National Indian Health BoardFALL 2014
Visions: A Tribal Perspective on Methamphetamine and Suicide Prevention 
In This Issue
Spotlight Story: Kodiak Area Native Association
Project Management Series: Risk Management Lessons from the Field
Bullying Prevention is Suicide Prevention
Have You Heard ... 



A User Friendly Guide to the DSM-5: Part II

Webinar presented by Jeanne Bereiter, MD and Avi Kriechman, MD


Wednesday, October 1, 2014

2 pm ET

1 pm CT

12 pm MT

11 am PT

10 am AKT

1 hour long

Room Code: child


Hepatitis C: Clinical Overview and Practical Considerations

Webinar presented by Jonathan Isalu, MD, FACP, and Amy Nguyen, PharmD, PhC, BCPS


Thursday, October 2, 2014

2 pm ET

1 pm CT

12 pm MT

11 am PT

10 am AKT

1 hour long

Room Code: hcv


Chronic Pain, Addiction and Depression: Opioid Dependence/Substance Use Disorders

Webinar presented by Snehal Bhatt, MD


Monday, October 6, 2014

12 pm ET

11 am CT

10 am MT

9 am PT

8 am AKT

1 hour long

Room Code: addiction


Palliative Care in Indian Country - What's Working

Webinar presented by Bruce Finke, MD, Blythe Winchester, MD, Christopher Piromalli, MD, Alex Kipp, MD, Kimberly Moh, MD, Kathy Morsea, MD, and Gary Vaughn, MD


Thursday, October 9, 2014

3 pm ET

2 pm CT

1 pm MT

12 pm PT

11 am AKT

1 hour long

Room Code: rounds


2015 Tribal Public Health Summit

NIHB has set the date for its 2015 Tribal Public Health Summit.  This conference has become the hallmark public health event annually for all of Indian Country.  It will be hosted by the California Area next year and will be held in California (the actual location is pending).  The dates are April 6-10, 2015.  So please save those dates and plan on joining us in California. 





Quick Links
Vist the NIHB web page

NIHB MSPI Project Management Toolkit

NIHB has updated its project management toolkit to include new tools, links and webinars.  There is now a powerpoint slide set on sustainability and sustainability planning, as well as a new sustainability readiness checklist.  There is also a powerpoint slide set on logic models, as well as two handouts for logic model.  And lastly there are two tip sheet for recruiting and retaining high quality staff for your programs.  All of these article appear in the MSPI Practice Guide on NIHBs Behavioral Health webpage




NIHB Hosts Annual Youth Summit


NIHB recently hosted its annual youth summit, September 4th-8th.  20 youth representing 12 Tribes joined three NIHB staff and 2 consultants in Window Rock, AZ to create digital stories on personal experiences with health and wellness, help film ad for the Affordable Care Act, and to just have fun engaging in a variety (like marching in the Navajo Nation Fair Parade and rappelling).  The Summit was sponsored by the Centers for Medicare and Medicaid, The Centene Corporation, and the Navajo Nation. The digital stories produced were all featured at a film festival held on September 8th in Albuquerque, as part of NIHB's Annual Consumer Conference.  These stories are powerful and reflect the strength of the youth voice in health promotion activities.  These videos have all been posted on NIHB's YouTube Channel and we invite you to take a look.    




NIHB MSPI Webpages


NIHB tries to disseminate information to all of our Tribal partners.  We have created some mechanisms in order to do that and want to make sure that all of our MSPI Partners are able to take advantage of this.  NIHB posts new and timely information regarding topics such as: training, webinars, funding, publications, conferences, meetings, legislation, Tribal consultation, and open comment periods all on our website as Behavioral or Public Health Alerts.  NIHB operates two separate alert lists to appeal to specific audiences.  We encourage you to check these posts often to remain abreast of current information and ensure that you have access to material in a manner that is timely enough to allow you to plan for it.  

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Don't forget to visit NIHB on our Facebook page and like us.  We frequently post blurbs, updates, and pictures about important public health information, happenings, trainings, and events. 


