Abstract
The We RISE Study aimed to support young American Indian mothers on a tribal reservation by addressing social determinants of health at an individual and community-wide level. To address community-based barriers, the study developed the Tribal Resource Guide, a comprehensive list of available resources that was created through partnerships with community programs and staff. In addition to the guide, the study also developed the Poverty and Culture Training in order to train program staff at numerous community programs to better understand and serve lower socioeconomic and/or Native clients. The two projects facilitated collaboration between community programs and provided tools for programs to address barriers and ultimately better serve their target audience. Despite challenges, the transdisciplinary approach used with the local community maximized potential for success. This process and model could be duplicated in communities with similar demographics, resources, and barriers.
INTRODUCTION
Throughout the United States, there is a great need to address the social, economic, and health disparities and gaps in care that exist among minority populations (Advocates for Human Potential, Inc, 2015; Moghani Lankarani & Assari, 2017). The Collaborate Research Center for American Indian Health (CRCAIH) aims to use a transdisciplinary approach to address these social determinants of health among American Indians (AIs) in the Northern Plains by supporting researchers across disciplines and community members in pilot projects like We RISE (Raising Income Supporting Education).
Poverty poses numerous supply and demand barriers to health service access, which contributes to poor health outcomes (Ensor & Cooper, 2004). Individuals on the lower end of the socioeconomic status (SES) scale are frequently segregated into communities with poorer resources, fewer opportunities for preventative health care, less general and health education, and worse environmental conditions (Cooper & Mulvey, 2015; Ensor & Cooper, 2004). Resource deficits can be financial, emotional, psychological, spiritual, and physical, including health, mobility, and transportation. These social, health, and resource deficits common on AI reservations are a prime example of how a zip code can be a better predictor of health than genetic code (Seavey, 2008).
American Indian Disparities
These disparities also exist in many tribal communities. Nationally, AIs die at higher rates than other Americans in many categories. For example, AIs die at rates 4.7 times higher from chronic liver disease and cirrhosis, 2.8 times higher from diabetes mellitus, and 1.6 times higher from suicide (Indian Health Service, 2015). In addition to these health disparities, AIs also have a high rate of trauma, violence, unintentional injuries, and substance abuse, which negatively impact health (Companion, 2008). There is a large body of evidence that suggests that racial health disparities and long-term outcomes are associated with socioeconomic conditions over time (Assari, 2018; Companion, 2008; Farmer & Ferraro, 2005; Moghani, Lankarani, & Assari, 2017). An editorial by 14 Native researchers affiliated with the National Institutes of Health calls for “a new approach to health disparities intervention research…that addresses the root causes of health disparities, the disparities in money, power and resources that have existed since colonization in order to improve the health of the AI/AN population” (Blue Bird Jernigan et al., 2015, pp. S376), which is exactly what the innovative We RISE study aimed to do.
Study Background and Significance
Young AI mothers with poor access to resources and, many times, a lack of adequate support systems struggle to promote healthy lifestyles for themselves and their children. However, perhaps it is not only access to resources, but rather lack of understanding of the resources that are available and how to utilize them that hinders the improvement of health disparities (Ensor & Cooper, 2004). Additionally, to compound difficulties in connecting young AI mothers to the resources available to them, community programs unknowingly have common barriers that reduce the utilization of their resources, which often stems from a lack of understanding of poverty and culture.
Because these poverty and health issues are widespread among communities of color, in particular tribal nations, we developed the We RISE study, tailored for AI populations with low SES and poor health outcomes that are underutilizing community programs and resources. The study consisted of three components, each with a unique target audience: 1) the Tribal Resource Guide, targeted for individuals from the community; 2) the Poverty and Culture Training, targeted for the community workforce; and 3) the We RISE intervention, targeted for young AI mothers in the community. The We RISE study used community-based participatory research methods to develop the Tribal Resource Guide, Poverty and Culture Training, and the We RISE intervention, which aimed to impact social factors influencing health behavior through motivational interviewing techniques, goal setting with attainment, and improved utilization of community resources.
