were elicited through interviews with key community members (i.e., cultural leaders, council members, and Head Start administration). Community interest was gauged by noting comments and concerns voiced by Fort Peck administration, Head Start teachers, parents, and ancillary school staff. Teachers’ interest was gauged through individual interviews.

Step 2– Decision

Key feedback from the TAB and qualitative data collection yielded a strong interest in using culture as a solution for stress, a concept which has been largely overlooked in other research studies (40). Based on the results of literature search (detailed in results section), we explored the possibility of adapting an intervention currently being implemented with Head Start parent-child dyads on the Fort Peck Reservation via a randomized control trial (RCT) (ClinicalTrials.gov: NCT04201184).

The RCT, Wakȟáŋyeža, hereafter referred to by its translation - Little Holy One - is an intergenerational intervention designed to reduce parental stress and trauma-related symptoms among parent-child dyads, where the children are 3–5 years of age and attending tribal Head Start (23). The intervention is a strengths-based, 12-module curriculum focused on promoting family wellness across a holistic well-being (i.e., physical [behavioral], emotional, mental [cognitive], and spiritual) spectrum. There are four cultural components in the Little Holy One curriculum, designed to support the psychological health and well-being of parent-child dyads by 1,2) promoting tribal identity and communal mastery (group efficacy), 3) addressing contemporary and historical trauma, and 4) promoting smudging. With support from the Principal Investigator of Little Holy One (TB), our TAB, and Head Start administration—we adapted the four cultural lessons into a stress reduction curriculum for Head Start teachers. Table 2 outlines the lessons taken from the Little Holy One curriculum for adaptation to the tribal Head Start teacher context. The cultural lessons were originally developed in partnership with a Fort Peck-based TAB and community members, and Little Holy One pilot data demonstrate lessons were feasible and acceptable to participants.

Table 2

Lesson description
Lessons for adaptation in original order	Description of lessons	Lesson Activities and time to complete
Promoting Tribal Identity	Connects one to the Creator, responsibility to live a good life by walking spiritual path	Practice greeting of relatives in Nakoda and Dakota. Traditional naming 1 hour.
Understanding our Emotions	Understand association among thoughts, feelings, and behavior	Identifying depression, managing anger and stress; working through challenges Visualization activity 1 hour.
Smudging	Therapeutic healing practice to resolve unsettling feelings and thoughts	Smudging together; smudging as a daily routine 45 mins.
Strengthening Family and Community	Therapeutic value of connectedness to relatives and community	Knowing our relatives Family tree exercise. My friends and family exercise 1 hour.
Healing Historical & Contemporary Trauma	Identify imbalances in physical, emotional, mental, and spiritual domains created by historical trauma.	Identifying and coping with effect of historical traumas. Strength and resilience Forgiveness exercise Smudge at end 1 hour.

Step 3– Adaptation using theater testing methodology

The next step involved gathering community feedback for adapting the cultural lessons. Theater testing is a pre-testing methodology that involves presenting an original product to an audience aligned with the intended target audience (34). The TAB, Head Start teachers, and community members were invited to a presentation of the four cultural components, whereby they could respond and ask questions, allowing the study team an opportunity to gauge their reaction to the product. A CHW trained to deliver the cultural lessons, as they are intended for Little Holy One, implemented the modules to this target audience because of her expertise with the original format and knowledge of local tribal culture. Being the audience encompassed the population of interest, they were able to provide an important assessment of the cultural components and provide direction for the study team to ensure the cultural adaptation would meet their needs.

The research team led a discussion in between presentation of each lesson, which included the following prompts: 1) appropriateness of the lessons for teachers, 2) order in which lessons should be implemented, 3) additional materials and/or activities that might enhance its relevance, and 4) appropriateness of reflection and activity handouts and assignments 5) burden of the intervention. Information extracted from qualitative interviews and focus groups (Step 1) was also introduced during these discussions, which included: teachers often do not realize the degree or impact of their stress, they will not travel to get mental health support, and the need for support mechanisms to be made convenient.

Step 4– Production

After listening to theater session recordings and reading transcripts and field notes, a first draft of the adapted intervention with accompanying handouts was developed. This was then

presented to the designers of the cultural lessons to ensure the adaptation maintained the integrity of their original intervention.

