Visions: A Tribal Perspective on Methamphetamine and Suicide Prevention
a publication of the National Indian Health Board
Winter 2014 
In This Issue
Spotlight Story: Toiyabe Adapts AILS to Promote Youth Resiliency
American Indian Life Skills Story of Development
Reentry Series 
Part II: Reentry is a Behavioral Health Issue
Project Management Series Part I: 
Good Project Management = Effective Risk Management
Have You Seen...
SAMHSA's Native Suicide Publication  
The Substance Abuse and Mental Health Services Administration (SAMHSA) published To Live To See the Great Day That Dawns: Preventing Suicide by American Indian and Alaska Native Youth and Young Adults, a 172 page book detailing best and culturally relevant practices to assist a community with instances of suicide and create resources to prevent future suicides through a strength-based, protective approach.  For more information and to order a copy of the publication, please click here. 
The "How to Start a Suicide Survivor's Group" Guide 
 The International Suicide Advocacy Group and the World Health Organization produced this comprehensive guide detailing the importance of self-help groups in suicide prevention and treatment, establishing the purpose of such a group and providing tips on how to organize the operational framework for such groups.  For a copy of the guide, please click here



APHA American Indian, Alaska Native, Native Hawaiian (AIANNH) Caucus is
accepting abstracts for upcoming conference. 

The 2014 American Public Health Association (APHA) Annual Meeting & Expo will take place November 15-19 in New Orleans, LA. The theme is "Healthography: How Where You Live Affects Your Health & Well-Being." The AIANNH Caucus invites abstracts for papers addressing health programming, research and policy for Native populations and the conference theme. Abstracts are due February 11th and can be submitted online (please click here)


Depression on College Campuses Conference

March 12-13, 2014

Ann Arbor, MI


13th Annual Native Women & Men's Wellness Conference 

March 16-19, 2014

San Diego, CA


5th Annual National Tribal Public Health Summit

   March 31-April 2, 2014

Billings, MT


Illinois Statewide Suicide Prevention Conference

April 5, 2014

Springfield, IL


47th American Association of Suicidology Annual Conference

April 9-12, 2014

Los Angeles, CA


White Bison hosts annual Wellbriety Gathering and Conference 

White Bison, Inc. will be hosting its annual Wellbriety Gathering in 
Denver, CO,
April 10-13, 2014
The Gathering will address the impact of historical and intergenerational trauma, the experience of boarding schools, and the impacts of alcohol and drug abuse on our families. For more information and to register, please
click here to visit the website.

April 23-24, 2014
Casper, WY

April 27-29, 2014
Duluth, MN

April 30, 2014
Centralia, WA


Funding Opportunities:

SAMHSA Announces New Circles of Care Grant
The Substance Abuse and Mental Health Services Administration (SAMHSA) recently released a new call for proposals titled Planning and Developing Infrastructure to Improve the Mental Health and Wellness of Children, Youth and Families in American Indian/Alaska Natives (AI/AN) Communities.  This grant (being called the Circle of Care IV grant) is to assist tribal and urban Indian communities to provide tools and resources to plan and design a holistic, community-based, coordinated system of care approach to support mental health and wellness for children, youth, and families. Ultimately, these grants are intended to increase the capacity and effectiveness of mental health systems serving AI/AN communities.  There will be up to 11 awards.  Project can last up to 3 years and can submit budgets for costs up to $400,000 per year.  
Proposals are due by March 7, 2014.  
For more information, please click here.
SAMHSA Releases Tribal Healing to Wellness Court RFA!

The Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Substance Abuse Treatment (CSAT) is accepting applications for fiscal year (FY) 2014 Grants to Expand Substance Abuse Treatment in Adult Tribal Healing to Wellness Courts and Juvenile Treatment Drug Courts. The purpose of this program is to expand and/or enhance substance abuse treatment services in existing adult Tribal Healing to Wellness Courts and in Juvenile Treatment Drug Courts which use the treatment drug court model in order to provide alcohol and drug treatment (including recovery support services supporting substance abuse treatment, screening, assessment, case management, and program coordination) to defendants/offenders.

Application Due Monday, March 17, 2014.
For more information, please click here to visit SAMHSA's website and access the application.

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Mission of the National Indian Health Board

One Voice affirming and empowering American Indian and Alaska Native peoples to protect and improve health and reduce health disparities.