Quick Links
Vist the NIHB web page
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.
Kodiak Area Native Association Engages Youth
for a Healthier Tomorrow

The Kodiak Area Native Association (KANA) provides health and social services to the Alaska Native people of the Koniag, Inc. region. The region encompasses all of the Kodiak Island Archipelago, which is located approximately 150 miles across the Gulf of Alaska from Homer, Alaska. The archipelago is only accessible by boat or airplane-this is also true of the communities within the archipelago. Kodiak Island, the second largest island in the United States, does not have a road system that connects the communities, creating complex challenges that are less common in the contiguous United States.

One of such difficulties includes the lack of music programs in the six villages of the region: Akhiok, Karluk, Old Harbor, Ouzinkie, Port Lions, and Larsen Bay. While the region has approximately 13,000 residents, the majority live in the City of Kodiak, with only 2,000 combined people living in the six villages. The smaller populations make it difficult for the schools to operate a music program. Using MSPI funds, KANA is able to participate in the Village Music Program. The program started more three years ago as a way to bring music programs to middle and high school students to students in the rural villages. Utilizing a web-based video conferencing program, the students are able to receive instruction and practice. The after school programs gives youth the opportunity to develop their creativity and self-confidence while providing them a healthy activity that encourages inclusiveness.

Another popular, MSPI-funded, after school program is KANA's Running Cubs. The program started in 2013 in the City of Kodiak to promote mental health building in fourth and fifth graders. High school cross country runners served as trainers, mentors, and role models for the young students as they trained for a 5K. The program not only encouraged students to develop running skills, it also included discussions on bullying, respect, safe choices, trusting instincts, and reaching out to adults. The debut of the Running Cubs was enormously successful, with over 50 fourth and fifth graders and 4 high school mentors signing up. KANA has been invited back to the elementary school and looks forward to another successful year of programming.

While KANA's programming may seem geared towards youth, there are many pre-existing services available to adult members of the communities through KANA's Behavioral Health Department. KANA regularly holds evidence-based trainings, such as SafeTalk, at no cost to community members. The trainings teach community members how to appropriately respond to people in stress who may be thinking about suicide and engages the community at a deeper level in intervention and community health activities. Local community members have been very responsive, including some local teachers, who are required by the State of Alaska to receive suicide awareness and prevention training. In addition to the trainings, KANA hosts multiple drug and alcohol forums. KANA encourages other MSPI programs to include evidence-based curricula as part of their programing.
KANA strives to create sustainable programming by teaming up with coalitions, agencies, and other tribal entities. Forming a partnership allows the sharing of resources and a larger flow of ideas. Collaborations not only strengthen your program-they'll strengthen your community.


The National Indian Health Board would like to thank Jessica Lacy with the Kodiak Area Native Association for participating in an interview and supplying all of the materials necessary to write this article.  For more information or any questions about the Kodiak Area Native Association's programing, please contact Jessica Lacy at or 907-486-9812.

 "Umm... Evaluator is Not in my Job Title":

Risk Management Lessons from the Field 


The responses below to the questions posed were gathered from professionals in the field who have faced this issue, and would like to offer some practical tips.


Question: Why do I have to do the evaluation?


Answer: Evaluation is the practice of examining your project and your activities to ensure you are doing what you said you were going to do and if what you are doing is really working. People tend to roll their eyes when they think of evaluation because they do not see it as necessary or as part of project implementation. We have drawn an imaginary line between evaluation activities and project activities, when in reality, there one should not exist. Evaluation and project implementation should run parallel and if it is done correctly should not be burdensome and should become routine practice.


From the perspective of risk management, evaluation is one of the most important practices. Evaluation tells project managers and directors how well the project is performing. It is better for the project staff to know if things are not working first and have a chance to resolve any issues before Tribal leadership or funders find out. Often, by the time word reaches those higher up, poor practices are so ingrained, poor outcomes are expected, and staff morale is so low that it is triply difficult to climb out of the hole. So consistent and reliable evaluation data can help project staff from expending their valuable time and energy on activities that are not working, from getting frustrated, and use resources most effectively. Should evaluation results show positive performance or growth, then it is reason for celebration and praise among the team.


Question: If I have to do it, please help me understand what it is I am supposed to be doing?