Step 5– Topical experts

With a first draft ready for review we then piloted the pre-posttest survey with the TAB letting them naturally self-administer the survey as intended. Intentional care had been taken to choose measures validated in a Native American context. Discussion with the designers of the original intervention afforded the team access to two measures, cultural identity, and historical trauma, that have been specifically modified for the Assiniboine and Sioux culture. Table 3 details the full list of proposed pre-posttest outcome measures. The TAB is considered an expert group and representative of the target population; thus, their responses were important to assess appropriateness of the chosen outcome measures. The primary outcome of the proposed feasibility study will be to reduce self-perceived stress (measured using the validated self-perceived stress scale (41)). Secondary outcomes are to increase well-being (satisfaction with life (42)) and decrease depression (Center for Epidemiologic Studies Depression Scale- CESD_10 (43)). Longitudinally, we hope to see a decrease in historical loss associated symptoms, and an increase in resilience (Connor Davidson Resilience scale (44)), tribal identity (45), and communal mastery.

Table 3

Proposed Pre- and- Post Test Outcome Measures
Concept	Measure	Number of items and scoring range	Cronbach’s alpha	Time to complete
Stress	Perceived Stress Scale 10 (PSS-10) (41)	Widely used and has been adapted for Native American populations. 10 items 5-point scale. 0 = Never to 4 = very often	0.78	2 min
Well-being	Satisfaction with Life Scale (42)	A better measure of subjective well-being in Indigenous populations. 5 items. 7-point scale. 1 = strongly agree to 7 = strongly disagree	0.87	1 min
Depression	Center for Epidemiologic Studies Depression Scale Revised (CESD-R-10) (43)	Self-Report. Validated among Native American populations. 10 items	0.86	1 min
Childhood trauma/adversity	Stressful Life Events Questionnaire (SLESQ) (56)	Self-report measure to assess life-time exposure to traumatic events. More accurately captures traumas experienced by Native American population then BFRSS ACE score. 13—item scale	0.73	7 mins
Group Self Efficacy	Communal Mastery Scale (57)	Developed specifically for Native American contexts. Uses two commonly employed measures of mastery and self-efficacy 10 items 4-point scale. 1 = strongly disagree to 5 = strongly agree	0.85	2.5 min
Cultural Identity	Tribal Identity (45)	Modified from Orthogonal Cultural Identification Scale specifically for Assiniboine and Sioux identity. 6-items	0.9	1.5 min
Historical Trauma	Historical Trauma (58)	3 questions developed specifically for Native American context: yes/no		1.5 min
Historical Trauma	Historical Trauma Checklist	15 items adapted for Assiniboine/Sioux Tribes. Yes/no don’t know, refuse to answer		3.0 min
Historical Trauma	Historical losses Associated Symptoms Scale (58)	12 questions. 5-point Scale 0 = Never to 5 = Very often	0.91	1.5 min
Resilience	Connor-Davidson 10-item Resilience scale (CD-RISC-10) (44)	Is more effective with Native American populations than CD-RISC-25. 10 items. 5-point scale. 0 = Never to 4 = Very often	0.85	1 min
Childhood resilience	Benevolent Childhood Experiences Scale (BCEs) (59)	Has been used in Native American populations. 10 items yes/no		1 min
Quality of teacher-children relationships	Student Teacher Relationship Scale (short form) (60)	Has been used with Head Start teachers. Items are grouped into two subscales: conflict and closeness. 15 items.5-point scale 1 = definitely does not apply to 5 = definitely applies	conflict 0.73 Closeness 0.72	2min
Childhood Trauma	Adverse Childhood Experience (ACEs) (4)	Validated measure that tallies the different types of abuse, neglect, and other adverse childhood experiences. 10 items – yes/no	.67	5 min
TOTAL TIME				30 minutes

TAB members were each given the proposed pre-posttest survey and asked to take notes as they navigated the questions. Following completion, we conducted a focus group-style discussion. TAB members were asked to consider the following questions about the survey: 1) was there any confusion with the survey instructions, 2) do the survey instructions help introduce and guide participants through the survey, 3) was there any variability in your interpretations of the questions, 4) was there any discomfort in answering any of the questions, 5) what did you think of the length of the survey, and 6) what did you think of the order of the measures?

Step 6– Integration

The research team presented the draft of an adapted 5-lesson curriculum for implementation with Fort Peck Head Start teachers to the TAB where it was approved. Finally, we took the feedback from the piloting of the pre-posttest survey and presented the final draft to the TAB once more prior to planned implementation. This iterative process helped ensure no gap between the measures and theoretical constructs and integrated local, cultural perspectives (46)

At the time of data collection, the Fort Peck Reservation experienced a surge in COVID-19 cases, which required a reduction in number of participants for safety, IRB compliance, and adherence to university and tribal protocols. As such, interviews were conducted via Zoom or telephone and focus groups delayed until the tribal government allowed in-person gatherings. The four theater testing sessions were conducted in-person with numbers limited to the TAB members (five in total), one CHW, and one researcher (DW) to comply with tribal government restrictions on how many people could gather.

