Keenan A. Pituch

• Doctor of Philosophy
• Professor at Arizona State University Phoenix AZ

Background There is growing evidence that cardiorespiratory fitness (CRF) mitigates the likelihood of dementia caused by Alzheimer's disease and may underlie the cognitive benefits observed from aerobic exercise. Previous evidence further demonstrates neurodegeneration is the biological substrate for cognitive deterioration and younger brain age ma...

Objectives: First, to examine the effects of household food insecurity discordance status on adolescent antisocial behavior. Second, to determine if adolescents’ gender moderates the association between household food insecurity discordance and adolescent antisocial behavior. Design: Cross-sectional data of Latino parents and adolescents from the s...

Background Compassion fatigue and satisfaction impact nurses’ patient care. Resilience acts as a mediator between protective organizational practices and mental health. Objective This study aimed to examine the mediating effect of resilience among nurses during the recent emerging infectious disease outbreak, the COVID-19 pandemic. Methods This i...

Introduction Unpaid caregivers of people living with dementia often experience lower levels of perceived life satisfaction and higher rates of depression and anxiety compared with those caring for individuals without Alzheimer’s disease or related dementias. While research on unpaid caregiver well-being and satisfaction has primarily focused on the...

Objective Although dysregulated inflammation has been postulated as a biological mechanism associated with post-acute sequelae of severe acute respiratory coronavirus 2 (SARS-CoV-2) infection (PASC) and shown to be a correlate and an outcome of PASC, it is unclear whether inflammatory markers can prospectively predict PASC risk. We examined the ass...

Background A potential mechanism underpinning the cognitive benefits from physical activity and aerobic exercise is cardiorespiratory fitness (CRF). Greater cardiorespiratory fitness (CRF) was associated with better executive function, short‐term memory, and global cognition in older adults without cognitive impairment. Sex differences in CRF has b...

Background Subjective cognitive decline (SCD) represents an important therapeutic target to prevent future cognitive decline associated with aging as well as neurodegenerative diseases such as Alzheimer’s disease. One such therapy is the “dual‐task” exergaming with concurrent aerobic exercise (AEx) and cognitive training. The primary aim of this St...

There is growing evidence that CRF mitigates the likelihood of dementia caused by Alzheimer’s disease (AD) and may underlie the cognitive benefits observed from aerobic exercise. Previous evidence further demonstrates neurodegeneration is the biological substrate for cognition deterioration and brain age may protect the brain from the deleterious e...

Accidental falls are an increasing problem among older adults in the United States (US). Older adults’ self-report of falls is the primary method of fall risk identification. However, up to 72% of Medicare beneficiaries do not report falls and fall-related injuries to their healthcare providers. Limited research suggest that older adults prefer the...

Physical activity (PA) during midlife can reduce risk for Alzheimer’s disease and related dementias. However, adherence to national PA guidelines (≥150 min/week of moderate-to-vigorous intensity aerobic PA [MVPA]) among midlife adults is rarely achieved through behavioral PA interventions, which may be due to inconsistent or unsuitable approaches t...

Introduction To examine whether within‐person changes in total, regional and organ fat were associated with within‐person changes in type 2 diabetes (T2D)‐related biomarkers following interventions. Methods A secondary analysis from a randomised trial among Latino youth (30 males, 25 females) aged 12–16 years with obesity. The study sample combine...

Dental anxiety, a predictor of both dental treatment avoidance and health outcomes, has been linked with early negative dental experiences. The causes of this relationship remain largely unexplored. This study provides a preliminary exploration of within-cultural variations of dental normative beliefs on the perception of negative dental experience...

Introduction Chronic overlapping pain conditions (COPCs), such as chronic low back pain (cLBP) and fibromyalgia, frequently cooccur and incur substantial healthcare costs. However, to date, much focus has been placed on individual anatomically based chronic pain conditions, whereas little is known about the mechanisms underlying progression to mult...

Problem, Research Strategy, and Findings: Low physical activity (PA) and Type 2 diabetes are associated with cognitive aging and Alzheimer's disease, but the evidence is inconsistent and particularly limited by ethnicity. The purpose of this study was to examine the relationships of PA and Type 2 diabetes with cognition in Mexican Americans and non...

