Wellness and Prevention

Wellness describes a healthy balance of the mind, body, and spirit. It plays an important role in protecting and promoting our health in every area. This balance results in an overall feeling of wellbeing. People who are mentally, physically, and spiritually healthy enjoy life, are open to change, are self-confident, and maintain fulfilling relationships. Well developed life skills, or overall knowledge, skills, and abilities in each area, can support our wellbeing. For Alaska Native peoples, subsistence activities are a highly valued and are understood to help people develop healthy life skills and address holistic wellness.

• "Mind" refers to your mental health--your emotions, thoughts, cognitive (brain) functioning, behavioral functioning, relationships, resiliency, and mental illnesses. This includes how you think, feel, relate to others, and respond to your everyday life.
  • Emotions include your feelings, expressions, and overall mood (e.g., happiness or sadness, smiles and tears), affect (outward expression of your feelings, e.g., smiles or tears), and ability to express these in healthy ways. Emotional health also refers to your self-esteem, self-confidence, and self-worth.
  • Thoughts include both what you think about and how you think about it. For example, this area includes thinking about your plans for tomorrow and how you organize and approach those thoughts.
  • Cognitive functioning includes your intellectual abilities (which may or may not be measured by IQ), short- and long-term memory, how you navigate day-to-day life in relation to your age and developmental level, and how you apply what you learn to day-to-day situations.
  • Behavioral functioning includes engaging in behaviors that are appropriate for your age and development and whether and how you use positive coping skills to handle challenges and make informed decisions to keep yourself safe and healthy.
  • Resiliency includes your coping skills and ability to "bounce back" from stressors.
  • Healthy relationships include relating in a positive and functional manner to parents, romantic partners, friends, community members, and peers.
  • Mental health includes the presence or absence of symptoms that restrict your functioning in any of the above areas. These symptoms, if present, directly influence your sense of self and ability to interact positively with others. Mental health problems can be difficult to identify because they are often misunderstood by the person who experiences them and their family members. In addition, the stigma attached to mental illness can prevent people from seeking help. However, early intervention in mental illness is the best way to manage or resolve it.
• "Body" refers to your physical health--your general health, diet and nutrition, sexual health, physical activity, environment, lifestyle, and illnesses and conditions.
  • General health includes your overall physical condition, injuries, past illnesses, important vaccines, and routine physical examinations. It also refers to immunodeficiencies, environmental allergies, dental hygiene, and drug or alcohol use.
  • Diet and nutrition include your eating habits and routines, nutrient content of foods, and allergies or food sensitivities.
  • Sexual health includes both your sexual knowledge and sexual practices.
  • Physical activity includes the type and amount of exercise you do. It can also encompass fatigue levels and sleep habits.
  • Lifestyle includes your attitudes, habits, and choices (such as whether you smoke tobacco).
  • Environment includes your home, work, school, and social contexts and how those encourage and support your wellness. It also includes the presence or absence of factors such as secondhand smoke and how clean your environments are.
  • Illnesses and conditions includes any disease or medically diagnosable condition that impacts your physical wellbeing, such as temporary illnesses like the flu or long-term conditions like chronic pain or an autoimmune disorder.
• "Spirit" refers to your spiritual health--your beliefs and faith, values, sense of worth and purpose, connectedness with people and nature, commitment to growth, introspection, and spiritual practices. Spirituality is very personal and often uniquely defined by the individual. A healthy sense of spirituality is directly related to your ability to find and achieve a sense of balance in your life and accomplish your goals.
  • Strong beliefs and faith include a sense of trust and security in whatever your spiritual beliefs are.
  • Values, morals, and ethics include how you relate to others, contribute to the greater good, define integrity, and connect with your faith.
  • Your sense of worth and purpose integrates your cultural knowledge, self-identity, and sense of direction in life. It means taking pride in yourself, feeling optimistic toward the future, and contributing to your culture and its beliefs and practices.
  • Connectedness with people and nature means promoting interpersonal peace and the health of the earth by respecting nature and all of its inhabitants.
  • A commitment to growth involves continued sharing, learning, internal discovery, and self-reflection.
  • Introspection and self-reflection are a lifetime process that facilitate spiritual and personal growth.
  • Spiritual practices can include the ability to be mindful or meditate, pray, or be still in nature.
  • Note that spirituality is not necessarily the same as religion or religious beliefs; belief in a religion is one of the ways people can express or guide their spirituality but is not the only way. What matters is that each person connects with the kind of spirituality that best relates to who he is and represents his morals, values, and ethics. This sense of spiritual groundedness can improve overall health and wellbeing.
  • Note also that personal and historical trauma can contribute to spiritual distress. If a client expresses spiritual struggles, reassure her that these are a typical part of dealing with other life stressors and can be overcome.