About this Publication
This publication features information on suicide prevention, intervention, postvention and methamphetamine prevention, treatment and aftercare.  We welcome your suggestions, questions and comments and invite you to submit materials for future publications.  
Toiyabe Adapts American Indian Life Skills to Promote Youth Resiliency  


Located in the beautiful and rugged inlanmountain region of California, the Toiyabe Indian Health Project serves a consortium of seven federally recognized Tribes and two American Indian Communities. Toiyabe works to address a range of health-related hardships endured by the communities they serve, using medical services as well as public health and wellness programing.  As part of their health promotion work, they have focused on increasing the resiliency and coping skills of the youngest members of their communities.


As part of their Methamphetamine and Suicide Prevention Initiative (MSPI), Toiyabe adapted the evidence-based American Indian Life Skills Curriculum to create the Numa Life Skills Program for Tribal youth attending one of the local Elementary schools.  While the American Indian Life Skills Program seeks to increase resiliency in high school aged youth, the curriculum Toiyabe created looks to build coping skills in younger children.  Sheila Turner, Toiyabe Behavioral Health Director, explained the strategy this way: "Our communities face the same problems as communities everywhere.  We see substance abuse, depression, and people at- risk.  We thought a good way to address these issues was to make sure people have the resilience and coping skills they need to face life's problems, starting at a young age."


Building Resilience

Resilience - the quality that allows people to withstand adversity and still thrive - develops over time, and touches upon many different aspects of a person's life. Resilience comes from supportive relationships with family and friends, and the support that culture and traditions provide. Resilience also requires a set of personal life skills; these skills allow a person to navigate difficult situations by managing their thoughts, emotions and behaviors in constructive ways. Resilience can be developed across the life span by cultivating supportive relationships, by engaging with culture and traditions, and by learning life skills.  A number of evidence-based curricula focus on building resiliency, including the program Toiyabe used as a model - American Indian Life Skills.


American Indian Life Skills (AILS) (formally the Zuni Life Skills) Development program is a school-based program that aims to build protective factors in youth and prevent suicide ideation. The AILS curriculum includes anywhere from 28 - 56 lesson plans covering topics such as: building self-esteem, identifying emotions and stress, recognizing and eliminating self-destructive behavior, and increasing communication and problem-solving skills. The design of the lessons allows for them to be easily adapted to incorporate situations and experiences relevant to the youth community served. Importantly, the curriculum has been rigorously tested and shown to be effective.


Getting Buy-In & Creating the Program

The success of the AILS program helped when it came time to propose the idea to Bishop elementary school.  The project also required building relationships with the school administration, carefully explaining the vision of the project, and getting feedback from parents, teachers and the community. Natalie Vega, Behavioral Health Therapist Intern at the Toiyabe Indian Health Project and the core developer Numa Life Skills explained the process: "Initially, we worked with the Native American liaison as the school.  She was really helpful in the process and she knew about the needs of the Native students, especially those at risk. After working with her, we had meetings with the school principle and vice principle, we conducted surveys with the teachers, and we shared information with parents. After this groundwork, the program was accepted into the school."


Ms. Vega has put many hours into the adaptation of the AILS program to make it more kid-friendly and culturally relevant. For example, some components in the AILS curriculum, like directly speaking to students about suicide, are hard to translate to 5 - 10 year olds. The Numa Life Skills curriculum adapts this material. In the example of talking about suicide, death is discussed in more general terms to level with the younger population while teaching coping skills to deal with the tragedy of death in the family.


Vega and Turner have also worked to incorporated many cultural practices and traditions to teach children about their heritage. The curriculum works various Paiute words into their activities to familiarize the children with a Native language. Turner and Vega also reach out to community members to share legends and traditional stories to teach lessons, as well as songs and dances that help children learn how to express themselves and understand how to deal with difficult situations. Numa Life Skill has even incorporated sign language into their curriculum. "Different languages can give kids the skill sets and tools to communicate in new ways and to express the things they don't know how to before," offered Turner.


The Program in Action; Seeing Significant Results

"The initial planning is the most difficult, but once you put the work in and get the program, going, it speaks for itself," Vega reported.  She explained that the kids enjoy these activities so much that they don't realize they are learning at the same time. Positive feedback from children, parents and teachers has led to overwhelming participation in the program. Now in its fourth year, the program began with 30 kindergarteners and has grown to 70 participants. The course is offered for a length of 5 months over the spring semester, and convenes twice a week so that students have the opportunity to attend at least one session a week.