Data Analysis

All focus groups and interviews were recorded and transcribed verbatim. TAB meetings and theater testing sessions were recorded, and detailed notes taken. Qualitative data was thematically coded using qualitative analysis software F4Analyse by two researchers who met to compare coding and discuss emerging themes. Results were discussed with the research team and brought to the TAB so that findings could be incorporated into intervention adaptation.

Results are highlighted below in sequential order for steps one through six of the ADAPT-ITT process.

Step 1– Literature search, focus groups, and interviews

The literature search found that successful evidence-based resources to support Head Start teachers in coping with the demands of their profession include mindfulness-based cognitive therapy (47); access to mental health consultants and social workers(48) and self-care and classroom-management skills (49). We did not find any studies that center or prioritize Native American culture, values, and strengths (like tribal and/or spiritual identity), or challenges (such as historical trauma, discrimination, and health disparities) when adapting and implementing psychological health and wellness interventions (2). These findings motivated the shift from adapting an existing evidence-based psychological intervention to exploring and choosing the culturally informed intervention Little Holy One.

Purposive sampling was used because of the specific thematic focus on teacher stress and coping factors. Thematic saturation was reached with sample size of 27: four Head Start administrators; seven Head Start teachers, four Head Start teacher assistants, eight Head Start parents and four ancillary staff. Two focus groups were conducted in person one with teachers and teachers assistants (n = 5) and one with parents (n = 4). All other participants were interviewed individually via telephone or Zoom.

Four major themes emerged from the focus groups and interviews: 1) existing mechanisms, 2) mental health and stress, 3) interest in a culturally informed intervention, and 4) sustainability. Key themes from each are documented in Table 4. Participant input helped identify existing mechanisms for support, gaps in support, and identify what type of intervention may fit this population. They also ascertained the willingness of administration to work on sustainability of the intervention if deemed feasible and acceptable. Other themes that emerged during coding and through iterative discussion with the research team will be reported in a future qualitative publication.

Table 4

Major themes from qualitative data
Theme	Qualitative exemplar quotes
Existing mechanisms (Usual practice)
Lack of support	“There have been lost promises for mental health support for our teachers” (Head Start supervisor 2).
Existing Services	“Counselors (that come to the reservation) don’t understand the spirituality of the culture, the poverty, violence, and trauma that took place…” (Head Start supervisor 1)
Existing coping mechanisms	“Teachers cope by venting and smoking” (ancillary staff 2)
Mental health and stress
Barriers to Mental Health access	“Native People are not used to that type of ask [..to ask for help] they are not necessarily processing up here emotion wise.” (Head Start supervisor 2) “Mental health support is not a priority; we need to do something for our employees.” (Head Start supervisor 3)
Stressors for teachers	“Teaching don’t get the mental health support it needs… kids commit suicide… it affects the teacher.” (Parent focus group) • “COVID has kicked us down.” (Teacher 7)
Historical and contemporary trauma	“They have been trying to wipe us out [reference to historical genocide]. We need a breakthrough, and we all have a little bit of spirituality.” (Teacher 5)
Interest in a culturally informed intervention
Culture as treatment	“Cultural activities with the adults would be creating that positive [resolving stress, promote well-being]. Everybody respects the traditional ways, share an understanding of traditional ways.” (Head Start supervisor 3) “The suicides, drug abuse, these disparities are related to our loss of culture and language. The more you know about your culture, connect to your community, there is strength in that.” (Parent Focus Group).
Barriers to a culturally informed intervention	.. “But there are also different religions on the rez so you may run into some issues [with a cultural intervention].” (Head Start supervisor 1)
Sustainability
Supporting mechanisms	“The Tribal Handbook pays for 30 mins a day for physical health – time to go for a walk, but we have not thought about using it for mental health” (Head Start supervisor 1) “We could incorporate a mental health program into our monthly teacher days on Fridays” (Head Start supervisor 2)
Barriers	“Technology is an issue – 85% of our teachers don’t know how to use zoom.” (Head Start supervisor 1) “The Wellness center, you know, it would be nice to go there when we are stressed but it’s hard to get over there. There is nothing else.” (Teacher 9)

Step 2, 3– Decision, adaptation

Upon completion of each theater testing presentation the researcher facilitated a discussion using the prompts listed in the methods section to elicit feedback on the lessons and how to adapt for the Head Start teacher context: 1) appropriateness of the lessons for teachers: Overall participants were pleased to see traditional cultural practices being used as the treatment itself and felt that this could contribute to well-being, tribal self-determination, and reclamation of culture. One participant commented that this was better than seeing a Western evidenced-based practice adapted to their tribal context. All participants felt that such an intervention would work well with little adaptation for the Head Start teachers although mention was made that some teachers are very religious and might not feel comfortable being immersed in cultural ways.

