Well, thanks for joining us. I'd like to welcome you all to today's training, Effective Prevention Strategies for Youth Substance Use, a Culturally Informed Approach. This training is brought to you on behalf of Mississippi Department of Mental Health and sponsored by the Tribal East Region Opioid Response Network. Next slide. I'm Jenna Fold, technology transfer specialist working for the Tribal East Region of the ORN. The ORN is funded through a grant by the Substance Abuse and Mental Health Service Administration and our grant prime is the American Academy of Addiction Psychiatry. We provide technical assistance to individuals, groups, and organizations in the form of education and training regarding opioid and stimulus disorders, and we cover the areas of prevention, treatment, recovery, and harm reduction. Next slide. So this is all provided at no cost as it's covered through the SAMHSA grant and our organization covers the entire United States and the U.S. territories and it's broken up into regions who all have their own technology transfer specialists who can assist you with a request. Next slide. If you wish to submit another request in the future, here's our contact information and we would be happy to connect further to discuss any of your technical assistance needs. We are fortunate today to have Dr. Lala Forrest as our presenter for this topic. Before I turn the meeting over to her, I just wanted to review a few of the Zoom controls, although I know it's a little bit different because you're all in the same room, but I have enabled the live transcript feature if you want to use that. I will not have everybody sign into the chat. Usually we have everybody sign into the chat, but we will be monitoring the chat if anybody wants to submit any questions, but we will be doing the questions at the end. So I am recording this first part and then I will turn off the recording and then we will go into the Q&A portion of the training. And then I just want to let everybody know that the last slide, we'll leave it up on the screen, it'll have some information for our learning management system and that's where we'll be able to access our ORN survey, which is just really, really important for us. It helps the ORN to maintain the funding it needs to continue offering these free trainings and it also allows us to see how we can improve our services. So when we get to the end, I'll go over the instructions on how to access that survey and we just really appreciate your feedback. You'll also be able to get a certificate of completion, a copy of the slides and a recording of today's training. And just note that that will probably take about three to five days to get the recording and slides up there. And that's all I have. So without further ado, I will now turn it over to Dr. Forrest. Thank you so much, Jenna. And thank you, Chan. Hello, everybody. My name is Lala Forrest. I am a member of the Pitt River Tribe from Northern California. And it's an honor to be with you all here today. I am a physician at Yale University. I'm training in the psychiatry program with plans to transition to the Child and Adolescent Psychiatry Fellowship, specializing in addiction. And I want to start us out in a good way by my understanding is most of you live, work and play in the lands now known referred to as Mississippi. But I want to honor and recognize the Indigenous peoples of this area, the tribes and bands who continue to remain resilient to this day and are caretaking for the ancestral lands of this area. For today, I'm going to be fighting against time here. I did a for this talk, I did a comprehensive dive into these different sections about substance use trends, nicotine, cannabis, alcohol, and then some and I want to also address some evidence based prevention strategies, but from a cultural perspective in response to working with Native youth in particular. And my intention with this talk is to provide you with resources that you can later on refer to and come back to. So I would encourage you to write down a slide number that interests you, because time is our limiting factor here. And I want to start out by saying that I'm very excited to talk about Native youth. I love presentations, talks like this, because I think it's very, very important. And this is a great quote that I have, that I always come back to. And I wanted to share it all with you today. That reads, with children, we always have to think about seven generations to come, but yet unborn. And that is why we are all here today to talk about our youth and what we can do here and now to help build and cultivate a future that we envision for them. But also, I want to recognize our parents and our grandparents and our ancestors from seven generations ago, who also were working to provide us today with the same privileges and resources that we have today. All right, so we're going to dive right in. And I want to start out also by sharing this study from 2018. It's a great review that shows the different estimated proportion of different substance use across the lifespan. So here we have alcohol, tobacco, cannabis, opioid. And unfortunately, the study only provides the differences in binary genders, male, female. I am not aware of any studies that have any relevant information about our other gender expressive identity people. But importantly, the reason, you know, this is a resource for you to come back to if you're interested. But the common thread