Each component of the study had a unique purpose, with an underlying theme of impacting social determinants of health by improving access and utilization of community resources. The Tribal Resource Guide, which included local program contact information and a description of resources, was developed to improve knowledge and utilization of available resources. The Poverty and Culture Training aimed to improve knowledge of poverty and Lakota culture, encourage programmatic changes to increase access and reduce individuals’ barriers to resources, and strengthen existing relationships between community programs. The We RISE intervention component is discussed in more detail in a previous article in this special issue (see McCormack et al., 2019). The Tribal Resource Guide was used with the young AI mothers who participated in the We RISE intervention, but because the resources young AI mothers need is essentially the same as the resources needed by the community-at-large, the Tribal Resource Guide was intended to benefit the entire community. Likewise, the Poverty and Culture Training was geared directly to the community program workforce, but the impact of the training is presumed to benefit young AI women in the community. This paper will explain the process and results from both the development and dissemination of the Tribal Resource Guide and the Poverty and Culture Training. An editorial by 14 Native researchers affiliated with the National Institutes of Health calls for “a new approach to health disparities intervention research…that addresses the root causes of health disparities, the disparities in money, power and resources that have existed since colonization in order to improve the health of the AI/AN population” (Blue Bird Jernigan et al., 2015, pp. S376), which is exactly what the innovative We RISE study aimed to do.
METHODS
The concept and design for the We RISE CRCAIH pilot project began with a transdisciplinary partnership between tribal community professionals and researchers at the State’s 1862 land-grant university. However, uniquely, this project was driven by local professionals from the tribal community, as opposed to a university or researcher approaching a tribal community with a preconceived intervention that may not meet the community’s needs, or lacks cultural relevance. The We RISE team came from diverse disciplines including public health, epidemiology, sociology, American Indian studies, nutrition, and community development. This approach and partnership between the tribal community professionals and the university researchers across disciplines exemplifies the transdisciplinary methods used from concept to dissemination and promotes mutual beneficence for the tribal community, participants, and research team. All protocols and procedures were originally approved by the South Dakota State University Institutional Review Board (IRB) and the Great Plains IRB. Local tribal approval was also obtained.
Target Population
This study was conducted with a Lakota tribal nation, which is languished by extreme poverty (> 25% of families below the federal poverty level) and numerous health disparities, despite a variety of social and health programs available to community members. Located in rural north-central South Dakota, the reservation is roughly the size of Connecticut, with a population density of one to two people per square mile (U.S. Census Bureau, 2017a; U.S. Census Bureau, 2017b). Table 1 identifies demographic and general health data for the two counties that make up the reservation and the state of South Dakota for comparison. Overall, when compared to South Dakota, the population is more rural and has a higher proportion of AIs, unemployment, children in poverty, young people who are not working or in school, and poor housing conditions. The reservation also has a lower proportion of people age 65 years and older, adults with college experience, and lower median household income. Additionally, there are nearly twice as many adults reporting poor or fair health and deaths under age 75 in the study population.
Table 1.
Population demographic and general health data
| County A | County B | South Dakota | |
|---|---|---|---|
| % Rural | 64.1% | 73.5% | 43.3% |
| % below 18 years of age | 36.6% | 32.7% | 24.6% |
| % 65 and older | 9.6% | 7.5% | 16.0% |
| % American Indian and Alaskan Native | 73.2% | 71.4% | 9.0% |
| % of adults (age 25–44) with some college | 45% | 44% | 68% |
| % of population (age ≥16) unemployed but seeking work | 8.5% | 4.2% | 2.8% |
| % of children in poverty | 33% | 47% | 17% |
| Median household income | $38,500 | $30,800 | $54,900 |
| % of population (age 16–24) who are not working or in school | 38% | 35% | 10% |
| % of households with overcrowding, high housing costs, lack of kitchen or lack of plumbing | 19% | 24% | 12% |
| % of adults reporting poor or fair health | 23% | 28% | 12% |
| Number of deaths under age 75 per 100,000 | 930 | 510 | 330 |
Tribal Resource Guide
Development
The team began by first developing a list of known community programs that offer a variety of resources (i.e., housing, wellness, childcare, and cultural). The team had informal interviews with resource experts in the community to identify programs missing from the list. The final list included 138 programs. Questions were developed by the WeRISE team, local elders, and community stakeholders, to interview representatives from the list of identified community programs. Utilizing community advisors from a variety of disciplines was another form of community-based participatory research. Attempts were made to contact program representatives in administrative positions to obtain the most accurate information, but if this was not possible, other professionals, such as administrative assistants or receptionists, were interviewed. The survey collected contact information, including official program name, person completing survey, phone and fax number, physical address, and webpage or social media pages. Resource questions included, “What resources does your program offer and how can they be accessed?”, “Can non-tribal members use your resources?”, and “Is there anything else you want us to know about tribal programs or resources?” This final question often resulted in recommendations for other programs to contact that offer resources to the Tribal community. Each representative was also asked to categorize their program into one of the following: 1) Education & Childcare; 2) Financial; 3) Food & Nutrition; 4) Health & Wellness; 5) Housing, Home Improvements, & Utilities; 6) Leisure & Recreation; 7) Religious; and 8) Legal & Cultural.