2) order in which lessons should be implemented: Changing the order of lesson delivery was discussed because of concerns that the cultural lessons were no longer buffered by the other eight lessons from the original 12 lesson Little Holy One RCT e.g., smudging was placed before historical trauma so that it could be used throughout lesson delivery to deal with any stress brought up by discussing such topics. Strengthening family and communities was chosen to be the last lesson as the TAB felt that it would end the study on a strong positive note. The final order of lessons agreed upon was: 1) Tribal identity, 2) Smudging, 3) Healing Historical Trauma, 4) Managing Your Emotions and 5) Strengthening family and community. For the Tribal Identity lesson TAB members were concerned that the teachers might feel shame at not knowing their native language or be shy about trying the greeting activity. They suggested creating an Mp3 with the language examples so that participants could practice at home with their family. Language can be intimidating, they said, and they did not want to make teachers afraid of the language because of fear of mispronunciation.

3) additional materials and/or activities that might enhance its relevance: The topic of dealing directly with stress was raised; wherein the CHW proposed adding a lesson from the other Little Holy One eight lessons called managing your emotions. This is a lesson taken from the Common Elements Treatment Approach (CETA) model. CETA was chosen for Little Holy One because of its success in trauma affected low resource communities (50). The CHW presented this lesson to the TAB who agreed it would be good to include in the adaption thus increasing the proposed adapted curriculum to five sessions.

4) appropriateness of reflection and activity handouts and assignments: A suggestion by a participant to switch the delivery from one-on-one to a group format was well received. The activity handouts were encouraging for a group-based setting, as they involve things such as a family tree exercise which may yield new connections for participants. There were suggestions to add specific group activities such as preparing a Native meal together or a traditional sewing activity.

5) burden of the intervention: Concerns about lesson attendance being a burden for teachers was addressed by the suggestion to conduct lessons before or after the monthly staff meetings to minimize travel for the teachers.

Step 4– Production

When presented with a draft of the lesson plan, the original designers first concern was regarding the addition of the fifth lesson – managing your emotions which is not a cultural lesson. However, after reviewing the qualitative data where teachers indicated lack of awareness about their stress—they were amenable to this content. The second concern involved cost and the time intensive nature of the proposed additional activities, (such as preparing a Native meal and sewing) which were discarded. The suggested switch in order of the lessons was approved.

A five lesson culturally informed intervention was adapted for Head Start teachers from the original Little Holy One 12-lesson curriculum that is currently being implemented with Head Start parents and children. The adapted intervention includes four culturally specific lessons and one CETA lesson resulting in a 5-lesson curriculum to be delivered at monthly Head Start teacher staff meetings starting in May or June 2022.

Step 5 and 6– Topical experts and integration

Expert opinion from the TAB and original designers of Little Holy One resulted in lessons adapted from an individual to a group format, with activities and hand-outs tailored to the new target population (Head Start teachers). A fifth lesson was added in response to perceived need for teachers to have the opportunity to explore and understand stress and depression and how to manage them. The pre-posttest survey that will be used in the proposed feasibility study was piloted and approved by the TAB with their feedback determining order and appropriateness of the measurement tools chosen for the survey. Instructions were deemed clear and the chosen measures appropriate for use with the Head Start teacher population. The final result is a 5-lesson culturally informed intervention aimed at reducing stress and promoting tribal Head Start teacher well-being ready for testing along with the pre-posttest survey. Results of the planed feasibility study will be reported in a future publication.

This study has been designed in response to a critical need for psychological and behavioral interventions that are culturally curated for the population(s) they intend to serve and are self-sustaining in rural, low-resource settings. More specifically, this intervention uses traditional cultural practices as the treatment and has been adapted to a different target audience within the same culture. Designing the aims based on community assets and strengths was a necessary first step, to eliminate characterization of the population and setting by challenges and deficits alone (51). The process outlined in this paper will contribute to growing evidence of the successes and potential challenges in adapting psychological health interventions for specific populations and cultural contexts. With the lack of access to psychological and behavioral health support identified in the Fort Peck community health assessment and qualitative data pointing to Head Start teachers being a stressed population in need of structured support this intervention has the potential to fill an identified gap and provide culturally appropriate psychological support. We are enhancing the potential of intervention sustainability by leveraging the roles and responsibilities of local CHWs in a setting that lacks specialty providers; thereby addressing the challenge of reaching populations that live in remote areas and lack access to psychological health services.