Nurturing a healthy mind, body, and spirit requires a commitment to wellness, including engaging in activities that support wellness and taking steps to prevent things that damage wellbeing. Everyone can benefit from focusing on wellness, including BHA/Ps and clients. Therefore, throughout this chapter, "you" will refer both to the BHA/P reading this and to the clients youserve.

Your wellness and overall health are influenced by many factors, including your self-care, or taking action to improve or maintain your own wellness.

Self-care is important for everyone. Try to:

• Learn signs of personal stress and identify activities that help reduce stress.
• Get regular exercise, even if it is just a short walk or taking a break to stretch your body.
• Give yourself time to truly rest and relax.
• Learn or discover new things.
• Pause to enjoy the beauty of nature or art.

Resiliency is a community, family, or person’s ability to bounce back from an unexpected event. It includes learning from experiences, applying that knowledge to future experiences, and building in redundancy. People who have high resiliency are better able to maintain a positive outlook and to remain focused, flexible, and creative as they solve problems.

Resiliency impacts everything in your professional and personal life. Resiliency is like a muscle; you can build and strengthen it over time. Consider these ways to improve your resiliency:

• Get comfortable asking for and accepting help from others. Nobody can do everything alone. Needing help is normal and healthy.
• Seek advice from elders.
• Know that having problems and struggles is normal and doesn't mean you are failing.
• Acknowledge your problems and struggles as the first step to addressing them.
• Learn how to regulate your emotions. Identify what triggers your emotions and stress and practice positive self-talk and relaxation techniques.
• Allow yourself to step back from difficult situations enough to nurture yourself and re-energize.
• Invest in friendships with people who build you up and inspire you.
• Spend quality time with loved ones for support and encouragement.
• Spend time alone. Use the time to get to know yourself, do things you enjoy, or engage in spiritual practices.
• Establish and maintain healthy boundaries.
• Dedicate regular time to self-care activities.
• Focus on personal development. Look at your past and future: learn your family, community, and personal history and set short- and long-term goals.
• Identify and build on your strengths. Engage in activities that maximize your strengths to build your confidence.

Your childhood experiences are part of your journey and impact you in adulthood. If you experienced any type of abuse or harmed another person, it can be helpful to find someone you trust and can talk to, such as a behavioral health professional or clinician who can help you process your thoughts, emotions, and impacts of your experience.

Wellness activities can help you, your family, and people in your community stay healthy and be energized. In your life and environment, you may encounter barriers to wellness, including limited access to healthy, fresh foods, not enough outlets for physical activity, and boundary difficulties. Even with these areas of difficulty, you can achieve wellness of mind, body, and spirit.

What you eat directly impacts your health. It is important to make healthy food choices.

• Eat foods low in added sugars, sodium, and saturated and trans fats.
• Be mindful of what and how much you eat. Try not to eat while distracted by the TV or other screens.
• Take good care of your teeth so you can eat well.
• Handle food safely and prepare it correctly.
• Eat a healthy diet to prevent health conditions such as heart disease, high cholesterol, constipation, and heartburn.
• Prepare your food in a sanitary environment and follow food safety guidelines, such as how hot to cook meats or how to wash produce, to ensure that no unwelcome bacteria are entering your body through your food.

Food allergies can lead to digestive problems, contribute to asthma, and cause or aggravate some skin conditions. If you are concerned that you may have food allergies, intolerances, or sensitivities, work with your health provider and a registered dietician.