A total of 132 interviews from the list of 138 were completed over the course of three months. Six programs on the list were unreachable, and 15 programs interviewed indicated that they do not currently offer a resource; after removing these 117 programs remained. Upon completion of surveys from all local programs willing to participate, data were organized into a guide. Total estimated time to gather and enter surveys was 350 hours. The first version of the Tribal Resource Guide listed programs alphabetically and identified the category(s) to which it was classified with a symbol. Because this tribal nation is home to both tribal members and non-tribal members, resources that were only available to enrolled tribal members were indicated with an asterisk (*).
To further the transdisciplinary approach, the guide was updated at the end of the study based on feedback from intervention participants and key stakeholders from the local community. Changes included the addition of 35 programs that were not originally identified, program descriptions were made more concise, and the guide was reorganized by category then alphabetically to improve usability. This resulted in some programs being listed in more than one category when appropriate. The final 32-page version of the Tribal Resource Guide featured 152 programs, a section for national emergency phone numbers, a section for local emergency phone numbers, and a variety of local photos.
Dissemination
All We RISE intervention participants (McCormack et al., 2019) were provided the Tribal Resource Guide during the study. Six hundred copies of the final Tribal Resource Guide were distributed to the general public and to all the programs featured in the guide. The Tribal Resource Guide was also disseminated online. Project staff contacted local community programs who have a webpage to facilitate sharing of the guide. Partner institutions, including CRCAIH and the subawardee, Missouri Breaks Industries Research, Inc., also shared the guide on their webpage (CRCAIH, n.d.; Missouri Breaks, n.d.). Missouri Breaks Industries Research, Inc. also highlights programs from the guide periodically on social media, with a link to the full Tribal Resource Guide. The online presence allows individuals to download and save or print a copy of the guide. For sustainability of the Tribal Resource Guide, a partner specializing in economic opportunity plans to maintain the document and provide updates as businesses change and evolve. Following local dissemination, there were requests for additional print copies, so local programs are opting to print additional guides at their own expense, which demonstrates the need for and value of the Tribal Resource Guide.
Poverty and Culture Training
Structure and Content
Another initiative of We RISE was to improve knowledge of Lakota culture and the culture of poverty, encourage programmatic changes to increase access by reducing individuals’ barriers to resources, and strengthen existing relationships between community programs by facilitating the Poverty and Culture Training for the local community workforce. A majority of the community members are Lakota and/or facing poverty, so knowledge about the community can translate to improved services. Community programs often struggle to reach their target population because of circumstances that come with poverty and lack of collaboration between programs. For example, some programs opt to discontinue services to individuals who miss three appointments, regardless of the reason for missing the appointment (i.e., no transportation or childcare).
The agenda for the training is provided in the Appendix. The three-and-a-half-hour training was led by local professionals knowledgeable on the subject matter, such as people trained in community leadership and development, trauma-informed care, and Lakota culture. Local professionals were used to maximize community buy-in for the training. The objectives of this training were to 1) educate community program staff on poverty and culture; 2) bring community stakeholders together to network, share resources, and ideas; and 3) discuss effective recruitment and retention strategies that reduce barriers to resources.
The training included concepts tailored to the local community from “A Framework for Understanding Poverty: A Cognitive Approach” by Ruby Payne because the local professional had experience with Ruby Payne’s work (Payne, 2005). Case examples focused on reducing the social costs of poverty, strengthening the workforce, and building a more prosperous and sustainable community. A copy of Ruby Payne’s framework was provided to each program that attended the training, and participants were encouraged to share the book and concepts from the training with other staff in their program to reach more professionals.