The research also illuminates the efficacy and acceptability of grounding an intervention in traditional cultural practices. This is important as not only is access to effective treatments urgent, but data suggests that psychological treatment-as-usual for Native Americans is often ineffective because they lack connection to the culture they are trying to serve (40). While still novel there is growing evidence that immersion in traditional cultural activities promotes healing and well-being (40). We hope that the proposed feasibility study will contribute to existing implementation literature. Using a CBPR framework to ensure culturally safe practices and community input throughout has further strengthened the process of adaptation and utilizing ADAPT-ITT has helped ensure a rigorous and replicable method.

Finally, the COVID-19 pandemic has led to increased individual, community, and societal stress with a National Head Start Association (2020) survey identifying need for greater access to trauma, grief, and mental health care for Head Start teachers, children, and at-risk families. The pandemic has disproportionately affected low-income communities leading to a greater urgency to find supportive avenues for managing stress, particularly in Native American communities where challenges are compounded by historical, intergenerational, and contemporary traumas many face (11, 52, 53).

The delays in data collection caused by closure of the reservation due to rises in COVID-19 cases afforded an opportunity for the research team to develop a working relationship with tribal Head Start administration. The digital divide was evident as teachers were not familiar with Zoom and thus unable to switch to teaching in an online format. Thus, the research team was able to work with administration to assist teachers in developing proficiency with online formats.

Limitations

This study should be interpreted within the context of its limitations. First and foremost, we must acknowledge that some of our research team members are of European descent. However, the Principal Investigator of record is Native American and has a long-standing relationship with the Fort Peck Tribes, and guidance was provided by the Little Holy One research team who all identify as Native American and reside on the Fort Peck Reservation. Finally, in-person research was delayed due to COVID-19. This necessitated initial qualitative data collection to be conducted remotely which was not ideal. As a team we decided theater testing required in-person meetings which necessitated delays in the research timeline.

This study has been thoughtfully designed to adapt, the four cultural lessons from the Little Holy One curriculum with a sample of tribal Head Start teachers on the Fort Peck Reservation in preparation for testing the adapted version in a feasibility study. These cultural lessons were originally developed by the Fort Peck community and aim to leverage cultural strengths as a buffer to psychological challenges. Meaningful input from the teachers and the TAB helped ensure that the adapted lessons would be applicable for the subgroup of Head Start teachers but that the core values, traditions, and practices of the cultural lessons remained consistent. The ADAPT-ITT methodology enhanced the relevance and rigor of the adaptation process. In adapting these lessons for tribal Head Start teachers, we hope to better understand the feasibility and acceptability of providing such content centered around their culture. This article presents an example of a replicable process using the principals of CBPR and ADAPT-ITT to allow cultural and context specific adaptations to be conducted in other settings with different populations. Finally, planned future research will explore the feasibility and acceptability of the adapted lessons when tested with the Fort Peck Head Start teachers. Results will contribute to greater understanding of how to best develop strengths-based, cultural interventions for educators to decrease their stress and enhance their resilience and holistic well-being.

ACES: Adverse Childhood Experiences

CBPR: Community-Based Participatory Research

CETA: Common Elements Treatment Approach

CHW: Community Health Worker

IRB: Institutional Review Board

IPV: Intimate Partner Violence

PTSD: Post Traumatic Stress Disorder

TAB: Tribal Advisory Board

U.S. United States

Ethics approval and consent to participate

The study was authorized by the Fort Peck Executive Board through Tribal Resolution (Resolution #30-348-2020-03). All study team members have completed required training on human subjects’ research, conflicts of interest, and health privacy issues. Study team members completed consent with all participants prior to the start of data collection, which included consent to publication of findings. Human subjects review was conducted by the Fort Peck Tribal IRB (September 2020) and Johns Hopkins School of Medicine IRB (IRB00252294). Any modifications to study protocols were submitted to both IRBs for approval prior to implementation. Fort Peck Tribal IRB reviews all manuscripts prior to publication.

Consent for publication

Not applicable.

Availability of data and materials

The government-to-government relationship between the U.S. and federally recognized tribes acknowledges tribal sovereignty, tribal laws, and the tribes’ capacity to make decisions about research that is conducted within their jurisdictional boundaries. The tribal law that supports this research acknowledges the importance of community consent as well as individual consent and will provide the particularities for data sharing as part of tribal research regulation. All resources and data generated by this project will be made available in the most user-friendly, accessible, secure, and ethical format to all study partners. We will take necessary steps to ensure we adhere to Fort Peck Tribal Law (Resolution #30-348-2020-03) and National Institutes of Health guidelines on sharing of data, in collaboration with our tribal partners, including seeking the appropriate tribal approvals to respect their tribal sovereignty and confidentiality.