The children are split up into groups roughly according to age, with some grade levels mixed. Vega and Turner have seen this structure benefit students in ways they never expected: "With the mix of older and younger and previous and new students in the program, we are seeing kids becoming leaders and taking on the role of peace builders. The older students who have been through the program are learning how to help new and younger kids who are struggling." 


While the program is open to all students within this non-Native school, the curriculum is culturally geared toward American Indians and 98% of the students are Native. Enrollment is on a first come, first serve basis, but referrals from the Native American Liaison are taken into consideration. The Native American Liaison plays a special role in the success of this program, and has the advantage of observing the students' behavior and well-being on a day-to-day basis. She not only helps to reach out to the students who need the most help, but she also reports on the many significant changes and tangible positive effects the program has within the school.


Building Sustainability through Partnerships

Toiyabe Indian Health Project's partnership with the Bishop Elementary School makes a large impact on the program. Through outreach to administration and teachers, the project secured an outlet to reach the youth, staff to assist with the program, and a location to hold the sessions. While there were some hesitations from staff that the program was too focused on one group of students, the need presented was very great in the eyes of most teachers and administrators, who overwhelmingly have supported the Numa Life Skills Development program. By keeping in touch with staff and faculty through surveys and on-going discussions, the program has allowed for continuous quality improvement in order to find ways to best serve students and kept up their positive relationship with the school.


Beyond the school, the Numa Life Skills Development program also has reached out to parents throughout the process. Seeking parents' opinions while building the program, engaging them through meetings during the first couple years, and sending home newsletters to update parents on program activities has built valuable partnerships with the community as well. Through this collaboration, the program has been able to call on parents as volunteers for much of their programing. Involving parents and the community has also expanded the outreach of behavioral health staff in general. These meetings and other interactions acquaint families and community members with the behavioral health staff and build relationships that encourage more individuals to seek the clinical care they need.


Numa Life Skills also has engaged in important partnerships with other community programs like Temporary Assistance for Needy Families (TANF). Twice a week, during the lunch hour lessons, TANF provides all the food for the students, saving the program time and money. Additionally, much of the staff for the program are already staff of the school, the Toiyabe Indian Health Project, or volunteers, which make the costs of the program extremely manageable.


Bringing it all Together

Understanding the need, choosing a successful approach, and building essential partnerships has allowed Toiyabe to make impressive strides in their goal of promoting resiliency in their youth. The success of Toiyabe's MSPI project and the Numa Life Skills Development program rely upon the collaborative relationships that staff have cultivated - all reinforcing each other and hold the promise of long-term sustainability, and the long term positive impacts on the communities they serve.


To learn more about Numa Life Skills, please contact:

Natalie Vega, M.S.

Behavioral Health Therapist

52 TuSu Lane, Bishop, CA 93514

American Indian Life Skills Story of Development: Interview with Dr. LaFromboise


The National Indian Health Board staff extends appreciation to Dr. Teresa LaFromboise, developer of AILS, for agreeing to be interviewed for this article. 


Tribal programs looking for an evidence-based prevention curriculum have a number of promising options they can choose.  While almost all of these curricula demonstrate effectiveness with general populations - only a small handful have been designed for and shown effective with American Indian/Alaska Native (AI/AN) youth.  American Indian Life Skills (AILS) Development program stands out as one of those exemplary AI/AN programs.


"In 1989, in light of recent tragedies in the community, I was invited to the Pueblo of Zuni and asked to build a suicide prevention program for their high school students," Teresa LaFromboise shared when asked what sparked the development of this program. Dr. LaFromboise brought down her education graduate students with her from Stanford and was welcomed into the community. Working closely with school administration and invited into the homes of community members, Dr. LaFromboise and her team developed what was originally known as the Zuni Life Skills Development program.  "We spent one year developing the program, one year piloting it, and one year to do a final evaluation."


Much work and promising outcomes have been accomplished since then and have led to what is now American Indian Life Skills.  The curriculum has been implemented in schools across the country. After great success in Zuni Pueblo, Dr. LaFromboise was invited to implement this program with Cherokee youth at Sequoyah High School. "This was a unique situation in which we were working to serve students from 20 different Tribes at the time in this boarding school." Dr. LaFromboise explained that they started by identifying Zuni specific references, practices or images in the curriculum. These portions of the curriculum were altered, but many Tribal specific examples were interspersed throughout the curriculum to accommodate diverse Tribes.