here is that when we look at all of these different substances, and today we'll be talking about these three here on the left, is that the highest peak of use is in the adolescence and young adult age. And to preface why the youth is an important population for us to address and to think about is because the youth is a period of transition. This is such an amazing time. It's also a very difficult time for a youth as they're learning how to become more independent, looking for autonomy, pushing boundaries, figuring out who they are as individuals. And it's also a time that they're vulnerable developmentally in terms of their frontal lobe development responsible for their executive function, their reasoning. And this is continuing to develop. The brain is a very plastic, malleable state. And so this is why there needs to be a lot of dedicated efforts and trainings and talks about our youth today. So we're going to jump into the different substances that I was requested to speak about today. And we'll start with alcohol. So this is study, this is data from the Monitoring the Future study out from the University of Michigan. And this is the alcohol trends in the last 30 days prevalence in youth by different grades. We have 8th, 10th, and 12th. And we can see that we've done a pretty great job of reducing alcohol intake. This is a very similar trend for past one year use. Also noted that it's been declining in the past few decades. However, it's still the number one, alcohol is still the number one substance that youth are using today. And importantly, what I want to highlight today is that binge drinking is still, and this has been reported time and time again in the literature, a really great indicator of negative consequences, potential negative consequences of alcohol use. So this was a study done in 2018 that looked at the prevalence here on the Y-axis. And you could see that those people, the youth who were having binge drinking behavior had increased prevalence of alcohol use disorder, harmful drinking behavior. So driving under the influence, perhaps getting into legal difficulties, and then alcohol dependence. So that's still the number one thing that I want to bring you all to your attention because there are studies out there that report up to around 90% of alcohol use in the youth is in the form of binge drinking. And then I also wanted to, understanding that you all are from the Mississippi area, I wanted to provide you with some information I was able to find about what is going on here in your state. And so this is a great chart that looks at the different age brackets. And you could see that the ages 18 to 20 have the highest past month alcohol use. And this is actually pretty comparable on par for being the average compared to the general US population here in the orange. But when we look at the binge drinking behavior, it is higher, 17.2% compared to the national average. And this is important for you all to know. And then there's also some additional information located here below about the average age of initiation, as I'll talk about later, that increases your risk for possible negative consequences, substance use, and then also attributable deaths. All of that could be found here that you could reference later if you're interested. And then I will transition us to vaping. So vaping, I'm so excited to talk about this topic because it's becoming a significant issue in our youth. Vaping is a relatively new phenomenon ever since the early 2000s. And the companies are starting to be very strategic and specifically targeting our youth to increase the tendency for them to engage in vaping behavior. And so we have, these are some pictures of illustrations of what the different generations of the vape pen may look like or vaping methods. And you could see that there are even some that are in the forms of school supplies, such as highlighters. I've seen some that look like little boba drinks or little slushies, and that they're visually appealing and even appear candy-like. It may not be regulated to be childproof. So sometimes little kids will get into them and accidentally ingest them. So there's been very strategic marketing to target our youth. And in the next few slides, I want to provide kind of a deep dive into the main points that I want to address with vaping. And the first one is let's look at the contents of what is vaping. There's a lot of misconceptions. There's a lot of comparing to commercial tobacco use and which is better. And those are just like not comparable. And when we look at vaping, we have to look at what is the substance that potentially our kids are using. It could be nicotine, it could be cannabis, or it could be both. And when we look at our commercial tobacco, commercial cigarettes, we know that there are thousands of reported toxins. And for vaping, their research shows that there are still hundreds of toxins within the vaping. And some of them are listed here, such as propylene glycol, heavy metals could be found in here. The flavorings that are used that are part of perhaps increasing the tendency to develop dependent addiction behavior like diacetyl has been known to be a correlator for causing certain lung diseases, benzene. And then there's also, maybe some of you have heard about e-cigarette or vaping-associated lung injury or EVALI. And not that there was anything conclusive done by the investigation, but a lot of our youth were coming in with EVALI being