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no financial or non-financial competing interests.

Funding

This work was supported by the National Institute of Nursing Research of the National Institutes of Health under Award Number F31NR019742. “The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.”; Sigma/Jonas Philanthropies Collaborative Research Grant under grant number 138054; Johns Hopkins University School of Nursing Discovery and Innovation Fund under grant number 80055563; and Johns Hopkins School of Public Health Center for Qualitative Studies (no grant number).

Authors' contributions

Indigenous expertise: TB; 2) Content expertise: DW, KN, AG, TB, 3) Conceptualization of study design: DW, TB 3) Data collection and analysis: DW, AG 4) Manuscript drafting and editing: DW, KN, AG, SL TB, 3) Critical revisions and proofs: DW, KN, AG, SL, TB. All authors reviewed and approved the final manuscript.

Acknowledgements

The authors would like to thank the Tribal Advisory Board: Jewel Ackerman Four-star, Alex James, Griffin Ricker, Suzzanne Turnbull, and Cathy Wetsit. They guided and advised the research team to ensure culturally safe research with all tribal members and organizations that participated.

Authors' information

Dr. Teresa Brockie is an enrolled member of the Aaniniiin Nation

Gone JP, Trimble JE. American Indian and Alaska Native mental health: diverse perspectives on enduring disparities. Annual review of clinical psychology 2012 Apr 27,;8(1):131–160.
Wexler L, Chandler M, Gone JP, Cwik M, Kirmayer LJ, LaFromboise T, et al. Advancing suicide prevention research with rural American Indian and Alaska Native populations. Am J Public Health. 2015;105(5):891–9.
Brockie TN, Heinzelmann M, Gill J. A framework to examine the role of epigenetics in health disparities among Native Americans. Nurs Res Pract. 2013;2013:410395.
Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) study. Am J Prev Med. 1998;14(4):245–58.
Petruccelli K, Davis J, Berman T. Adverse childhood experiences and associated health outcomes: A systematic review and meta-analysis. Child Abuse Negl. 2019;97:104127.
Walls ML, Whitbeck LB. Advantages of stress process approaches for measuring historical trauma. Am J Drug Alcohol Abus. 2012;38(5):416–20.
Giano Z, Wheeler DL, Hubach RD. The frequencies and disparities of adverse childhood experiences in the U.S. BMC public health 2020 Sep 10,;20(1):1–1327.
Brockie T, Dana-Sacco G, Wallen G, Wilcox H, Campbell J. The relationship of Adverse Childhood Experiences to PTSD, depression, poly-drug use and suicide attempt in Reservation-based Native American adolescents and young adults. Am J Community Psychol. 2015;55(3):411–21.
Hackett C, Feeny D, Tompa E. Canada's residential school system: measuring the intergenerational impact of familial attendance on health and mental health outcomes. Journal of epidemiology and community health (1979) 2016 Nov;70(11):1096–1105.
McQuaid RJ, Bombay A, McInnis OA, Humeny C, Matheson K, Anisman H. Suicide ideation and attempts among First Nations Peoples living on-Reserve in Canada: the intergenerational and cumulative effects of Indian residential schools. Can J Psychiatry. 2017 Jun;62(6):422–30.
Gone JP. Reconsidering American Indian historical trauma: Lessons from an early Gros Ventre war narrative. Transcult Psychiatry. 2013;51(3):387–406.
Yehuda R, Lehrner A. Intergenerational transmission of trauma effects: putative role of epigenetic mechanisms. World psychiatry. 2018 Oct;17(3):243–57.
Bethell C, Jones J, Gombojav N, Linkenbach J, Sege R. Positive childhood experiences and adult mental and relational health in a statewide sample: associations across Adverse Childhood Experiences levels. JAMA pediatrics 2019 Sep 9,;173(11):e193007.
Baum N, Stokar Y, Ginat-Frolich R, Ziv Y, Abu-Jafar I, Cardozo B, et al. Building Resilience Intervention (BRI) with teachers in Bedouin communities: From evidence informed to evidence based. Children and Youth Services Review 2018 Apr 1,;87:186.
Bullough RV, Hall-Kenyon KM. The call to teach and teacher hopefulness. Teacher development 2011 May 1,;15(2):127–140.
Gibson M. 'I want to educate school-age children': producing early childhood teacher professional identities. Contemporary issues in early childhood 2013 Jan 1,;14(2):127–137.
Carroll T. The high cost of teacher turnover. National Commission on Teachings and Americas Future; 2007.