Good health is about balance. Consider incorporating traditions practiced by your ancestors, including subsistence gathering, hunting, and fishing. Alaska Native people have used foods from the land and sea for thousands of years, and traditional foods have many benefits. Create a balanced traditional diet by choosing foods from each of these categories.

• Protein: Moose, caribou, fish, birds, bird eggs, seal, and whale.
• Omega-3 Fatty Acids: Seal oil, seal meat, and ocean fish like salmon.
• Fiber: Wild greens and roots.
• Carbohydrates: Berries and wild greens.
• Good fat: Marine mammals such as whale, seal, and walrus, fish such as salmon, and land mammals such as moose and caribou.
• Iron: Moose, caribou, seal meat, seal liver, walrus, whale meat, birds, bone marrow, and wild greens.
• Calcium: Black fish, bone marrow, fish head soup, smelt, tomcod, canned fish with soft bones, and kelp with herring eggs.
• Vitamins: Whale and seal oil, wild rhubarb, duck eggs, blueberries, blackberries, salmonberries, fireweed, sourdock, fish, fish oils, and liver.

Alaska’s Food Guide Pyramid recommends:

• Whole grains.
• Dark green and orange vegetables, such as peas and lentils.
• A variety of fruits.
• Foods rich in calcium, such as milk, yogurt, and cheese.
  Note: Speak with your health care provider about whether to choose full-fat, low-fat, or nonfat dairy for yourself and others in your household.
• Protein from lean meat, beans, eggs, nuts, and seeds.
• Limited saturated and trans fats, cholesterol, and sodium to reduce your risk of getting a chronic disease such as heart disease, some cancers, and high blood pressure.
• Enough vitamins and minerals to improve your health and possibly prevent things like bone loss and heart disease.

Limit drinks with caffeine, especially if you have sleep problems. Caffeine is a stimulant found in coffee, most sodas, energy drinks, black and green tea, and chocolate, among other foods and drinks. Caffeine can cause problems by:

• Stimulating your central nervous system, which can lead to nervousness, irritability, insomnia, anxiety, or panic attacks. This can cause you to be fatigued or overtired.
• Reducing the amount of iron and calcium your body absorbs. Since it causes calcium loss, it may also increase the risk of kidney stones.
• Stimulating the release of acid in your stomach; this is more harmful for people with ulcers or gastritis.
• Briefly raising your blood pressure.

Food labels tell you how much of each nutrient category is in one serving of that product so you can understand your food's nutrition content and make informed decisions about what and how much to eat. Pay special attention to serving sizes and calories. For example, a 20-ounce drink will often contain 2.5 servings. If it has 100 calories per serving, that means it has a total of 250 calories.

The FDA recommends an average of 2,000 calories per day for women and 2,500 calories per day for men and recommends appropriate daily servings of things like fat and carbohydrates. Food labels tell you what percentage of the recommended daily amount of each category is in the food. This is called the "Percent Daily Value."

Proper nutrition is important for people of all ages and walks of life. In addition to making your own food decisions, if you are a parent or caregiver or you are responsible for planning your family's meals, you play a critical role in shaping your loved ones' relationships with food.

When your emotional or mental wellbeing is compromised, you are at a greater risk of compromising your physical wellbeing as well through unhealthy food choices, such as:

• Eating too much.
• Eating too little.
• Choosing foods high in saturated or trans fats, sodium, or sugar.
• Snacking on highly processed food products instead of fruits, vegetables, and nuts.

Healthy eating habits have numerous benefits beyond their impact on physical health. They include:

• Developing trust and a sense of safety.
• Establishing independence.
• Learning about and practicing self-control.
• Trying new experiences.
• Improving the bond between parents or caregivers and family members.

Sometimes, people develop unhealthy relationships with food and with their bodies. This can manifest as unhealthy behaviors and eating patterns or develop into an eating disorder (anorexia or bulimia). Eating disorders can have serious short- and long-term health consequences. See Chapter D-17: Emotional Eating Problems for more and see the National Eating Disorders Collaboration for information on protective factors against eating disorders.