Study Objectives The coronavirus disease 2019 (COVID-19) pandemic impact on infant sleep (IS) is understudied. The purpose of this study was to examine the relationships between family impact and distress from COVID-19 pandemic stressors, parental insomnia symptoms, infant temperamental negative affectivity, and parent-reported IS. Methods Parents...

Objectives: To identify subgroups of patients with distinct chemotherapy-induced vomiting (CIV) profiles; determine how these subgroups differ on several demographic, clinical, and symptom characteristics; and evaluate factors associated with chemotherapy-induced nausea and CIV profiles. Sample & setting: Adult patients (N = 1,338) receiving can...

Introduction Maternal stress levels, sleep, and mother-infant interactions are associated with infant sleep. However, the potential impact of these factors experienced during the early postpartum period on future infant sleep development is understudied. This study examined whether maternal stress and sleep at 3 weeks postpartum predicted infant wa...

Alzheimer’s disease (AD) affects Latinos disproportionately. One of the reasons underlying this disparity may be type 2 diabetes (T2D) that is a risk factor for AD. The purpose of this study was to examine the associations of T2D and AD blood biomarkers and the differences in these associations between Mexican Americans and non-Hispanic Whites. Thi...

Objective To examine the associations of cardiorespiratory fitness with executive function, episodic memory, and global cognition and sex differences in these associations in community-dwelling older adults with amnestic mild cognitive impairment. Design A cross-sectional study using baseline data from the aerobic exercise and cognitive training (...

Objectives: To examine the extent to which older adults’ perceived balance, a balance performance test, and fear of falling (FOF) were associated with falls in the last month. Methods: The Health Belief Model served as the theoretical framework. A retrospective, cross-sectional, secondary analysis using data from the National Health and Aging Trend...

Background and Objectives The primary aim of this Stage IB randomized controlled trial (RCT) was to test the preliminary effects of a dual-task exergaming telerehabilitation intervention on cognition and aerobic fitness, compared to aerobic exercise (AEx) only and attention control (stretching) in older adults with SCD. Research Design and Methods...

Background Unpaid caregivers of people living with dementia often experience lower levels of perceived life satisfaction and higher rates of depression and anxiety compared to those caring for individuals without Alzheimer’s Disease or Related Dementias. While research on unpaid caregiver well-being and satisfaction has primarily focused on the cha...

Background Latent inhibition occurs when exposure to a stimulus prior its direct associative conditioning impairs learning. Results from naturalistic studies suggest that latent inhibition disrupts the learning of dental fear from aversive associative conditioning and thereby reduces the development of dental phobia. Although theory suggests latent...

Objectives: The present study examined how different family level (family financial stress, family violence) and individual (food insecurity, gender, race) determinants of health were associated with mental health among Puerto Rican adolescents living in the U.S. during the COVID-19 pandemic. Method: A sample consisting of 119 Puerto Rican adole...

Aims To examine how perceived balance problems are associated with self‐reported falls in the past month after controlling for known correlates of falls among older adults. Background Approximately 30% of adults age 65 and older fall each year. Most accidental falls are preventable, and older adults' engagement in fall prevention is imperative. Li...

Background Dental stimuli can evoke fear after being paired - or conditioned - with aversive outcomes (e.g., pain). Pre-exposing the stimuli before conditioning can impair dental fear learning via a phenomenon known as latent inhibition. Theory suggests changes in expected relevance and attention are two mechanisms responsible for latent inhibition...

Background Alzheimer’s disease (AD) disproportionately affects Mexican Americans, however, reasons underlying this health disparity remain unknown. Type 2 diabetes (T2D) is a risk factor for AD and may contribute to AD pathogenesis. The purpose of this study was to examine the associations between T2D and AD blood biomarkers among Mexican Americans...

Accidental falls are a significant health threat among older adults. Approximately 30% of adults age 65 and older suffer one or more falls each year. Most accidental falls are preventable, and older adults’ engagement in fall prevention is imperative. Limited research suggest that older adults do not use the term “fall risk” to describe their risk...

Introduction During the COVID-19 pandemic, sleep problems were highly prevalent. However, few studies assess sleep quality among parents and caregivers with young children. This study aimed to describe the impacts of the COVID-19 pandemic on sleep patterns among parents and caregivers with young children (<6 years) and identify the factors associat...