Trauma-informed care, stories of resilience, and the seven Lakota values were also incorporated into the training. Because of the stress and trauma often associated with low income and minority status, discussion on historical trauma of the Lakota, toxic stress, Adverse Childhood Experiences, and symptoms of trauma was led by project staff to provoke empathy for community members who have experienced trauma. Stories of resilience were then shared to demonstrate the profound ability of the Lakota people to bounce back and break the cycle of trauma. Fostering resilience through relationships and community collaborations was shared as a method for program staff to be part of the solution to enhance community services and empowerment. The Lakota values of courage (wóohitike), compassion (wówauηšila), generosity (wówačhaηtognake), wisdom (wóksape), patience (wówačhiηthaηka), respect (wóyuonihaη), and humility (wóuηšiič’iye) were embedded in the training to demonstrate the application of Lakota culture to better serve our community. Incorporation of Lakota values and acknowledgment of community strengths ensured cultural and community relevance. Symptoms of trauma, resilience, and practicing the Lakota values are essential understandings to a resilient and united community.
Administrators, owners, and leaders of all 138 community resource programs identified on the list developed for the Tribal Resource Guide were invited to the Poverty and Culture Training via postcards and email. After rescheduling twice for inclement weather, the Poverty and Culture Training was held in December 2016. Twelve individuals representing nine different community programs attended the training.
Evaluation
To evaluate short-term outcomes of the training, two surveys were conducted: 1) a pre- and post-evaluation to assess the knowledge of poverty and Lakota culture, and 2) a survey to assess program procedures and policies regarding recruitment and retention which was collected before the training and three months later.
The pre- and post-evaluations were collected before and after the training and included five questions. Two true/false questions were asked: 1) “Poverty is more about a lack of resources than it is about money,” and 2) “Relationships and education are key ingredients to help individuals and families living in poverty.” Three multiple-choice questions were asked relating to the Lakota values important for community programs to practice, symptoms of trauma, and ways community programs can help individuals build resilience. All 12 participants completed pre- and post-evaluation materials. Percent of correct responses for each question and the mean percent correct from all participants combined was analyzed from the pre- and post-evaluations to assess a change in knowledge (see Table 2).
Table 2.
Pre- and post-training evaluation and results
| Questions | Responses | Pre-Training Results | Post-Training Results |
|---|---|---|---|
| 1. Poverty is more about a lack of resources than it is about money. | a. True b. False |
a. 12/12 (100%) | a. 12/12 (100%) |
| 2. Relationships and education are key ingredients to help individuals and families living in poverty. | a. True b. False |
a. 12/12 (100%) | a. 12/12 (100%) |
| 3. Which Lakota values are important for community programs to practice? Select all that apply. | a. Humility & Patience b. Respect & Compassion c. Prayer & Wisdom d. Fairness & Responsibility |
a. & b. 6/12 (50%) | a. & b. 10/12 (83%) |
| 4. Drugs, alcohol, risky sexual behavior, violence and incarceration are… | a. Lifestyle choices b. Examples of moral character c. Symptoms of trauma d. None of the above |
c. 6/12 (50%) | c. 10/12 (83%) |
| 5. Which component in this list does NOT build resilience? | a. Individual factors, like personality b. Experiences a person has throughout life c. Community, such as local resources working together d. Relationships that are stable and supportive |
b. 5/12 (42%) | c. 6/12 (50%) |
| Mean score: | Mean score: | ||
| 68% | 84% |
Bold = correct response
The recruitment/retention survey was collected before the training and three months following the training, with one survey for each program represented. Of the nine programs that completed the initial recruitment/retention survey, eight completed the 3-month follow-up survey online. The survey collected before the training asked six multiple-choice questions and one qualitative open-ended question (question 6). Questions 1–4 each had one response that was coded as favorable and two responses that were coded as non-favorable. Participants were asked to select all that apply for questions 5 and 7; each response selected was coded as favorable. The total favorable responses possible was 13; mean total favorable responses for all programs were reported. A comparison of baseline data and the 3-month recruitment/retention survey data on program policies was analyzed to measure intermediate impact. Three additional multiple-choice questions (questions 8–10) were asked at only 3-month follow-up survey; responses were purely informational and not coded as favorable or non-favorable (see Table 3). Because funding and time constraints did not allow for community input during the design of the training, the participants were allowed to write-in feedback on the training structure and content.
Table 3.