Just like healthy eating, physical activity should be a part of your daily routine. Engage in a variety of physical activities to avoid getting bored with your approach to exercise. Try these ways to stay active:

• Walk a few miles or more each day.
  • You can walk outside, on a treadmill, or even around your local grocery store or community center.
  • Instead of sitting while you are on the phone, pace back and forth.
  • The American Heart Association recommends 10,000 steps each day for healthy adults. Consider wearing a fitness tracker that will count your steps.
  • Even putting away laundry can help you reach your step goal for the day as you walk back and forth between the laundry basket and your closet.
• Play with your child; the parent-child emotional connection is important to overall health and children can help us have fun with movement.
• Do household chores such as sweeping, mopping and vacuuming.
• Hunt, fish, pick berries, and prepare subsistence foods.
• Play sports, such as basketball, or participate in the Native Youth Olympics (NYO).
• Go on hikes.
• Participate in Native dance.
• Purchase a yoga or home workout DVD and exercise in your living room.

Take care of your body when you exercise:

• Be sure to warm up and cool down with light activity or movement.
• Stretch to increase flexibility and prevent injury.
• Include strength-building in your exercise plan.

Children and teenagers in school should eat a variety of foods and have regular meals and snacks. Encourage them to drink lots of water and limit or avoid drinks with sugar, such as soda, fruit drinks (even juice), and energy drinks.

To promote healthy food choices, encourage subsistence activities and the use of the Alaska Food Guide Pyramid as a reference.

Physical activity is critical for this age group. It has a number of benefits, including giving them the skills and motivation to make healthy choices. Encourage children and adolescents to be active in sports or other forms of exercise daily. Suggest some options for healthy activity:

• Basketball.
• Walking or running.
• Native dancing.
• Hunting, fishing, and berry picking.
• Native Youth Olympics.
• Dog mushing.
• Jumping rope.
• Helping with chores like sweeping, mopping, hauling water, or chopping wood.

Adolescents learn about wellness by doing and participating. Consider the following activities with youth:

• Discuss their lives (e.g., subsistence, sports, goals, and friendships).
• Explore values by encouraging them to reflect on life and what’s important.
• Encourage them to lead conversations.

Limit screen time to up to two hours per day for minor children. Too much screen time can:

• Make it harder to sleep at night.
• Increase the risk of attention problems, anxiety, and depression.
• Increase the risk of becoming overweight or obese.
• Reduce their involvement in their "real world" lives.

Health is impacted by the amount of sleep and rest a person gets. Sleep impacts almost every area of your immediate and long-term health. Sleep is as important to your health as nutrition and exercise.

Short-term sleep problems. After a night of restless or limited sleep, you're likely to be more irritable and stressed. Your reaction time is slower, putting you at risk of accidents while using motor vehicles like cars, snowmachines, or boats. Your memory is weaker and it's harder to recall what you learn when you are tired. This is important to be aware of in the summer, when long hours of sunlight often result in less sleep for Alaskans. These short-term sleep problems are reversible with a return to good sleep habits and adequate rest.

Long-term sleep problems. Chronic insomnia can put you at risk of developing a mood disorder such as anxiety or depression. It can also be the first sign that a mood disorder is developing. Insufficient sleep can also increase the risk of problems like heart disease, diabetes, obesity, and frequent colds. On the other hand, adopting healthy sleep habits can increase your odds of leading a long, healthy, happy life.

Good sleep starts with healthy sleep habits. To improve your sleeping habits, consider the following suggestions:

• Make and following a regular schedule, especially close to bedtime.
• Create a bedtime routine that includes relaxing activities, such as quiet reading, a bath, or drinking non-caffeinated tea.
• Relax when you feel tired.
• Eat a balanced diet, especially at dinner.
• Choose snacks high in protein and low in added sugar, sodium, and saturated and trans fat.
• Avoid eating just before bedtime.
• Avoid light from screens, like TVs and phones, in the one to two hours before bedtime.
• Drink at least eight cups of water every day.
• Exercise daily; this naturally helps prevent stress and lowers your risk of sleep-related problems such as Restless Leg Syndrome.
• If you feel tense or have muscle pain, consider taking a bath with Epsom salts to relax your muscles.
• If you consume alcohol, added sugar, or caffeine, do so in moderation, as each can have negative impacts on your sleep. Avoid them entirely as you get closer to bedtime.
• Practice the tips and strategies for preventing stress discussed later in this chapter.