Hydon S, Wong M, Langley AK, Stein BD, Kataoka SH. Preventing secondary traumatic stress in educators. Child Adolesc Psychiatr Clin N Am. 2015;24(2):319–33.
Sharp Donahoo LM, Siegrist B, Garrett-Wright D. Addressing compassion fatigue and stress of special education teachers and professional staff using mindfulness and prayer. J school Nurs. 2018 Dec;34(6):442–8.
Hughes K, Bellis MA, Hardcastle KA, Sethi D, Butchart A, Mikton C, et al. The effect of multiple adverse childhood experiences on health: A systematic review and meta-analysis. The Lancet Public health. 2017;2(8):e356–66.
Jeon L, Buettner CK, Snyder AR. Pathways from teacher depression and child-care quality to child behavioral problems. J Consult Clin Psychol. 2014;82(2):225–35.
Fort Peck Tribal Health Department. Fort Peck Community Health Assessment. 2016.
Brockie T, Haroz EE, Nelson KE, Cwik M, Decker E, Ricker A, et al. Wakȟáŋyeža (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. BMC public health 2021 Dec 18,;21(1):2298.
Tracey C. Montana's Urban Indians face health care barriers. 2007.
Siddons A. The never-ending crisis at the Indian Health Service. Roll call (Washington, D.C.) 2018 Mar 5.
Wexler LM, Gone JP. Culturally responsive suicide prevention in Indigenous communities: unexamined assumptions and new possibilities. Am J public health (1971). 2012;102(5):800–6.
Walls M, Pearson C, Kading M, Teyra C. Psychological wellbeing in the face of adversity among American Indians: preliminary evidence of a new population health paradox? Annals of public health and research 2016;3(1).
Wexler L. Looking across three generations of Alaska Natives to explore how culture fosters indigenous resilience. Transcult Psychiatry. 2013;51(1):73–92.
O'Keefe VM, Cwik MF, Haroz EE, Barlow A. Increasing culturally responsive care and mental health equity with indigenous community mental health workers. Psychological services 2019.
Anastario M, FourStar K, Ricker A, Dick R, Skewes MC, Rink E. A preliminary needs assessment of American Indians who inject drugs in northeastern Montana. Harm Reduct J. 2017;14(1):22.
Haroz EE, Ingalls A, Kee C, Goklish N, Neault N, Begay M, et al. Informing precision home visiting: identifying meaningful subgroups of families who benefit most from Family Spirit. Prev Sci. 2019;20(8):1244–54.
Israel BA, Schulz AJ, Parker EA, Becker AB. Review of community-based research: Assessing partnership approaches to improve public health. Annu Rev Public Health. 1998;19(1):173–202.
Wallerstein NB, Yen IH, Syme SL. Integration of social epidemiology and community-engaged interventions to improve health equity. Am J Public Health. 2011;101(5):822–30.
Wingood GM, DiClemente RJ. The ADAPT-ITT, Model. A novel method of adapting evidence-based HIV interventions. JAIDS Journal of Acquired Immune Deficiency Syndromes 2008 Mar 1,;47 Suppl 1, The First National Scientific Meeting of the Social and Behavioral Science Research Network(Supplement 1):S40-S46.
Craig Rushing S, Gardner W. Native VOICES. Adapting a video-based sexual health intervention for American Indian teens and young adults using the ADAPT-ITT model. Am Indian Alsk Native Ment Health Res. 2016;23(1):24–46.
Hoffmann TC, Glasziou PP, Boutron I, Milne R, Perera R, Moher D, et al. Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ (Online) 2014 Mar 7,;348(mar07 3):g1687.
Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349–57.
Fort Peck. Assiniboine & Sioux Tribes. Fort Peck Tribes. 2022; Available at: http://www.fortpecktribes.org/. Accessed March 1, 2020.
Brockie TN, Hill K, Davidson PM, Decker E, Krienke LK, Nelson KE, et al. Strategies for culturally safe research with Native American communities: an integrative review. Contemporary nurse: a journal for the Australian nursing profession 2022 January 4,;ahead-of-print(ahead-of-print):1–25.
Gone JP, Calf Looking PE. American Indian culture as substance abuse treatment: Pursuing evidence for a local intervention. Journal of psychoactive drugs 2011 Oct 1,;43(4):291–296.
Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. Journal of Health and Social Behavior 1983 Dec 1,;24(4):385.
Diener E, Oishi S, Lucas RE. Personality, culture, and subjective well-being: Emotional and cognitive evaluations of life. Ann Rev Psychol. 2003;54(1):403–25.
Schure M, Goins RT. Psychometric examination of the Center for Epidemiologic Studies Depression scale with older American Indians: The Native Elder Care Study. Am Indian Alaska Nativ Mental Health Res (Online). 2017;24(3):1–13.