"Suicide is an end stage behavior - when problem solving skills are lacking, an individual does not have the tools needed to cope with traumatic events. Many prevention activities like suicide awareness day, talks, and trainings are sporadic and seldom internalized by youth.  They don't instill a fundamental change." Dr. LaFromboise explained that prevention focusing upon fundamental coping and social skills building can empower youth with adaptive resilience.   


To accomplish this, AILS Development program is based in 7 core topics:

  1. Building Self-Esteem
  2. Identifying Emotions and Stress
  3. Increasing Communication and Problem-Solving Skills
  4. Recognizing and Eliminating Self-Destructive Behavior
  5. Learning about Suicide
  6. Role-Playing around Suicide Prevention (learning how to help a friend who is suicidal)
  7. Setting Personal  and Community Goals

These topics have been developed into sets of lessons that are designed to be administered to youth in anywhere from 28 to 56 lessons. This high school-based curriculum is typically delivered over 30 weeks, with students participating in lessons 3 times a week. "It is most beneficial to recruit a credible interventionist to teach these lessons; someone in consulting, public health, social work or human resources. And in order for this program to truly work well, there must be support from the Tribe, school administration and community." Guest speakers are often part of the curriculum, and Dr. LaFromboise recommends reaching out to members of the community that would really connect with the students to heighten the effectiveness of the program.


After various trials and evaluations, American Indian Life Skills was granted the status of an evidence-based practice and is listed on SAMHSA's National Registry of Evidence-based Programs and Practices. Various studies have shown that AILS programing consistently lowers hopelessness and suicide ideation and raises a collective self-esteem, self-efficacy and self-awareness. At least one study has shown that after implementing AILS there were no deaths from suicide among students over a 12 year period of time.

More recently, Dr. LaFromboise and her team have been working to adapt the AILS Development Curriculum for middle school students. In the process, they identified 13 essential lessons and developed them into 35 minute lessons. Dr. LaFromboise explained that this shorter version also includes much more age-appropriate content. "We are piloting this new curriculum with middle-schoolers in the northern plains at the time and are looking forward to sharing further information about this work in the near future."
ReEntry: Reentry is a Behavioral Health Issue 


This article is the second article in a series that looks at successful reentry strategies with a specific focus on people with a history of substance use, including meth use. To revisit the first article in this series, The Need for Reentry Efforts, please click here. The National Indian Health Board will run the third and final article in this series in the next quarterly Visions newsletter.
Although increasing costs of incarceration have brought much attention to the complexities of reentry in recent years, not enough attention has been paid to the behavioral health needs of people recently released from jails or prisons. The Federal Interagency Reentry Council convened by the Attorney General in 2011 emphasized that reentry is a public health and behavioral health issue.[1] A 2006 report released by the U.S. Department of Justice (DOJ) estimated that around 50% of prisoners met the Diagnostic and Statistical Manual for Mental Disorders (DSM - IV) criteria for substance abuse and dependency, yet fewer than 20% of drug users in prison received treatment.[2] 


Many American Indian/Alaska Native (AI/AN) communities suffering from high rates of substance abuse are concerned about ex-offenders with histories of abuse reentering the community. The DOJ's report revealed that more than half of all inmates in prison reported drug use within the month of their offense, with one third of all inmates reporting drug use at the time of the offense.  This report also noted that while overall drug use among prisoners has not changed since 1997, methamphetamine use has increased.[2] Methamphetamine abusers that are released from detention run a particularly high risk of relapse and recidivism and generally pose a greater challenge due to the uniquely difficult nature of meth addiction and the intensive treatment required.



Statistics suggest that reentry programming in Indian Country needs greater attention. AI/ANs are incarcerated at a 25% higher rate than the national average,[3] and as many as 3 out of every 5 AI/AN are arrested for new crimes within 3 years of release from prison.[4] AI/AN peoples also face disproportionately high rates of substance use and disorders[5] and greater disparities in access to health care and treatment as well as many other resources need to combat these issues.[6] Efficient, cost effective, well-rounded and culturally relevant reentry efforts could constitute an important component of a coordinated public health response.  