Answer: Evaluation is often times a matter of proper documentation. A sign-in sheet is an evaluation instrument, just as much as a focus group or survey. Every activity should be evaluated - from a group session to a health fair booth. The extent and type of evaluation as well as the instruments used will vary, but all will capture information on one of the following areas:

  1. How the activities were performed/delivered and to whom?

  2. Did the activities align with what we intended to do?

  3. What was the result of the activities we performed/delivered?

  4. Were the results we saw directly attributable to the activities we performed/conducted?

So creating evaluation activities that will collect information on one or more of these at all of your events will provide you with information that you can use to: improve project activities, enhance outreach and recruitment efforts, identify gaps in staff knowledge and skills, improve data collection, and identify any areas where participants may need further resources. All evaluation data should be collected, treated confidentially, and entered into a central database or spreadsheet. This information has to be analyzed in order to understand it (which sometime is just a matter of reading it), and shared with the whole team. Evaluation does nobody any good if it just sits on a shelf collecting dust. Honor the time and effort it took to collect the information by using it. Evaluation is about continuous project improvement, and what better risk management strategy is there than to ensure that the project continues to get better.


Question: We don't do our own evaluation, so how can we manage it?


Answer: If your project hires an external evaluator or consultant, then be sure that you and the entire team are thoroughly briefed on what the evaluator is doing at all times. Do not let them operate in a bubble. They are a part of the project team and should attend meetings and work alongside the implementation staff. Having clear responsibilities for your evaluator is important. They should have deliverables and timelines just like implementation staff does. If they do not meet them, then it is not unreasonable to withhold payment of invoices. External evaluators should not be paid on a regular basis, rather they should receive payment when invoices representing completed work are submitted.


Question: We want to use Facebook for our project, but we are having problems deciding the best way to use social media.


Answer: Most departments and Tribes have guidelines that govern how employees can communicate with the media (even a Tribal newspaper). It is important that project staff understand these restrictions and adhere to them. Such guidelines should contain talking points and common messaging that is approved to share with all parties at any time. These guidelines may or may not include the use of social media (including Facebook, Twitter, Instagram, etc.), and if they do not, then project team may consider creating regulations on the use of social media by project staff (especially if the project is going to have its own social media presence). Some guidelines to conside r include:

  • Not using or posting any pictures without written consent of the people in the picture

  • Not using names in social media postings

  • Considering the confidentiality of participants when posting information on project activities and meetings.

  • Instituting an internal review process for all social media posting and activity

  • Allowing only two people access to usernames and logins for any one social media account

  • Regularly logging into the account to monitor external posts and activities

  • Setting benchmarks for how many daily/weekly/monthly posts

  • Setting timelines for responding to comments

  • Setting percentages to govern the amount of posts of a certain nature appear on your page (e.g., 50% educational posts or links, 30% questions or interactive posts, 10% event listing or announcements, 10% community news)

Social media is a powerful tool, but as such an open and uncontrollable interface with the community, it inherently creates many opportunities to risk.  


Question: It seems like we plan great activities, but they just never take off. The staff is getting frustrated with the lack of response from community members. We aren't sure what to do.


Answer: The will and the climate of the community will ultimately decide if a project will be successful, accepted, and sustainable. A community has values as a whole, and these values drive many attitudes and behaviors - oftentimes without people knowing it. For example, a project may seek to promote condom use as an effective means of birth control. But if the community as a whole holds procreation and the family sacred, then any messaging about contraception (no matter how sound or well-documented) may appear contradictory to the community values, and stands a diminished chance of success. As another example, a project is holding discussion forums on meth in the community, and they are ordering in pizza for each forum. However, people are not attending the forums because in that community it is seen as an insult to serve guests food that has not been personally prepared. We have seen other programs plan wonderful events with great and dynamic speakers, but nobody comes because it is in the middle of hunting or fishing season. It is critical for any project team to seek to understand the climate of the community through direct communication with community members and stakeholders. This is an opportunity to learn:

  • Language to use

  • Timing and nature of activities to put forth

  • Kinds of food to bring or prepare

  • How to communicate with the community

  • What topics of off limits

  • Predominant viewpoints on relevant issues

 Projects should allocate time (preferably early on in a project lifecycle) to liaise with the community members and leadership directly to construct activities that meet both the needs of the community and the project. Staff can also hold focus groups right now and simply ask people why they aren't coming or what can be done differently to make activities more appealing. Making it increasingly important to understand the climate of the community is the fact that Tribal leaders are often times, as elected officials, beholden to the climate and will of community members, and a project can quickly lose favor with leadership if they are seen as violating some of the values of the community.