diagnosed. And they found that there's this compound vitamin E acetate that was found to be correlated in this disease presentation. There's also pesticides that may be left over from the cannabis solvents, the paraformaldehyde, aldehyde that is used to help extract these compounds could be present also as well. And that's been directly shown to fixate cells and kill off cells. And the next thing I want to talk about the last point here is the increased THC content. So looking more closely at that, this is the percent of THC and CBD in cannabis that has been seized by the DEA over the past few decades. And the concentration is on the Y-axis here in the percent and the THC is an orange. And we see that steadily throughout the decades, the THC concentration has increased. We're averaging about 16% right now, but also that we have to make room to consider the different modes of ingestion of cannabis because the THC percent concentration can be upwards to 80% for dabs or using the wax formulation. So this is something that we should be aware about. And then lastly, I was also asked to touch a little bit about the gummy mode modality for ingesting cannabis. And in particular, it was interesting. I found, here is a picture of the gummies, potentially a gummy, but what came up for me in my work here was, we have the Delta 9 or D9 THC compound here that is primarily known for its psychoactive properties with the high that people experience. And then we also have now the introduction ever since the farm bill was introduced back in 2018, where people are directly extracting different compounds from hemp. So that way it's not regulated at a federal level is Delta 8 or D8. And can anybody notice the difference between these two? Really, it comes down to, I don't know if you can see my mouse, but it just comes down to a different double bond. This D8 is an isomer of D9. It's been reported to be around 50 to 75% as potent as D9. But the important thing is that because it comes from hemp, and it has less than 0.3% of D9, that it does not need any regulation federally. So right now this is in a gray area. This is discussed more in the news about kids ingesting this. Kids can come in and buy this without any regulations in some states. And because it's a different compound, it's not regulated at a federal level. And because this is becoming more of an issue in our youth, we just started reporting data on this. The University of Michigan just started measuring this back in 2023. So we have some preliminary data of what's been going on in the past year. And we found, this was a study that was published earlier this year, that about one out of 10 12th graders are using D8. And that there's a higher prevalence of using it in the South and Midwest regions of the United States, and in states that have no regulation of this. So I think this would be relevant for you all as well. And lastly, the important thing that I want to also reiterate about the vaping is, as I mentioned, there are different generations here that are being created. And as we continue to make these new generations, these companies are thinking about ways on how to entice people to become more dependent on these. And one of them is by manipulating the nicotine itself. In traditional and commercial cigarettes, the nicotine is in a free base form. It's very alkaline. And with the newer generations, the nicotine has been manipulated to be more in an acidic, in a salt state. And the ability of it to be in a salt state actually makes it more palatable. It's less harsh. So it's more easy to ingest and actually more pleasurable to digest, especially with the flavorings. And so it's hitting the dopamine circuits within the brain. And because it's also a second point is that the nicotine is more able to be absorbed in the system. So kids in the newer generations with the nicotine salts are absorbing more nicotine compared to the commercial cigarettes. So let's hop into the data. So we have data from monitoring the future study that began in 2017 here. And you could see it showing all the way up until last year, the percent prevalence. Right now, there's no significant movements in the trends, but this is for e-cigarette use. When we look at the vaping with cannabis, it shows a little bit of a different story that we see some skewing towards uptrend, and especially perhaps in our older youth population and our 12th graders here. So that's a little bit of going into the alcohol, the nicotine, the marijuana. But I just want to also bring to your attention that there are limitations in the current data that we have. There needs to be more research on how interacting identities in our youth are perhaps related or driving vice versa, the use of substances within our youth. So for instance, this is a study that was done by the National Health Interview Survey back in 2021 that showed our youth who are identifying as female or as LGBTQ plus have higher anxiety and depression. And how does this play? We can make assumptions to why this is in regards to maybe discrimination, whatever, in a sense. But I think it's important that we start to really better capture what's going on in our youth so that way we can figure out the roots to this problem of why they're having increased substances with some substances. So I'll transition us to talk more about evidence-based prevention strategies next. And this is the Institute of Medicine's Continuum of Care model that they have. And