Objectives: To evaluate differences in the severity of global, cancer-specific, and cumulative life stress, resilience, and common neuropsychological symptoms among four subgroups of patients with distinct chemotherapy-induced nausea (CIN) profiles. Sample & setting: Adult patients with cancer (N = 1,343) receiving chemotherapy. Methods & varia...

Introduction Infant sleep is influenced by biopsychosocial factors. However, the influences of early parental sleep quality and parent-infant bonding on infant sleep development are underexplored. This study aimed to examine the relationships between early maternal sleep quality and mother-infant bonding at 8 weeks postpartum, and infant bedtime di...

Background: Due to the rapid spread of COVID-19 variants, the number of people hospitalized for COVID-19 may create psychological burdens on nurses. Nurses with high levels of compassion fatigue (CF) are more likely to make work errors, deliver poor-quality care, and have greater intent to leave their position. Objectives: This study utilized th...

Background Evidence suggests that dental anxiety and phobia are frequently the result of direct associative fear conditioning but that pre-exposure to dental stimuli prior to conditioning results in latent inhibition of fear learning. The mechanisms underlying the pre-exposure effect in humans, however, are poorly understood. Moreover, pain sensiti...

Background: Human papillomavirus (HPV) is the most common sexually transmitted infection. HPV can infect both females and males, and it can cause many cancers, including anal, cervical, vaginal, vulvar, and penile cancers. HPV vaccination rates are lower than vaccination rates within other national vaccination programs, despite its importance. Res...

Objectives Dementia-related anxiety (DRA) is the concern about current or future cognitive decline and potential diagnosis of Alzheimer’s disease or related dementias (ADRD). Existing research suggests that DRA likely develops due to diverse reasons (e.g., family ADRD history, self-perceived risk, and health-related anxiety), and approaches to mana...

Introduction Increased sleep problems in adults have been repeatedly reported during the COVID-19 pandemic. However, infant sleep was understudied. We aimed to examine the relationships between the impact of the COVID-19 pandemic, parent insomnia, infant temperament, and infant sleep during the COVID-19 pandemic. Methods Parents from the Phoenix m...

Background: Unrelieved chemotherapy-induced nausea (CIN) occurs 48% of patients undergoing chemotherapy and is one of the most debilitating symptoms that patients report. Objective: The aims of this study were to identify subgroups of patients with distinct CIN profiles and determine how these subgroups differed on demographic and clinical chara...

Touch associated with sleep (sleep-touch; reported physical contact during or shortly before/after sleep) is underexplored as a distinct contributor to affect regulatory processes associated with adult sleep. Given the affect-regulating effects of interpersonal touch, we theorized that among healthy co-sleeping adults, sleep-touch would add to slee...

Background Chronic conditions are common and require ongoing continuous management and preventive measures. The COVID-19 pandemic may have affected the management of chronic conditions by delaying care. We sought to understand the impact of personal characteristics (i.e., age) and healthcare factors (i.e., access to a provider) on healthcare access...

Chronic conditions require on-going continuous management and preventive treatment. Over 80% of adults aged 65 and older have multiple chronic conditions. Concerns have arisen about how the COVID-19 pandemic is affecting the management of chronic conditions. Delay, avoidance, and poor management of healthcare during the COVID- 19 pandemic may incre...

The purpose of this cross‐sectional study was to examine factors associated with nurses' resilience during the COVID‐19 pandemic. Data were collected in the latter half of 2020 from 904 nurses across Japan, Republic of Korea, Republic of Turkey, and the United States. The questionnaire included the Connor‐Davidson Resilience Scale 10, plus demograp...

Cultural stereotypes that equate aging with decreased competence and increased forgetfulness have persisted for decades. Stereotype threat (ST) refers to the psychological discomfort people experience when confronted by a negative, self-relevant stereotype in a situation where their behavior could be construed as confirming that belief. The purpose...

Objectives: To describe changes in sleep patterns during the coronavirus disease 2019 (COVID-19) pandemic, develop profiles according to these patterns, and assess sociodemographic, economic, COVID-19 related, and sleep and mental health factors associated with these profiles. Design, setting, and participants: A 25-minute online survey was dist...

Purpose In this secondary analysis we tested whether 12 h of Senior WISE (Wisdom Is Simply Exploration) memory or health training with older adults would produce better outcomes by gender in perceptions of anxiety and bodily pain and whether the effects of the Senior WISE training on pain were mediated by anxiety. Design An implemented Phase III r...