For clients who struggle to get adequate sleep, see Chapter D-16: Sleep Problems.

The choices you make impact your health. The people you surround yourself with and the activities you engage in also impact your health.

Personal boundaries are physical, emotional, and mental rules and limits that each person establishes to identify reasonable, safe, and permissible ways for others to behave around them. Boundaries help people to feel safe, protected, and respected.

Personal boundaries are shaped by several things, including:

• How you view or feel about yourself (self-concept).
• Your ability to enjoy yourself and to reduce how often you make choices based solely on others' thoughts and feelings and not your own.
• Your personal limits (which are influenced by personal values, desires, and needs).
• How much you respect yourself; if you respect yourself, you will naturally respect others and expect the same in return.

A person with healthy boundaries has:

• Self-confidence.
• A positive self-concept and self-esteem.
• Better communication and relationships with others.

Learn more about setting boundaries in Chapter B-1: Values and Ethics for BHA/Ps.

All caregivers contribute to a developing child’s health. Fostering good health in children begins during pregnancy and early childhood. An expectant mother needs to take care of herself during the pregnancy and after the child is born, and her family and community should support her and her child's health.

Women must abstain from all alcohol and drug use while pregnant. They should also avoid alcohol and drugs while nursing. Some agencies and providers advise breastfeeding mothers that no amount of alcohol or tobacco use has been shown to be safe during breastfeeding and encourage breastfeeding mothers to abstain from alcohol and tobacco. However, if a nursing mother chooses to use alcohol or tobacco, encourage her to consult with her medical provider or a nursing consultant to identify potential ways to reduce any risks to the child; she may be able to continue nursing with the right modifications.

General guidelines for alcohol and tobacco use by parents of young children:

• Parents who are currently under the influence of alcohol or tobacco, or who have the smell of tobacco on their bodies or clothes, must never share a bed with their children because doing so has been shown to increase the risk of death for children.
• Parents who smoke must only do so outside and away from their children.
• Parents who smoke need to use a designated “smoking jacket” that they take off after smoking and must wash their hands thoroughly immediately after smoking.
• Breastfeeding mothers who choose to drink alcohol need to be familiar with the latest AAP and La Leche League guidelines related to alcohol consumption and breastfeeding.
• If a breastfeeding mother does consume alcohol, she needs to wait to nurse until she no longer feels the effects of alcohol.

Tips for pregnant and nursing women:

• Be active for 30 minutes each day, unless your physician has told you not to do so.
• Eat healthy, drink at least eight glasses of fluid per day, and take your prenatal vitamins.
• Breastfeeding is best. It strengthens the mother-child connection. Babies benefit from:
  • The physical contact with their mother. This promotes bonding, comfort, and security.
  • Balanced nutrition that evolves as the baby gets older.
  • Disease-fighting antibodies that come from breastmilk.
• Only take medications that your physician has prescribed and has told you are safe for your fetus or breastfeeding baby. Talk with your provider before taking over-the-counter medications.

The health and safety of children is important to Alaska Native people and families. To help nurture this value and put it into action, parents and caregivers should:

• Schedule regular well-child visits, also called EPSDT exams (Early Periodic Screening, Diagnosis, and Treatment). Encourage follow-up appointments to be kept. If certain services are not available in the community, the family may be referred to another facility for care.
• Make sure children receive immunizations in a timely manner. Immunizations help a child stay healthy and prevent illnesses and disease. They also help to prevent illnesses from spreading to people who are unable to be immunized or who have compromised immune systems.
• Remember that physical disabilities and mental disabilities are separate issues. A child with a physical delay who grows and develops at a slower rate will not necessarily have any cognitive or emotional delays.
• Contact the local Infant Learning Program (ILP) if a child under age three may be experiencing a delay or disability. ILP services are available for families with infants and toddlers with special needs.
• Contact the local school district if a child age three or older may be experiencing a delay or disability. The school district can conduct an evaluation for an Individualized Education Program under the Individuals with Disabilities Education Act or a 504 Plan under Section 504.

