Table 2.

Factors influencing screening, brief intervention and referral for treatment of trauma in order of most frequent citation

Theme	Subtheme/belief	Sample quote
Nature of trauma in AI/AN communities	Ongoing impacts on health and well-being of individuals and families	“I know because I grew up in an alcoholic home, and also domestic violence in the home, and I got beat also, and it’s just like, it’s just keeps going. Because that’s what you learn. That’s what you learn as a child.”c
	Reduced capacity to function effectively in daily life	“[Trauma] creates disorder in their life, and then it spills over into other areas of their life, so it makes it harder for them to care for their children and have healthy relationships.”a
	Impact on society	“Lost productivity… they don’t do as well in school, they generally don’t pursue school quite as much, they generally have a lot of health and behavioral health issues.”b
Barriers to healing from trauma	Lack of resources and timely intervention	“I will tell you that the wait time is sometimes catastrophic. They end up back for me because they’ve already gone off the edge again.”a
	Problems with follow-up	“I don’t think there’s a real structured way for people to get follow up after they’ve had traumatic events. I’m not sure that there’s – I can see how it would be very easy for people to slip through the cracks.”a
	Stigmatization and barriers to reporting	“The issue that I have with the clinics, like I said, is that label that they put on your back. I’ve been dealing with this label since 2008, when it started showing up on my papers. And they’ve already got their mind made up that what kinda treatment I’m gonna get because of a diagnosis that someone put in [my record].”c
Screening concerns	Education and buy-in needed	“It’s almost like it requires a major sort of health campaign, where you spend a good chunk of time educating the community that this happens to people. And then when they come to the clinic, you ask them about that. Maybe that, those wheels start turning.”a
	“Opening a can of worms”	“So there is, I would say, an audience of people who can tolerate this. And then we have to be careful. There will be people who can’t. And for those people, we could – I mean, the danger is high. We could have them relapse.”b
	Logistics	“So I’m wondering where this is going to be asked, how it’s going to be asked, is it gonna be in a rush before I see the doctor, so I’m getting shoveled down the hallway and saying oh, so you ever experienced anything [LAUGHTER] traumatic, or is it gonna be after I see the doctor in a time and a place where I, if I need to talk for a5 minutes or b0 minutes, that’s gonna be available to me.”b
	Trust	“I was abused when I was a kid. So I don’t trust many people. I don’t wanna talk to people about my situation.”c
	Immensity of problem	“I think that there’s a dilemma here, and the dilemma is the sheer volume. When you were mentioning doing the – piloting the tool, the screening tool, I’m thinking well how are you gonna handle it if 80% or 70% of the people who come endorse yes.”a
Screening and intervention preferences	Increased and multi-faceted resources	“How do I help people come together, let’s say in a drumming circle, and do some drumming. Or singing. Or meditating. Or massage therapy. Or trauma-informed yoga. And know that that’s all appropriate treatment for someone’s history. And it’s all integrating stuff in addition to this.”a
	Community-based, culturally-aware approaches	“So that what’s utilized is the community. All the community of peoples. So that we’re all in it together then. And so the community that I’m thinking of in the behavioral health world is you drop below the master level psychologists and psychiatrists and utilize everybody who can be a part of us getting well.”b
	Education for patients, staff, and community	“I think getting medical providers comfortable with the idea that asking someone how their background has impacted them. Getting medical providers comfortable with those types of conversations is a huge issue. More than I would’ve thought even two years ago. I think having providers who are comfortable when someone is expressing intense emotion without feeling like they have to shut it down or stop it, or give them some piece of paper that’s got some intervention on it. I think we’ve gotta rethink that.”b
	Reduction of Stigma	“I think there needs to be an understanding for each individual case. ‘Cause not everybody’s the same. And not being treated as if you’re a drug seeker.”c

^aProvider

^bLeader

^cPatient