Background: The first COVID-19 case in the US was diagnosed late January 2020. In the subsequent months, cases grew exponentially. By March 2020, SARS-CoV-2 (the novel coronavirus that causes COVID-19) was a global pandemic and the US declared a national emergency. To mitigate transmission, federal guidelines were established for social and physica...

‘Older adults’ have been identified as a high-risk population for COVID-19 by the United States Centers for Disease Control and Prevention (CDC). Though well-intentioned, this nonspecific designation highlights stereotypes of older adults as frail and in need of protection, exacerbating negative age-based stereotypes that can have adverse effects o...

Objective The COVID-19 pandemic has been a source of worry for many, but older adults have been identified as more vulnerable to serious cases and may therefore feel more concerned about the virus. We assessed whether COVID-19 worry was related to indicators of mental health and preparedness for future care, in an adult lifespan sample. Method An...

Several challenges have emerged in ensuring uptake of preexposure prophylaxis (PrEP) for HIV prevention. By applying the health belief model, the present study assessed associations between novel psychosocial variables and PrEP use among gay and bisexual men. Logistic regression analyses indicated that heterosexual self-presentation, sexual risk, P...

In intervention studies having multiple outcomes, researchers often use a series of univariate tests (e.g., ANOVAs) to assess group mean differences. Previous research found that this approach properly controls Type I error and generally provides greater power compared to MANOVA, especially under realistic effect size and correlation combinations....

Agentic engagement is a potential gateway to improving the classroom climate and adolescent students' motivation. The current investigation provided the first test of daily and short-term longitudinal relations between U.S. high school science students' agentic engagement during class and their psychological need satisfaction, other forms of engage...

The current research aimed to investigate students' daily experiences in high school classes by answering the following questions: to what extent does daily perceived difficulty of science classwork predict daily feelings of competence and disengagement? Are autonomy-supportive teaching strategies useful when work in science class is perceived to b...

Women remain underrepresented in physical science, engineering, and computer science college majors and careers. Prior research has suggested that motivational beliefs and experiences in high school play a critical role in girls’ persistence in science fields. We hypothesized that compared to male students, female high school students may experienc...

When data for multiple outcomes are collected in a multilevel design, researchers can select a univariate or multivariate analysis to examine group-mean differences. When correlated outcomes are incomplete, a multivariate multilevel model (MVMM) may provide greater power than univariate multilevel models (MLMs). For a two-group multilevel design wi...

This investigation examined relations between adolescent students' daily and cumulative perceptions of teachers' practice and their experience of autonomy. Two-hundred and eighteen high school science students in 43 classes participated in a 6-week diary study. Multilevel modeling results suggested that perceptions of 8 out of 9 practices predicted...

This diary study provided the first classroom-based empirical test of the relations between student perceptions of high school science teachers’ various autonomy supporting and thwarting practices and students’ motivation and engagement on a daily basis over the course of an instructional unit. Perceived autonomy supporting practices were hypothesi...

The current investigation examined relations between high school students’ daily and cumulative situational interest in science class and their engagement, as well as their perceptions of the motivational climate of the classroom. Two-hundred and eighteen high school students in 43 science classes participated in a diary study in which students pro...

Use of multivariate analysis (e.g., multivariate analysis of variance) is common when normally distributed outcomes are collected in intervention research. However, when mixed responses—a set of normal and binary outcomes—are collected, standard multivariate analyses are no longer suitable. While mixed responses are often obtained in intervention s...

Marginal maximum likelihood estimation based on the expectation-maximization algorithm (MML/EM) is developed for the one-parameter logistic model with ability-based guessing (1PL-AG) item response theory (IRT) model. The use of the MML/EM estimator is cross-validated with estimates from NLMIXED procedure (PROC NLMIXED) in Statistical Analysis Syste...

A multivariate multilevel model (MVMM) extends standard multilevel modeling by including multiple dependent variables and thus could be used in place of traditional multivariate analyses. For a two-group study with two correlated dependent variables, a simulation study was conducted to compare the performance of MVMM to traditional MANOVA and a ser...

This article presents 3 standardized effect size measures to use when sharing results of an analysis of mediation of treatment effects for cluster-randomized trials. The authors discuss 3 examples of mediation analysis (upper-level mediation, cross-level mediation, and cross-level mediation with a contextual effect) with demonstration of the calcul...