Recruitment/retention evaluation and results
| Questions | Responses | Training Day Results | 3-Month Follow-Up Results |
|---|---|---|---|
| 1. Does your program currently have a written process or policy for recruiting or reaching out to community members? | a. Yes b. No c. Don’t Know |
Yes 5/9 (55%) No 4/9 (45%) |
Yes 5/8 (63%) No 3/8 (38%) |
| 2. Does your program currently have a written process or policy for retaining clients to ensure they keep coming back? | a. Yes b. No c. Don’t Know |
Yes 3/9 (33%) No 6/9 (67%) |
Yes 5/8 (63%) No 3/8 (38%) |
| 3. Does your program have a no-show policy? If yes, please explain. | a. Yes b. No c. Don’t Know |
Yes 3/9 (33%) No 6/9 (67%) |
Yes 2/8 (25%) No 6/8 (75%) |
| 4. Does your program currently advertise its services or resources to the general public? | a. Yes b. No c. Don’t Know |
Yes 6/9 (67%) No 3/9 (33%) |
Yes 7/8 (88%) No 1/8 (13%) |
| 5. If yes to previous question, what methods do you currently use to advertise? Select all that apply. |
a. Paid newspaper ad b. Free newspaper articles c. Radio d. Printed materials (flyers, banners brochures, etc.) e. Social media (Facebook, Twitter, etc.) |
Mean total advertising methods = 1.89 out of 5 possible | Mean total advertising methods = 4 out of 5 possible |
| 6. What changes, if any, do you plan to make at your place of work to assist customers as a result of the training? | Open response | Highlights in text | |
| 7. Does your program currently offer any of the following services for clients? Select all that apply. |
a. Childcare assistance b. Transportation assistance c. Snacks or beverages d. Scheduling flexibility |
Mean total services = 2 out of 4 possible | Mean total services = 2.63 out of 4 possible |
| Mean total favorable responses = 6.11 out of 13 possible | Mean total favorable responses = 9.5 out of 13 possible | ||
| Additional 3-Month Follow Up Questions | |||
| What changes, if any, did you make at your place of work to assist customers as a result of the training? | Open response | Highlights in text | |
| What have you done with the Ruby Payne Poverty book since the training? Select all that apply. | a. Read it or parts of it b. Looked through book, but did not read it c. Nothing d. Shared it with others |
a. 6/8 (75%) b. 1/8 (13%) c. 1/8 (13%) d. 4/8 (50%) |
|
| How much do you feel the training has impacted your work with those in poverty? | a. A lot b. Somewhat c. Not at all d. Not sure |
a. 4/8 (50%) b. 3/8 (38%) c. 0 d. 1/8 (13%) |
|
| Would you recommend a poverty and culture training like you attended to others? | a. Yes b. No c. Not sure |
a. 7/8 (88%) b. 0 c. 1/8 (13%) |
|
Bold = favorable response
RESULTS
Tribal Resource Guide
At the time of publication, a total of 600 printed Tribal Resource Guides have been distributed, reaching all 20 communities on the reservation. Three programs have shared the Tribal Resource Guide on their webpages. Before the We RISE study began, the tribe’s webpage identified 29 tribal programs with limited descriptions and contact information. As a result of the resource guide being posted on the tribe’s webpage, all 50 tribal programs that offer a resource and 102 other non-tribal programs are now identified with accurate and up-to-date information and descriptions of resources. As a result of online dissemination, one other Tribe in the region recognized the need for and value of a Tribal Resource Guide and sought advice and assistance to replicate the We RISE process to create a guide specific to their reservation.
Poverty and Culture Training
According to the pre- and post-evaluations, knowledge of poverty and Lakota culture, determined by the percent of correct responses, went from 68% before the training to 84% after the training (Table 2). Each participating program was assigned a total number of favorable responses before the training and three months after the training for comparison. One program did not complete the 3-month follow-up survey, two programs showed no change in favorable responses, and six programs showed an increase in favorable responses. Of the 13 possible favorable responses on the recruitment/retention survey, the mean favorable responses for all participating programs went from 6.11 before the training to 9.5 at the 3-month follow-up (Table 3).
Program representatives who participated in the Poverty and Culture Training were asked what policy or protocol changes they made as a result of the training. Two programs established a new written process or policy for retaining clients to ensure they keep coming back, which was encouraged during the training. One program reported initiation of advertising services or resources to the general public, and several others reported expanding advertising services, which was also encouraged at the training. Additionally, 75% of respondents reported reading the Ruby Payne book or parts of it, and 50% shared it with a colleague. When asked if the training had impacted their work with those in poverty, 88% said “a lot” or “somewhat,” and 88% indicated they would recommend the training to others.