you can see that they break down how to address mental, emotional, and behavioral health interventions into these four different domains, the promotion aspect, the prevention aspect, which is what we're going to focus on today, the treatment, and then recovery. And then a person could fluctuate in between these throughout their lifetime. And this is a model that we this is a model that we can use to reference, but I also want to share with you all that as we are working with Indigenous communities and thinking about Indigenous communities is this is just one model in that there are other models out there that would, that may better align with Indigenous communities. Indigenous communities vary culturally from tribe to tribe to tribe, nation to nation, band to band. And it's important for us to consider the way that they see things, the way that they believe, the way that they feel like health is going to be best addressed within their specific community. So going into the prevention side of things, the framework that we have traditionally used in the past is the cognitive conceptual model, meaning, oh, I think what we could do is we can just show our kids the negative consequences of using our substance use. You know, we can invoke fear, we can put pictures of what their lungs would look like on cigarettes. And we found that that actually does not work well at all. So we've shifted our paradigm to be more of a, you know, from a psychiatric perspective, a biopsychosocial cultural model here. And the way that I like to see prevention and the way that I look at it is listed here in these three different levels. So we can look at and include the domains, the second, the level of influence, and the three, the variability. And I'll go into exactly what that means in the next slide to help capture the complexity of prevention efforts. So here we have the different domains that I was talking about, where we have the factors on a personal level, on an individual level. But then there's also factors that we need to consider socially, their relationships that they're in, their family, their friends, but then also cultural, the the large macroscopic factors at play here. But then I also think that when we think about prevention, we have to think about the level of proximity, what is going to be impacting our youth more likely, what what what do our youth care about that's more proximal to them, and then also considering things that maybe be that are more distal, not as easily accessible for our youth, but then also giving room for variability, right? Each person is different. One thing that works for one person may not work for another. So I do think that there needs to be room for that as well when we conceptualize exactly our prevention framework. So shifting to our current understanding of substance use in our Native youth. And I want to start out by saying that the data, specifically on Native youth, is scarce. There's not a lot of great studies out there that are considering the multidimensionality and the multilayers of complexity when it comes to the structural forces at play for a lot of Indigenous communities. So for instance, when we look at the smoking rates, e-cigarette use, there's this general consensus that when we look at smoking rates in our Native youth, that they may have higher smoking rates of the commercial tobacco. They may have higher e-cigarette use. There's some studies that show there might be higher vaping cannabis usage as well. And all of that's relevant to a degree, but we also need to have better context, exactly what is going on. Are these rates, you know, and I appreciate Jenna's comments on this and the team, the ORN team on this in the sense of there's traditional tobacco use practices within a lot of Indigenous communities. And is that being accounted for in these studies? I do not know of a single study that has differentiated between the two. So that's something for us to consider moving forward is that there are different things at play here that we need to conceptualize. We do know that there is some study, there is some data out there that show that Native youth are receiving treatment rates for substance use related disorders compared to non-Native peers, that there's a higher mortality rate reported by the Indian Health Services, nearly double than the general U.S. population. But also importantly, we have lower prevalence, the Native youth has lower prevalence in alcohol use. And this is based on data from 2023, from the National Survey on Drug Use and Health, that shows the Native youth from ages 12 to 20 actually have one of the lowest, based on race and ethnicity, alcohol use within the past 30 days and binge drinking behavior. And when we're talking about the structural factors that we need to consider, one that I want to make sure that we better understand as we leave this talk today is the impact of colonization and what that may be, how that's kind of conceptualized. And I use this, this is a slide that I've adapted from Michael Yellowbird, who's really been focused on the neuro-decolonization process that I encourage you all to look up, it's really fascinating. So here we understand colonization to be three parts, the first part being invasion, when European settlers first arrived to the lands of Indigenous people. And then we shift into this second phase of contamination, introducing foreign antigens and ways of looking and viewing the world. And then the