Goins RT, Gregg JJ, Fiske A. Psychometric properties of the Connor-Davidson Resilience Scale with older American Indians. Res Aging. 2013;35(2):123–43.
Oetting ER, Swaim RC, Chiarella MC. Factor structure and invariance of the orthogonal cultural identification scale among American Indian and Mexican American youth. Hispanic Journal of Behavioral Sciences 1998 May 1,;20(2):131.
Groves R, Fowler F, Couper M, Lepkowski J, Singer E, Tourangeau R. Survey methodology. 2. ed. ed. Hoboken: Wiley; 2009.
Gold E, Smith A, Hopper I, Herne D, Tansey G, Hulland C. Mindfulness-based stress reduction (MBSR) for primary school teachers. J Child Fam Stud. 2010;19(2):184–9.
Raver CC, Jones SM, Li-Grining CP, Metzger M, Champion KM, Sardin L. Improving preschool classroom processes: Preliminary findings from a randomized trial implemented in Head Start settings. Early Child Res Q. 2008;23(1):10–26.
Rombaoa Tanaka N, Boyce LK, Chinn CC, Murphy KN. Improving early care and education professionals' teaching self-efficacy and well-being: A mixed methods exploratory study. Early education and development 2020 Oct 2,;31(7):1089–1111.
Murray LK, Dorsey S, Haroz E, Lee C, Alsiary MM, Haydary A, et al. A Common Elements Treatment Approach for adult mental health problems in low- and middle-income countries. Cogn Behav Pract. 2014;21(2):111–23.
Kelley A, Small C. Establishing the reliability and validity of the sources of strength in one American Indian community. Am Indian Alaska Nativ Mental Health Res (Online). 2016;23(2):84–92.
Nagasawa M, Tarrant K. Who will care for the early care and education workforce? COVID-19 and the need to support early childhood educators’ emotional well-being. New York Early Childhood Professional Development Institute, CUNY. 2020.
Wexler L. The importance of identity, history, and culture in the wellbeing of indigenous youth. J history Child youth. 2009;2(2):267–76.
Hacker K. CBPR—step by step. Community-Based Participatory Research 55 City Road. SAGE Publications, Inc; 2013. p. 63.
Balazs CL, Morello-Frosch R. The three Rs: how community-based participatory research strengthens the rigor, relevance, and reach of science. Environ Justice. 2013;6(1):9–16.
Goodman L, Corcoran C, Turner K, Yuan N, Green B. Assessing traumatic event exposure: general issues and preliminary findings for the Stressful Life Events Screening Questionnaire. J Trauma Stress. 1998;11(3):521–42.
Hobfoll SE, Schröder KEE, Wells M, Malek M. Communal versus individualistic construction of sense of mastery in facing life challenges. J Soc Clin Psychol. 2002;21(4):362–99.
Les Whitbeck B, Chen X, Hoyt DR, Adams GW. Discrimination, historical loss and enculturation: culturally specific risk and resiliency factors for alcohol abuse among American Indians. J Stud Alcohol. 2004;65(4):409–18.
Narayan AJ, Rivera LM, Bernstein RE, Harris WW, Lieberman AF. Positive childhood experiences predict less psychopathology and stress in pregnant women with childhood adversity: A pilot study of the benevolent childhood experiences (BCEs) scale. Child abuse & neglect 2018 Apr;78:19–30.
Pianta RC. Student-teacher relationship scale. Lutz: Psychological Assessment Resources; 2001.

PDF

Version 1

posted 23 Jun, 2022

You are reading this latest preprint version

Adaption of a culturally informed stress reduction intervention for Native American Head Start Teachers using ADAPT-ITT and CBPR methodologies

Status:

Version 1

Abstract

Figures

Contributions To The Literature

Introduction

Adverse childhood experiences

Tribal Head Start teacher stress

Reservation community needs assessment

Cultural and community strengths

Study Purpose, Community-Based Participatory Research and ADAPT-ITT methodology

Methods

Study design and population

CBPR framework

ADAPT-ITT methodology

Ethics approval

Tribal Advisory Board

Data Collection

Step 1– Assessment

Step 2– Decision

Step 3– Adaptation using theater testing methodology

Step 4– Production

Step 5– Topical experts

Step 6– Integration

Data Analysis

Results

Step 1– Literature search, focus groups, and interviews

Step 2, 3– Decision, adaptation

Step 4– Production

Step 5 and 6– Topical experts and integration

Discussion

Limitations

Conclusion

Abbreviations

Declarations

References

Supplementary Files

Status:

Version 1