DISCUSSION
Together, the Tribal Resource Guide and Poverty and Culture Training facilitated connecting individuals to resources, and it supported community programs to collaborate and interact with individuals more effectively. The process of disseminating details on resources in a user-friendly guide and training the community workforce on poverty and culture were relatively simple and low-cost approaches to addressing a community need. These approaches were not without barriers, but the overall impact exceeded the difficulties faced.
Tribal Resource Guide
Barriers
Barriers experienced in development of the Tribal Resource Guide include inconsistencies and changes in reported services, miscategorized programs, and dissemination challenges. Identifying all the community programs that offer a resource and staying informed about the continuous changes in resource availability was a challenge. This is why it was important to keep a list of changes needed and additions to the first version of the guide. The continuous changes are often due to variable funding from short-term grants or donations, as well as changes in administration and program goals. The initial plan for dissemination included an area on the local Chamber of Commerce webpage that would allow searching for resources by keyword, eligibility, or category. Due to staff turnover, this was not able to be accomplished. However, We RISE project staff are committed to working with future Chamber of Commerce personnel to make this plan a reality as soon as possible.
Successes
A great strength to the We RISE project is that it was conducted on a reservation that has many existing resources that were simply underutilized. Compiling, organizing, and disseminating the Tribal Resource Guide generated the opportunity for the entire community to learn about available resources and access them more easily. We RISE intervention participants, Poverty and Culture Training participants, and community program staff interviewed for the development of the Tribal Resource Guide consistently reported enthusiasm that the guide was developed because of the great need for community members to know what resources are available to them to increase utilization of community programs. Of the program staff who were interviewed, many expressed feelings that “no one knows what we do here.” For many of the community programs, getting a new client in the door created opportunities for expansion and reach on both an individual and community level. Community members also benefit through improved accessibility to resources.
Poverty and Culture Training
Barriers
Winter weather negatively impacted the number of programs that were able to participate in the Poverty and Culture Training, as many that were pre-registered were unable to attend, which is an unfortunate, but common, barrier in rural communities. Additionally, we were unable to get all of the programs who participated in the training to complete the online 3-month follow-up recruitment/retention evaluation.
Successes
The programs that were represented at the Poverty and Culture Training had the opportunity to learn from each other and discuss possibilities for collaboration. Fostering discussion on poverty and culture enables partners to work together in addressing mutual barriers. The Poverty and Culture Training facilitated collaboration and a better understanding among the various community programs, which provided them with tools to ultimately better serve their target population. The bottom line is that without open conversations, nothing changes. One participant commented, “I believe all tribal officials, department heads, and state programs working within the reservation should attend a poverty training.”
When asked about program changes made as a result of the training (Table 3, question 6), one program stated, “[Staff are] more understanding of barriers people face due to poverty. [Staff] work harder to reduce barriers within the organization so interested persons can participate in meetings and events.” Another program stated, “Being understanding and flexible with scheduling is much more effective for retention. Also, staff have a better appreciation for the circumstances that come with poverty.”
CONCLUSION
Collaborating with community program staff and key stakeholders to develop and disseminate the Tribal Resource Guide and providing a culturally appropriate training on poverty were effective methods of using CRCAIH’s transdisciplinary approach to community-based participatory research in this Lakota community. As a result of this partnership between the local tribal community and the university, transdisciplinary research capacity was enhanced for the tribal community and the university-based research professionals. It is plausible that this process and model could be duplicated in communities with similar demographics, resources, challenges, values, and needs.
ACKNOWLEDGEMENTS
We would like to thank the Tribal Council that approved and supported the We RISE Study, the programs that participated in development of the Resource Guide and the programs that attended the Poverty and Culture Training. Research reported in this publication was supported by the National Institute on Minority Health And Health Disparities of the National Institutes of Health under Award Number U54MD008164. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
APPENDIX
| Poverty and Culture Training Agenda | |
|---|---|
| 12:45 PM | Pre-Surveys |
| 1:00 PM | Welcome, Prayer, Introductions, & Ice Breaker |
| 1:15 PM | Understanding who we are and where we come from: Poverty and barriers to relationships
|
| 2:15 PM | Trauma, resilience & Lakota culture
|
| 3:00 PM | Break |
| 3:15 PM | Breaking down silos discussion
|
| 3:45 PM | Where we go from here |
| 4:15 PM | Post-Surveys |
| 4:30 PM | Closing |
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