third phase is infection. So not only being physically infected with new diseases and illnesses that are, that were foreign to Indigenous communities, but also perhaps infecting our way of living, our way of being. And when people survive these three different phases, this, this is what colonization is. And at the root of this is the historical trauma that is lingering and is, that could be present for a lot of Indigenous folks that you may work with. And this is important because historical trauma has been strongly linked to substance use among Native people in general. And it's, has presented in the form of a trauma, significant trauma response that we need to recognize and to be aware of, and to understand exactly the historical and ongoing ways of oppression that Native communities are facing today and significant cultural loss that may be at play. And to highlight a little bit of the other structural factors, you know, when we talked a little bit about the colonial disruption of the way of being and living for Indigenous communities, but this also means disruption of their traditional practices, right? We have sacred medicines, we have sacred plants that we use, our, our way of, our ways of healing. And tobacco is a very common sacred plant for a lot of communities. But unfortunately, there is a lot of, the big tobacco companies have been targeting, strategically targeting Native communities to increase their revenue streams, to bypass certain state, federal laws. And also, when we look at their products, they're, they're directly targeted to, to Native people in the sense of giving this impression of like, this is, this is how, what a warrior looks like, or this is what a warrior, this is the product that a warrior uses. And so to be aware of those, and then also the socioeconomic inequities that we also need to consider in the sense of a lot of Indigenous communities reside in high areas of poverty, the on-reservation versus off-reservation. Are we doing, you know, looking at things from an urban level as well? But then also when we look at education, the amount of resources that are available, do they have access to prevention programs? Do they have access to their traditional homelands? Were they relocated? Are they living in the same home, their ancestral homelands? So these are all things that we have to consider and conceptualize when we are thinking about prevention efforts. And please don't try to read anything on this, on this slide. I, this is more of used as a reference. This is a beautiful review done by one of my mentors, Dr. Mel from University of North Dakota. And I just thought it kind of, where she, she looked at Native youth specifically. There aren't that many studies out there, but she did look at Native youth specifically about the unique interpersonal family and also societal factors that, that are protective or risk factors for Native youth. So this is here as a resource for you, but I'm going to also go into this a little bit and then also include a few other studies that I found that are relevant for us to look, to discuss. Because a different, another component of thinking about prevention is how do we increase certain behaviors that are known to be protective or give this youth strength, power? And then how do we decrease those behaviors that are known to show an increased risk for substance use? So when we look at things on an individual level for Native youth, we know there are some studies out there that show the older youth populations are around 18, 19, 20. And then youth can also be defined up to 25, but that's where generally we consider them older, young adults and has been known to be a risk factor as well as early age of initiation, which I mentioned earlier on. The earlier that you start using a substance, the more likely you may develop a use disorder, may have negative consequences from that substance. When Native youth who live on or near a reservation have been shown to be a risk factor, the gender varies and again is limited primarily to binary genders. If you all know of any other studies out there that are looking at are non-binary and other gender expressive relatives, please let me know. I'm trying my best to stay up to date on that, but there are some studies that I've looked at that show generally the female gender may be a risk factor, but importantly, the biological vulnerability belief. So this is when our youth are already thinking, I'm Native and that means I'm going to struggle with alcohol. I'm going to have an alcohol use disorder. I'm going to die from alcohol, or they believe in this biological vulnerability that they're predisposed to developing a negative relationship with alcohol. That in itself, that belief, that core belief has been shown to be a significant risk factor. And that's something that I think we should target as well, because according to the data, that's actually not the case, right? Our Native youth are not intaking a lot of alcohol compared to other races and ethnicities. And the thing is on the right side, I won't go through them all, but these are some protective factors for us to be aware of as well. Especially, you know, when I look at the bottom here, the mentored internship and having that adult figure or mentor to look up to is also an important protective mechanism here. And then on the social level, importantly, I want to highlight at a family level, there's increased interpersonal violence that a lot of