Considerations when Designing a Reentry Program



Compounded Personal Issues

When considering approaches to reentry programming, it is important to recognize and understand the characteristics unique to each individual released from jail or prison. In addition to the stigma attached to recently released individuals, they often face personal obstacles both during and after incarceration that complicate the process of reentering the community. Large numbers of prisoners struggle with substance abuse and mental health issues. On average, half of all inmates have been recorded to have a recent history or symptoms of a mental health problem, and like those struggling with substance use, very few of these inmates receive treatment. [7] Recognizing the need for increased substance use and mental health treatment within prisons, stakeholders have advocated to increase funding for these services in recent years. 


Effects of Incarceration

In addition to poor access to treatment, some argue that the fundamental structure of prison and jails can also negatively affect an inmate. A study by Craig Haney examined the psychological changes that many inmates undergo when experiencing the highly structured and isolated nature of institutionalization.[8] He identified major transformations, including: increased dependence on institutional structure, emotional over-control, social withdrawal, incorporation of exploitative norms of prison culture (i.e. frowning on signs of weakness and vulnerability), diminished sense of self-worth, and post-traumatic stress reactions to prison experiences. Not all people experience these outcomes of the correctional setting, and those that do exhibit these transformations experience them at varying levels.  This further complicates the de-institutionalization process with people presenting with wide-ranging needs and greater readjustments.


For AI/ANs incarceration brings additional challenges. Incarceration removes AI/ANs not just from the community, but also from cultural centers and spiritual practices - further compounding feelings of isolation. Some individuals are placed into an environment where they may be the only Native American, and facilities are not equipped, prepared, or permitted to facilitate participation in traditional practices (such as smudging, sweat lodges, or the use of traditional medicines) or communicate with spiritual advisors. AI/AN people may also be relocated to sites far from their Tribal communities, making it difficult for families and relatives to visit consistently and frequently. Losing these close connections with relatives and personal identity removes significant protective factors and heightens the psychological impacts and feelings of isolation that make reentry more complicated.


Overcoming Barriers of Readjusting

Difficulty adjusting is very common among people recently released from jail or prison reentering the community within the first year after release, and many experience heightened anxiety, discouragement and high risk of recidivism. Once people leave the highly structured settings of jails and prisons and enter communities, it is increasingly important that services are equipped to meet their complex behavioral health and treatment needs.  Building a program that is structured and requires responsibility and accountability, yet is welcoming and not off-putting is especially important in assisting ex-offenders with substance abuse histories to reenter the community. Programs should be tailored to individual needs, and be ready to address any transformations made during incarceration, generalized anxiety about returning to a community after such an absence, reuniting with families, navigating past relationships and social networks that might have contributed to past criminal or substance using behavior, and how all of these may trigger mental health lapses or substance use. 


Incorporating Principles of Drug Abuse Treatment

The National Institute on Drug Abuse (NIDA) released a research-based guide, last updated in 2012, that outlines 13 Principles of Drug Abuse Treatment for Criminal Justice Populations. In considering thorough, evidence-based programing when building a reentry program for substance abusers, this resource may be a helpful guide.  The principles of this guide are developed around identifying the nature of one's substance abuse, effective models of treatment, support of extended treatment plans, consideration of other personal factors influencing abuse and addiction, and incorporation of the criminal justice system and upholding the responsibility of the offender.[9]


Well-Rounded Programming

These research-based principles also align with the understanding that effective reentry programs start in prison, are present during actual reentry (in the pre-release, half-way houses or parole environments), and have a continuous presence within the daily lives of individuals reentering the community. A consistent presence and supportive program appears to be components of effective programming.  Various programming has also incorporated the participation of family and friends to build or reinstall a stronger support system.


Reentry programs should also not try to recreate services that may already exist in the community.  Peer groups, local or Tribal health departments, community and social services may be vital resources for persons recently released, and those managing a reentry program should reach out to these services to ensure that staff members are knowledgeable and prepared to meet the needs of those recently released from jail or prison. Additionally, implementing cultural practices within reentry programs or facilitating participation in cultural and spiritual practices can not only encourage persistent involvement, but are important in ensuring true healing.