Additional Resources

For more help with conducting and using evaluation, please feel to look at these additional resources:

And for help with using social media, check out the following resources:

Bullying Prevention is Suicide Prevention


More and more today, news is filled with stories of children being bullied by their peers, and even more horrific is when one of those young people take their own life because of what they had gone through. For those who do not choose to end their life, they may still suffer serious social and psychological consequences. Bullying is a serious problem, and it is impacting American Indian and Alaska Native (AI/AN) youth and alarming rates. According to the 2013 Youth Risk Behavior Survey, 21,5% of AI/AN youth did not to go to school at least one day in the last 30 days because they felt unsafe at school or on their way to or from school. This was the highest percentage of any reported race or ethnicity (Hispanic youth were second at 9.8%). Even more directly, 21.4% of AI/AN students said that they had been bullied on school property at least once during the previous year (compared to the national average of 19.6%), and 18.0% had been electronically bullied during the 12 months before the survey (compared to the national average of 14.8%) (Centers for Disease Control and Prevention, 2013).


What is Bullying?

Bullying now takes on several different forms and service providers should know the risks that exists. Bullying, also called peer victimization, generally occurs in person - where either psychical, emotional or verbal abuse is heaped upon a youth by a single person or a group of people. Now, with the proliferation of social media and mobile technology, youth are experience more and more electronic bullying - where a person is exposed to emotional or verbal abuse via e-mail, chat rooms, instant messaging, websites, social media or texting. Both forms are horrific, however, electronic bullying brings with it an entirely different set of risk factors. Bullying via social media may expose the bullying to a broader audience, thus multiplying the humiliation a youth may feel. And with face to face bullying, victims tend to looks for way to avoid confrontation (such as by skipping school, taking their lunch in different locations, walking different way home, etc.). However, with electronic bullying, the youth may find it difficult to avoid such harassment. And electronic bullying may not so easily catch the eye of adult witnesses, and many youth are forced to suffer in silence.


Research is also being conducted on what effects the amount and frequency of bullying can have on youth. It has been found that youth that are victimized one year and then the victimization stops (or episodic bullying) are far less likely than youth that are victimized repeatedly from year to year (or chronically bullied) to experience long term psychological trauma (Smokowski, 2014).


For all of these reasons, service providers and adults that work or interact with children regularly need to be able recognize the signs and symptoms of bullying in order to ensure that youth are not suffering with hope of support.


Signs and Symptoms of Bullying 

There are signs that a child is being bullied (Warning signs, n.d.). Adults and providers can become vigilant guardians against bullying by looking for, recognized and then acting upon the following signs. Note that the signs and symptoms of bullying are similar to suicidal ideation, which make sit doubly important that adults and friends intervene when they recognize any of the following.

  • Unexplainable injuries

  • Lost or destroyed clothing, books, electronics, or personal possession

  • Frequent headaches or stomach aches, feeling sick or faking illness (in order to miss school, for example)

  • Changes in eating habits, like suddenly skipping meals or binge eating. Kids may come home from school hungry because they did not eat lunch.

  • Difficulty sleeping or frequent nightmares

  • Declining grades, loss of interest in schoolwork, or not wanting to go to school

  • Sudden loss of friends or avoidance of social situations

  • Feelings of helplessness or decreased self esteem

  • Self-destructive behaviors such as running away from home, harming themselves, or talking about suicide 

Who are Bullies?

The days of the stereotypical images of schoolyard bullies are gone. Bullies are not just the brawny jocks that are taller, stronger, less intelligent, and poorer than all of their peers. It would do teachers, family members, and providers well to remember that anybody can be a bully. Bullies are not always academic underachievers. Those straight "A" students may also choose to use any intellectual prowess to make fun of those students who may be academically struggling. Students who come from affluent or influential families may find it easier to bully peers from families of lower socioecomoic or social status. Anybody can become a bully, or even be a bully and not even know it.


Adults can also be bullies - sometimes without even knowing it. Teachers who pick on students or even make jokes at a student's expense can become bullies. This can be especially true if the school personnel is not from the same race or community as the student. Teachers may purposefully or accidentally pick on students for things like mispronunciation, poor drawing skills, consistently poor grades, or handwriting and can have a lasting impact on the academic and social development of the youth, as well as how they view school and teachers in general.