Native youth are exposed to. Native youth have been shown to have reported more ACEs or adverse childhood experiences. There may be more permission from their household primary caregivers to utilize these substances or that it's okay to. And then also in a school, I want to highlight the disciplinary practices. I think this has been something that I've personally have encountered as well, where they're in the school setting, we are punishing our kids for certain behaviors rather than identifying, okay, what is driving, what are the underlying factors that are driving this behavior and how can we help them and provide them with resources and equip them. And so that's something also for us to be cognizant of. And then on the protective side of things, we see themes of connectedness, involvement, right? Having two parents in the household, healthy communication, and then in the school, if they have accessibility to activities that are culturally inclusive and representative of their culture and having active, healthy discussions about substance use in the classroom setting. And then on a cultural level, as I already mentioned, the importance of historical trauma, but perceived discrimination has been known to be directly correlated with increased substance use as well, lack of cultural identity, lack of self-esteem. So we can see this correlates well with the protective measures of having a positive ethnic identity. So associating and being directly involved in their community, having people that they know that they could reach out to and that they are being watched. So community monitoring, they know that their grandma is looking after them or aware of them or keeping tabs on them. So all of these have been shown to increase the protectiveness, the protective behaviors in our youth. And again, these are, this is just like certain snapshots. So please feel free to come back and look at that a little bit more closely if you wish. And so next, with the remaining time that I have together with you all, I want to just hop into a little bit more of these like culturally informed preventative-based, evidence-based strategies to enhance efficacy when we're working with Native youth specifically. And I think when we look at our protective and risk factors, we can see this, these themes, right? A lot of our researchers in the field and scholars and elders know what our youth need, Native youth need, that they need to be connected to their culture or certain traditions or to be active members and to hold certain responsibilities or to look after and care for one another. And so this has driven this movement of culture is medicine. And so we see that here with each tribe having their own unique knowledge systems, their own wisdom that they want to share, that this is a potential resource that we can use when working in partnership with Native communities. So that way we know exactly how we could best capture their traditional practices and help our youth. And so there's been a lot of movement on both ends everywhere to try to work in partnership with tribes and uplift communities to equip us with resources to do this. And one in particular that I'm going to be talking about is the Talking Circle intervention. So this is from a study back in 2013, and they had students, Cherokee students, 179, ages 13 to 18. And what they did is that they created a Talking Circle, 10 sessions, it's manual based, that was available in English and also available in Cherokee. And they found and they compared this to a traditional, the standard substance abuse education at the time that was amenable. And they looked at here on this graph, this substance problem scale, an objective measure of substance use issues here. And they found that the students who received the Cherokee Talking Circle intervention had a decrease level reported scale three months after the intervention. And so this was very exciting news at the time. And this was also demonstrating community-based participatory research working in conjunction and with Native communities. And so there's been further research out in the field applying the Talking Circle intervention to different communities, but also adapting it accordingly. And so this was done, this was a study from 2021, that showed what was common across three different Native community sites that they were hoping to apply this intervention to, that they did apply this intervention to. And I want to just highlight what's in the orange here. And I simplified it here on the left side, where the effective strategies that were found had an intergenerational approach. So our youth being able to access and have conversations and engage with our elders, and our elders having the opportunity to teach our youth, having community-based activities that are centered around our culture and traditions. And then importantly, having real life situations that are relatable to our youth. A lot of our youth, we, you know, we need to figure out exactly what is important to them. What do they care about? What is proximal to them? And then there's also this underlying theme of being able to get to their root, right? We see this kind of like understanding the structural forces, factors at play here. What is really driving the phenomenons that we see? And this is just one possible intervention. This was a great review, published back in 2014, that showed, they looked at all of, they did a systematic literature review, and they wanted