There is no 'one size fits all' formula for constructing and implementing an effective reentry program for American Indian and Alaska Native people released from jail or prison.  Unique experiences, criminal histories, stress of incarceration, and the stress of re-integration into a community all paint a distinctive and individualized portrait of need.  Reentry programs should focus on each participant and tailor their participation to meet varied, individualized needs.  It the purpose of these programs to support the vision of a healthier future by identifying and brokering resources, working closely with existing programs, communicating with the ex-offender to identify and prioritize his/her needs and design a corresponding wellness plan in order to effectively assist an individual reenter a community.  The wellness plan may include, but is not limited to: substance use treatment, behavioral health counseling, mentoring, peer to peer support, cultural activities, job training, or educational activities.  All of these activities support change, growth, and health.  After all, the correctional system focuses on what happened in the past, while reentry programs focus on supporting peoples' futures.  




  1. Reentry in Brief. (2011). Federal Interagency Reentry Council. Retrieved from:
  2. Mumola, C.J., and Karberg, J.C. 2006. Drug Use and Dependence, State and Federal Prisoners, 2004. Bureau of Justice Statistics, NCJ 213530.
  3. Minton, T.D. (2011). Jails in Indian country, 2009. Bureau of Justices Statistics, p.2.
  4. Perry, S.W. (2004). American Indians and Crime, A BJS Statistical Profile, 1992-2002. U.S. Department of Justice Bureau of Justice Statistics. NCJ 203097.
  5. Greenfield, B.Ll, and Venner, K.L. (2012). Review of Substance Use Disorder Treatment Research in Indina country: Future Directions to Strive toward Health Equity. The American Journal of Drug and Alcohol Abuse. 83(5): 483-492.
  6. Corbin, T.R. (2010). Barriers to Health Care Access Among American Indian and Alaska Native Populations. University of Pittsburgh Graduate School of Public Health. Retrieved from:
  7. James, D.J., and Glaze, L.E. (2006). Mental Health Problems of Prison and Jail Inmates. U.S. Department of Justice, Bureau of Justice Statistics. NCJ 213600.
  8. Haney, C. (2001). The Psychological Impact of Incarceration: Implications for Post-Prison Adjustment. University of California, Santa Cruz.
  9. Principles of Drug Abuse Treatment for Criminal Justice Populations: A Research-Based Guide. (2012). National Institute on Drug Abuse, National Institutes of Health, U.S. Department of Health and Human Services. Retrieved from:
Good Project Management = Effective Risk Management:
Risk Management Lessons from the Field


Whether you are running a project on a reservation in Washington state or Florida, a village in Alaska or a rancheria in California - whether the project is on methamphetamine, suicide, HIV, or diabetes, there are certain realities that all public health projects must face.  Staff turnover is high, staff development opportunities are few and far between, grant funds are limited, leadership buy-in and support ebbs and flows, and community support shifts just as frequently.  Even the best-run projects with a finely-tuned and culturally aligned curriculum will face such challenges.  This is not a cause for alarm, nor is it meant as a judgment for any projects that encounter such barriers - being armed with this knowledge is a cause for advance planning and preparation.  Being prepared for these inevitabilities can minimize their effect, and maximize efficiency.  These are the basic tenets of risk management. 


Risk management refers to the forecasting and evaluation of potential risks together with the identification of procedures to avoid or minimize their impact.  NIHB will be running a series of columns on risk and project management in this year's editions of Visions MSPI e-newsletter. We will be seeking to answer some questions that are often posed by front line staff and address some issues often faced in the field.  If you have any problems such as those you read here or in future columns, do not hesitate to request technical assistance directly from NIHB. 


Question: Why is risk management something I should even think about?


Answer: It is very easy while we are running our projects, to just focus on those deliverables written into our scopes of work, to hop on to calls with a project officer, to write the reports, and run the projects.  Then when something happens - such as when a reliable staff member accepts a promotion and moves on to a new position- we are left with a huge hole in our project.  While we are scrambling to fill that gap, we may fall behind in our deliverables, the groups stop running as they should be, reports and documentations are not completed as they once were, and the project begins to suffer.  While these are hopefully temporary trials, the people who suffer the most are the people whom our projects serve - these are the people who lose the benefits of our projects when our projects falter.   



Question: Isn't risk management something that only staff in the hospital should worry about?


Answer: In the public health field, risk management is often associated with clinical practices used to reduce the possibility of infection or cross-contamination.  That is why staff in hospitals and clinics wear gloves, masks, watch their hands, etc.  While the tenets are the same, when we speak about programmatic risk management, we are referring to a close examination of the programmatic practices, and asking ourselves two simple questions, 1.) What opportunities currently exist in our project that open us up to the possibility of risk, failure, misinterpretation, or wrong-doing, and 2.) What can we do to pre-emptively ensure that this never happens? 