After age 65, the incidence of episodic memory decline in males is greater than in females. We explored the influence of anxiety and depression on objective and subjective memory performance in a diverse sample of community-residing older adults. The study was a secondary analysis of data on three samples of adults from two states, Ohio and Texas:...

Objective: When several continuous outcome measures of interest are collected across time in experimental studies, the use of standard statistical procedures, such as multivariate analysis of variance or growth curve modeling, can be properly used to assess treatment effects. However, when data consist of mixed responses (e.g., continuous and orde...

For the cluster randomized trial, the treatment, implemented at the cluster level, may be hypothesized to impact a final outcome of interest via a mediating variable, with the mediator and outcome being measured typically at the participant level. Two opposing views—one that allows the mediation process to flow through a participant-level mediator...

This simulation study examined the performance of the curve-of-factors model (COFM) when autocorrelation and growth processes were present in the first-level factor structure. In addition to the standard curve-of factors growth model, 2 new models were examined: one COFM that included a first-order autoregressive autocorrelation parameter, and a se...

This article examines college students' self-reported mood states during a suicidal crisis and the relationship between mood and indicators of suicidality. Multilevel modeling demonstrated that the moods of hopelessness and anger predicted stronger intent; anxiety/worry predicted weaker thoughts of suicide; hopelessness increased the odds of receiv...

We designed an Internet survey to identify the educational priorities that parents have for their children with autism spectrum disorders and to examine the relation between these priorities and the children's level of adaptive behavior functioning. The survey listed 54 skills/behaviors (e.g., toileting, expressing wants and needs, and tantrums) re...

We tested whether at-risk older adults receiving memory training showed better memory self-efficacy, metamemory, memory performance, and function in instrumental activities of daily living than participants receiving a health promotion training comparison condition. We followed participants for 26 months. The sample was mostly female (79%) and Cauc...

This article illustrates the value and use of multilevel models to examine site-to-site outcome differences in the analysis of data from multisite evaluations. It shows how a traditional analysis approach can overlook effective interventions and miss important links between program implementation and outcomes. Practical issues regarding statistical...

Using multilevel models of data from the Early Childhood Longitudinal Study—Kindergarten Cohort (N = 20,356), the authors find that parental involvement in education partially mediates the association between family poverty and children’s math and reading achievement in kindergarten, but differences exist across race. In Asian families, poor and no...

To identify rehabilitation priorities that parents have for their children, including their adult-aged children, with Prader-Willi Syndrome (PWS) and to determine the relation between these priorities and the child's levels of adaptive behaviour functioning. Parents involved in organisations related to PWS were invited to complete an online survey....

This article describes the outcomes of a psychosocial intervention that tested whether health training could improve health and functional ability in a group of community-residing elderly persons. The health-training intervention consisted of eight 90-minute lecture and discussion classes conducted twice a week for 1 month. In 3 months following th...

Cognitive training improves mental abilities in older adults, but the benefit to minority elders is unclear. We conducted a subgroup analysis of subjects in the SeniorWISE (Wisdom Is Simply Exploration) trial to examine this issue. SeniorWISE was a Phase 3 randomized trial that enrolled 265 nondemented community-dwelling older adults aged 65 years...

There are few data on the educational needs of children with cri-du-chat syndrome: a neurodevelopmental disorder that affects learning and development. We therefore designed an Internet survey to identify parents' educational priorities in relation to children's level of need/ability. The survey listed 54 skills/behaviors (e.g., toileting, expresse...

Due to the clustered nature of field data, multi-level modeling has become commonly used to analyze data arising from educational field experiments. While recent methodological literature has focused on multi-level mediation analysis, relatively little attention has been devoted to mediation analysis when three levels (e.g., student, class, school)...

The authors examined the robustness of multilevel linear growth curve modeling to misspecification of an autoregressive moving average process. As previous research has shown (J. Ferron, R. Dailey, & Q. Yi, 2002; O. Kwok, S. G. West, & S. B. Green, 2007; S. Sivo, X. Fan, & L. Witta, 2005), estimates of the fixed effects were unbiased, and Type I er...

A Monte Carlo study compared the statistical performance of standard and robust multilevel mediation analysis methods to test indirect effects for a cluster randomized experimental design under various departures from normality. The performance of these methods was examined for an upper-level mediation process, where the indirect effect is a fixed...