In some Alaska Native families, children continue to be raised and guided with involvement from their extended family. Aunts, uncles, and other family members help teach children various life skills. This approach is consistent with Alaska Native values because it ensures that children learn about their origins, family health history, and culture.

Parenting styles influence how parents interact with their children. Studies show that children have better outcomes when their parents use parenting styles that encourage children to be responsible, to think for themselves, and to consider the reasons for rules.

Many factors influence children's development, including both "nature" and "nurture." For more information, see: Development Across the Lifespan and Parenting.

Promoting wellness is the first step in preventing many behavioral and mental health disorders. By assisting your clients in taking prevention steps outlined in this chapter, you will be helping them to reduce the likelihood of problems like depression, anxiety, suicide, substance abuse, and high-risk sexual behavior. Prevention is key to reducing the risk of developing various health-related illnesses and diseases. It involves education, personal commitment, and teamwork.

There are three types of prevention: primary, secondary, andtertiary. As a BHA/P, you are likely to engage in activities related to each type of prevention.

• Primary prevention: activities aimed at preventing a health-related problem before it happens. For example, you may provide community presentations or give your clients information about healthy wellness activities.
• Secondary prevention: attempts to reduce the impact of a health-related problem that has already been identified. For example, you may work with a client to develop coping strategies to manage behavioral health symptoms.
• Tertiary prevention: support provided to someone to lessen the impact of symptoms related to an ongoing or chronic health problem. For example, you may provide case management to ensure that clients with serious mental illnesses schedule and attend psychiatry appointments for medication management.

Prevention programs and activities can target:

• A whole community, not based on individual risk (e.g., community-wide domestic violence education programs).
• A smaller group of people that is at higher risk for a certain problem (e.g., parenting classes for young parents).
• An individual who is identified at being at high risk for a problem but who does not display signs or symptoms (e.g., a child who has been abused and is at high risk for other problems).

Part of prevention is understanding the risk factors for mental and physical problems. The following factors can contribute to (but do not necessarily cause) mental and physical problems:

• Genetics/heredity. Individuals with family members who have a mental or physical illness or condition are at a greater risk of having a similar illness or condition.
• Biology. A person's individual hormones, biological processes, and physical development and function will directly impact her physical and mental abilities. They can also impact how she feels about herself and engages with the world.
• Social relationships. The people surrounding us affect us, both in terms of how we feel about ourselves and our world and what habits (such as exercise or sexual behavior) we emulate. In addition, abuse and neglect directly contribute to all types of health.
• Physical environment. Being exposed to secondhand smoke, dirty surfaces, or allergens can drastically impact physical health. Mental health is also tied to our physical environment. For example, seasonal changes in light can affect energy, mood, and hormone levels.
• Existing mental or physical disabilities. Because these can make it difficult to engage with the world on a number of levels, they can also increase the risk of developing additional illnesses or conditions.

Falls are common for infants, children, and the elderly. To help prevent infants' and children's injuries from falls:

• Keep chairs, cribs, and other furniture away from windows.
• Do not hang wall decorations above babies' cribs.
• Use a baby gate if you have stairs. Gates at the top of staircases must be safety approved for this use.
• Do not let children play on furniture, beds, or appliances.
• Secure furniture like dressers to the wall and do not place TVs on top of dressers.

To help prevent injuries in the elderly:

• Make sure carpets are tightly secured.
• Install handrails along stairways and in the bathroom.
• Encourage use of ice grippers during the winter months.

If you hunt and/or own firearms, be responsible about gun safety:

• Properly store your firearms. This means keeping them locked and unloaded.
• Store the ammunition away from the firearms. This can help prevent both accidental injury (unintentional) and suicide or homicide (intentional).
• Remove guns from a person’s home if you know he is talking about suicide or wants to hurt himself.