Question: How is risk management different from what I already do all day just managing our projects?


Answer: Most risk management strategies are nothing more than sound project management strategies.  If project management is the process of planning, organizing, and managing resources in order to consistently and successfully implement project activities, then it stands to reason that risk management is the process of ensuring that the planning, organizing, managing of resources and implementation of activities run smoothly and without any barriers.  So it is no different than what you are already doing, risk management is just looking at project management from a different perspective. 



Question: My boss is always asking me to write things down and to save things. Is all of this documentation really necessary?


Answer: Staff may see routine documentation as a bureaucratic hurdle that they are forced to jump, and may view it as valuable time diverted from the provision of direct services or communication with the community.  While, admittedly, documentation can be a tedious process, it is absolutely necessary for all public health programs.  Documentation is what allows us to report back to our leaders, our funders, and the community and show them what we did, and why it is important to support the program (and the effort in general).  Sound documentation can actually ease frustration by making it easier for all staff to find information when they need it.  



Question: If filing and paperwork is so important, where should we keep everything?


Answer: A good practice is to centralize all project information either in a single file cabinet or in a single folder on a shared computer drive.  This allows equal and ready access to all project staff or project evaluators.  It also prevents one person from hoarding or controlling all of the data or information on a desktop computer or in their own office - where it can be hard to find when needed.  Utilizing a shared folder on a common drive housed on a larger server also has an added protective benefit.  The server is probably regularly backed up (either automatically or manually), whereas, desktop hard drives may not be backed up on the server.  So if a desktop computer crashes or is infected with a virus, then there is a good chance that the data and files stored on the hard drive may be lost.  Whereas data and files stored on a server are regularly backed up and easily recoverable.   



It is important to create a filing system that all parties understand.  A good practice is to create a single folder for the project on a computer or a designate a single drawer in a file cabinet.  Then designate subfolders with easily understood and non-abbreviated titles, such as "Project Meetings," "Grant Reports," or "Participant Information." And the within each of these subfolders, create additional subfolders with equally clear titles.  In this day and age, it is no longer necessary to abbreviate or shorten the names of files or documents, so simply title the documents what you would like everybody to call them.  The exact style or layout of a filing system will vary from office to office, and taking time to walk each staff member through the logic of the filing system will help ensure that staff understand and are comfortable using it. 


Question: When am I supposed to find time to do all of this documentation?


Answer: To help staff use both the systems of documentation and filing, look at the time spent on the project, and help project staff designate certain amounts of time either each day or each week dedicated to just documentation.  Staff during this time may be allowed to turn off their phone, shut down their e-mail, or shut their door just so they can focus on typing up their notes for the week.  By dedicated a set amount of time to the task, staff will begin to see that one hour spent on documentation is just as important as one hour spent facilitating a group. 



Question: Our participants hate filling out all of the paperwork that we have to complete.  What can I do?


Answer: When there is one sign in sheet for a group session, another format for a sign-in sheet for the community dinner, and then yet another sign-in sheet for the health fair booth, it can be cumbersome and confusing for staff to keep track of what form to use for which event.  Tools, forms, and data collection instruments should be standardized across activities (and ideally across projects throughout the department).  When there is only satisfaction survey to use regardless of the event, there is no chance that a new staff member will grab the wrong form when running out of the door.  Not only do you minimize the possibility for error, but it also helps when compiling the information for reporting purposes - the familiarity with the form will ease data entry or interpretation and allow for the creation of templates for reporting and compiling the data.   



In addition to standardizing tools, project staff should seek to combine as many instruments into a single document as possible to minimize the burden on project staff and project participants as well.  That is to say, combining a knowledge pre-test with a demographic form and a contact information form into a single document means one document that staff needs to copy and staple, and pass out to project participants, rather than three. 


Additional Resources

Feel free to visit the Community Tool Box hosting by the University of Kansas for a wide array of project management tools (especially Chapter 9. Developing an Organizational Structure for the Initiative).  And for additional tips on filing and documentation, here is a good online article:

The National Indian Health Board welcomes your input!  If you would like to submit materials for consideration, please contact the NIHB Public Health Department through
Public Health Communications and Program Manager Robert Foley at or (202)355-5494.