Consequences of Bullying 

In the short term, consequences of bullying include both social side-effects such as increased feelings of sadness and loneliness and loss of interest in activities that used to be enjoyed, and of course the potential for physical harm at the hands of a bullying (of even self-inflicted if the child is internalizing the pain). Data confirms that youth that are chronically bullied exhibit lower levels of school satisfaction, school safety, perceived social support, future optimism, and self-esteem (Smokowski, 2014,). This can lead youth to drop out of school, withdraw socially, and even commit suicide. According to Smokowski (2014) chronic victims also reported the highest levels of peer rejection, anxiety, depression and aggression.


The consequences of bullying can be far reaching and can follow youth into college and adulthood. Research has shown that the brain processes bullying much like it would process physical pain (Vaillancourt, 2013). So for those youth that are chronically bullied, a parallel can be drawn to continuous torture. This can lead to anxiety disorders, stunted social development, social maladaptation, long-term depression. Kids who are bullied are more likely to experience:

  • Depression and anxiety

  • Increased feelings of sadness and loneliness

  • Problems sleeping and eating regularly

  • Health complaints

  • Decreased academic achievement and school participation

A few youth who were bullied may relations through violent measures. In 12 of 15 school shooting cases in the 1990s, the shooters had a history of being bullied.


Reporting of Bullying 

Kids may not report that they are being victimized by their peers. Statistics from the 2008-2009 School Crime Supplement show that an adult was notified in only about a third of bullying cases (DeVoe & Bauer, 2011). Some reasons for withholding that information include:

  • Bullying can make a child feel helpless.

  • Kids may want to handle it on their own to feel in control again.

  • They may fear being seen as weak or a tattletale.

  • Kids may fear backlash from the kid who bullied them.

  • Bullying can be a humiliating experience.

  • Kids may not want adults to know what is being said about them, whether true or false.

  • They may also fear that adults will judge them or punish them for being weak.

  • Kids who are bullied may already feel socially isolated, and convince themselves that they don't have an outlet to disclose.

  • Kids may fear being rejected by their peers. 


Bullying can lead youth to commit suicide, and it is our responsibility to ensure that Native youth have the opportunities to lead the long, happy, and fruitful life that they deserve. Preventing bullying is about awareness and intervention - much like suicide prevention. It is about understanding youth and recognizing when something doesn't look or feel right - much like suicide prevention. Youth may not often disclose that they are being bullied for embarrassment - much like suicide prevention. That is why it is imperative that adults are prepared to intervene. Ask questions, observe carefully, and actively act against bullies. Gone are the days of 'boys will be boys,' 'let the kids work it out themselves,' or 'they'll never learn if we fight their fight for them.' Bullies are abusing power and that should never be rationalized or justified.


The Indian Health Services has developed an anti-bullying campaign that can be put up with your communities ( and providers can use their suicide prevention programs to incorporate anti-bullying and bullying intervention strategies. Other sites, like, are extremely helpful. We all have an obligation to help our kids.


Resources Cited

Bullying Definitions. (n.d.). In What is Bullying. Retrieved from


Centers for Disease Control and Prevention. (2013). Youth Risk Behavioral Survey [Data file]. Retrieved from


DeVoe, J. F., & Bauer, L. (2011). Student Victimization in U.S. Schools: Results from the 2009 School Crime Supplement to the National Crime Victimization Survey (NCES 2012-314). U.S. Department of Education, National Center for Education Statistics. Washington, DC: U.S. Government Printing Office.  


Smokowski, P. R. (2014, January). Differential effects of episodic and chronic bullying: How victimization affects school experiences, social support, and mental health. Oral presentation for the Society for Social Work and Research 2014 Annual Conference, San Antonio, TX.


Vaillancourt, T., Hymel, S., & McDougall, P. (2013). The biological underpinnings of peer victimization: Understanding why and how the effects of bullying can last a lifetime. Theory Into Practice, 52: pp. 241-248.


Warning signs. (n.d.). In Who is at risk. Retrieved from



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 Acting Director of Public Health Programs and Policy, Robert Foley at or (202) 355-5494.