The hierarchical linear model (HLM) is now commonly accepted as a useful modeling approach for multilevel data resulting from randomized field experiments. When multiple outcomes of interest exist, a multivariate extension of the conventional univariate HLM offers advantages over the usual application of separate HLM analyses for each of the outcom...

The authors examined the methodologies of articles in teaching-and-learning research journals, published in 1994 and in 2004, and classified them as either intervention (based on researcher-manipulated variables) or nonintervention. Consistent with the findings of Hsieh et al., intervention research articles declined from 45% in 1994 to 33% in 2004...

The Behavior Flexibility Rating Scale (BFRS) is designed to assess insistence on sameness or lack of behavioral flexibility, which is often associated with autism and other developmental disabilities. This study was designed to assess the factor structure of this scale for a sample of 968 individuals with autism, Asperger's syndrome, and Down syndr...

Many of the problems in daily living that affect individuals with autism seem to reflect a lack of behavioral flexibility. This apparent lack of behavioral flexibility is characteristically manifest by an extreme resistance to change and almost obsessive insistence on the maintenance of sameness. This chapter describes the characteristic resistance...

Researchers associate an insistence on sameness or lack of behavioral flexibility With autism and Asperger syndrome, but feW studies have sought to identify specific situations in Which individuals insist on sameness. Along these lines, We developed the Behavioral Flexibility Rating Scale (BFRS) and conducted an Internet survey of parents of indivi...

The benefits of an e-learning system will not be maximized unless learners use the system. This study proposed and tested alternative models that seek to explain student intention to use an e-learning system when the system is used as a supplementary learning tool within a traditional class or a stand-alone distance education method. The models int...

A Monte Carlo study examined the statistical performance of single sample and bootstrap methods that can be used to test and form confidence interval estimates of indirect effects in two cluster randomized experimental designs. The designs were similar in that they featured random assignment of clusters to one of two treatment conditions and includ...

Using Kennedy-Moore and Watson's cognitive-evaluative model of emotional expression and nonexpression, in the current study the authors investigated the relationship between men's restrictive emotionality and other emotion-related constructs. Among the emotion-related variables represented by the above model, negative attitudes toward emotional exp...

We developed an Internet survey to identify treatments used by parents of children with autism. The survey listed 111 treatments and was distributed via colleagues and through chapters of the Autism Society of America and Autism Organizations Worldwide. A total of 552 parents submitted usable returns during the 3-month survey period. On average the...

This study reports on a preliminary evaluation of the National Institute of Mental Health (NIMH)-sponsored "Real Men. Real Depression" (RMRD) campaign. Two-hundred-nine men with a range of help-seeking attitudes and gender-role conflict (GRC) reviewed the RMRD brochure, a similar brochure excluding gender references, or a depression brochure curren...

Professional health care providers and a general public better informed about addiction science research could lead to improved treatment for persons with drug dependence. This study examines whether a communication skills workshop can provide scientists with knowledge of basic communication methods and motivation to present findings on addiction s...

A Monte Carlo study extended the research of MacKinnon, Lockwood, Hoffman, West, and Sheets (2002) for single-level designs by examining the statistical performance of four methods to test for mediation in a multilevel experimental design. The design studied was a two-group experiment that was replicated across several sites, included a single inte...

This study reviewed 12 introductory statistics textbooks for the behavioral sciences published since 1998. The intent was to identify how well selected recent developments in the statistics field were incorporated into these texts. Textbooks generally included concepts such as effect size, confidence intervals, power and a priori sample size determ...

Communication of accurate, objective, and timely scientific information to treatment professionals is important--especially in the "drug abuse" and addiction field where misinformation and a lack of exposure to new information are common. The purpose of this study was to assess knowledge and belief changes that accompanied educational workshops (3...

College women enrolled in a strength training class were evaluated before and after the class using a combination of physical fitness measures, including weight, percentage of body fat, body circumference, and strength measures. Forty-nine subjects participated in strength training, twice a week for a total of 12 weeks. At the end of the class, par...

Having enough well-trained early intervention personnel continues to be a challenge on the reservations of our country. The Higher Education Partnership Project was designed to help address this challenge by providing a model of outreach training for reservation sites. The project involved collaboration with two tribal colleges, offering courses to...