Whenever traveling outdoors, spend time preparing for safety. When participating in activities on the water:

• Wear a personal flotation device (PFD) to prevent drowning.
• Keep PFDs in your boat, even if you might need more storage space.
• Carry a VHF radio and a signal flare in your PFD in case you need to call or signal for help.
• Remember, kids don't float. Borrow a life jacket from a loaner board if you don't have one for your child, and consider enrolling your child in a free water safety training.

Other transportation tips to keep in mind:

• Wear a helmet whenever you ride a bicycle, motorcycle, ATV, or snowmachine.
• Use a seatbelt at all times when driving or riding in a car.
• Do not use your cell phone while driving.
• Be sure that all infants and children use a car seat that complies with Alaska law.
• Never ride with anyone who is under the influence of alcohol or drugs.

Exposure to too much stress can harm the mind, body, and spirit. As a BHA/P, you need to protect yourself to avoid compassion fatigue and burnout. For more information, see Chapter A-4: Self-Care for BHA/Ps and Clients. You can also help your clients learn how to handle stress and reduce its impact on their health.

General tips for reducing stress:

• Take charge of your life. Be responsible for your emotions, schedule, and environment and the way you cope with problems. Develop a strong internal locus of control.
• Seek balance in your life between family, work, relationships, fun, and relaxation.
• Develop and maintain healthy boundaries.
• Proactively prevent stress through a healthy lifestyle:
  • Eat healthy.
  • Exercise on a regular basis.
  • Spend quality time with family and friends.
• If your stress level is impacting your quality of life, consider starting with a stress journal. Each time you feel stress, track:
  • The stressor (cause of your stress) if you know it.
  • Your guesses about what contributed to your stress in the moment.
  • How the stressor made you feel both physically and emotionally.
  • The way you responded to the stressor.
  • What you did to make yourself feel better.
• Help children reduce stress by role modeling healthy stress management techniques or teaching their caregivers to do so.
• Consider the four As of stress management. Choose one of these four ways to respond to your stressors:
  1. Avoid the stressor. Sometimes, we can stay away from things that stress us. For example, if you are too busy, say "no" next time someone asks for your participation. If you are stressed by not getting alone time during lunch at work, take lunch early or eat outside when the weather is nice.
  2. Alter the stressor. See what you can change for the better about your situation. For example, if someone you work with is more confrontational over the phone, send her carefully written emails about important issues.
  3. Adapt to the stressor. Change your standards, expectations, or way of thinking about a stressor. For example, if you want to cook a complicated meal every day but that is too stressful, adapt your standards to allow for macaroni and cheese or frozen meals occasionally. Try to focus on the positives of a difficult situation and find enjoyment.
  4. Accept the stressor. Sometimes, we have to live with our stressors and can only find peace by accepting them. For example, call a trusted friend who will keep your confidence to vent and process your situation. If you are frustrated with yourself about how you handle certain situations, take steps to improve your self-talk.

Depression, anxiety, and suicidal thoughts and plans are serious mental health concerns that can be prevented or mitigated through healthy protective factors, including:

• Open, safe communication with loved ones and peers.
• A sense of meaning and productivity at school or work and at home.
• Avoiding or minimizing the use of alcohol and drugs.
• Healthy eating habits.
• Regular exercise.
• Participation in both family and community activities.
• Stress management techniques, such as mindfulness, meditation, and breathing, yoga, or prayer.
• Finding a mentor in your community.
• Reaching out for help when needed. There is no shame in needing help!

As a BHA/P, you can help people who are at risk for depression or have depression by:

• Knowing the nature and symptoms of depression, anxiety, and suicidality.
• Learning both the risk factors and warning signs for suicide (see Chapter D-6: Suicidal Thoughts and Plans ).
• Identifying school and community resources for clients and families.
• Participating in community-based trainings related to suicide prevention and intervention, such as Applied Suicide Intervention Skills Training (ASIST) or Mental Health First Aide (MHFA).