to characterize all of the different cultural interventions that had been reported in the literature at that time. And we're actually, a team and I are working on a more up-to-date manuscript about updating this. And we see though, we're going to see similar themes, but that dancing, fasting, storytelling, singing, prayer, sweat lodge, there are different cultural interventions that may be more applicable for certain tribes that you are going to be working with or that you are working with. So that's something to keep in mind is that there are many options out there and we need to figure out exactly what may be best by working with Native communities. And importantly, the reason why I love this study is because when they looked at the 19 studies that were reported in the literature, they found in these studies that the substance use problems were reduced or eliminated, completely eliminated in 74% of these 19 studies, which is amazing results. So again, this kind of shows and provides evidence for the culture as medicine mechanism. And the last thing that I will give you a snapshot on is, I really wanted to include this study because I really liked the developmental perspective that it sheds light on. So this was a longitudinal study. This was done by White Cell back in 2018, where they looked at middle school students on the Northern Plains Reservation. They had 381 students and they followed them for two years. And they found, they looked at the students who started to use substances and what were the risk factors for that and what were the protective factors. And this study showed that there was an increased risk when the youth were older, identified as female, reported significant stressful life events, including puberty, or associated with, quote unquote, deviant peers. Protective factors were being able to have a very supportive peer influence and positive parenting experiences. So having parental warmth, having a good child-parent bond. And so these are just a few examples of culturally grounded prevention programs out there. And I, of course, I wanted to, to my knowledge, the best resource out there that I go to and I utilize is this repository on the Pacific Technology Transfer Center, where they have a document, you could download the attachment, and it has a document of all of the Native prevention programs out there in the U.S. that a lot of communities are utilizing. And these are the ones that I mentioned are also included on there too. Lastly, I came across this article that was published earlier this year. And I think a lot of, when you go back and you kind of access or look at some of these prevention programs that are at play, a common question I get is, you know, how do you adapt like a certain program for a specific community and undergo that process? So I would refer you to look at this resource here, where they looked at exactly that question is like, how do you adapt or how do you modernize or up to date? How do you adjust one program to be, to be more applicable for one community? And they specifically, I wanted to share with you all, because my understanding is we have a lot of social workers and teachers and substance use counselors and trainers here, is that when we're looking at curriculum development, some of the recommendations were to specifically look at language and to be culturally sensitive and gender inclusive to the language. But then also we see this intergenerational theme again, where we want to connect our youth and elders to one another, so that way we can facilitate that knowledge transmission across generations. Tribes want that. And then to promote family connectedness, so focusing on the family as well. For staff individually, what can you do in a school setting or in a community setting? We, to focus on inclusivity and to promote cultural awareness, and I would argue to promote cultural activation. So what are some things that you can do to help facilitate Native youth to participate or be more active members in their community? And then to acknowledge the historical and intergenerational trauma and other structural factors that are at play for substance use in Native youth populations. And I love this one, ask youth for feedback. I think a lot of the times we're, you know, kind of have our blinders on and we're like, how can we help? How can we help? But then we need to be making sure that we're inviting the youth who we're working with to the table and saying, what is going on in your life? And like, what is most relevant to you? What is most impactful for you? And hey, to check in with them. Hey, how is this working for you? And to be able to adjust accordingly. And so this is, I wanted to leave you all with kind of an example. And I think what we're going to do is if you, I would encourage you, we're going to send you the link to this. It's a 30 second campaign video, Next Legends. And I think it beautifully incorporates some of the principles that we talked about here to try to decrease the barriers that Native youth are facing. And that this one is specifically vaping. So I think this is a phenomenal campaign out there. And if we can try to help circulate and see and get this accessible to our youth as well, our youth size. So with that, Sisula, I appreciate your time.

Youth Substance Use

Culturally Informed Approach

Native Communities

Prevention Strategies

Community-Based Interventions

Historical Trauma

Indigenous Knowledge

Collaboration