You can also help community members who are interested in reducing rates of depression. Encourage them to:

• Coordinate healthy community activities for young people, elders, families, and all residents.
• Become a “big brother” or “big sister” for a child who may need extra support.
• Share their own depression and anxiety stories and how they have addressed their challenges.
• Support school-based programs that provide education and awareness of depression and suicide, such as American Indian Life Skills Development Curriculum or Gatekeeper Training.
• Advocate for community-based suicide prevention training.
• Take any threat of suicide seriously.

If a suicide occurs, be sure debriefing is provided for family, peers and others who have been impacted. This includes medical staff.

Abuse and neglect can have serious and lifelong consequences for the survivor (also called victim). Preventing abuse or intervening early is critical. Know what abuse is and how to address it. Abuse is often thought of as only physical or sexual, but it can also be verbal, emotional, or spiritual. As appropriate, help clients, including children, to have a basic understanding of each type of abuse.

To help reduce the risk of abuse and neglect of children and vulnerable adults, teach parents and caregivers to:

• Communicate openly with their children, model healthy boundaries, and provide a loving, safe environment.
• Be involved in their children’s activities.
• Get help if they suffered any childhood trauma or are in an abusive relationship. Unaddressed issues are often passed on from parents to children, and children suffer even when domestic violence is between parents and not directed at them.
• Find help to stop the cycle of abuse.
• Ensure their children’s safety at all times.
  • Children should only be cared for by safe people. Parents should carefully get to know people who care for their children and use licensed childcare providers when possible.
  • Children should hear their parents tell childcare and babysitting providers their rules.
  • Parents can do a "check-in" after being away from their children by asking how they are doing and if there's anything the children want to share. Open communication is a protective factor.
• Connect with and coach their children so they know how much the parents care. Parents can teach children:
  • "My body, my choice" and "no means no." A great way to reinforce this message is to respect when children say "stop" while being tickled or say "no" to hugging a relative.
  • If anyone tries to touch them inappropriately, they should say no, get away, and tell an adult they trust.
  • Never to keep secrets from them.

Teach parents how to respond if their children share with them about physical or sexual abuse:

• Provide comfort and say you will find help.
• Do not blame the child for what happened.
• Do not try to protect the person who may have done the harm.
• Seek help.

For more information, see Chapter D-3: Abuse and Neglect.

Some children experience a high degree of inattention and/or hyperactivity and may even be diagnosed with Attention Deficit Hyperactivity Disorder (ADHD). ADHD is a biologically driven, neurodevelopmental disorder that can be supported with environmental interventions. People with ADHD have trouble paying attention, thinking before acting, and sitting still for long periods of time. They can also be forgetful or have a difficult time completing tasks that have multiple steps.

Children who struggle with inattention or hyperactivity, whether or not they are diagnosed with ADHD, have a particularly high need for quality sleep and a healthy diet. They also benefit from consistent and predictable routines at home and school. They may need parents, caregivers, and teachers to be flexible about their need for movement. For example, they may need to pace while studying, use quiet fidget toys during school, or take movement breaks between academic subjects.

If a child's difficulties with attention or hyperactivity are affecting her performance at school, encourage the parents to request an evaluation for an Individualized Education Program under the Individuals with Disabilities Education Act or a 504 Plan under Section 504. Adults with ADHD or the parents of children with ADHD may also want to consider speaking with a medical provider about medication.

For more information, see Chapter D-14: Hyperactivity and Problems with Attention.

The benefits of quitting tobacco cannot be overstated and last a lifetime. Almost immediately after quitting, people will notice improvements in their health. The longer they go without tobacco, the healthier they become and the lower their risks of long-term health consequences are. Many people also see financial benefits from quitting tobacco.

Below are some ways the body will heal when a person quits using tobacco:

• Within 20 minutes, blood pressure and pulse rate drop to normal levels.
• Within 24 hours, the risk of heart attack decreases.
• Within three months, blood circulation improves.
• Within nine months, lung function starts to improve.
• Within one year, the risk of coronary heart disease is half that of a tobacco user.

How to improve your clients' chances of quitting tobacco:

• Talk with your clients about options such as Nicotine Replacement Therapy (NRT) and counseling.
• Help your clients come up with a quit plan and list their motivations to quit.
• Provide support or refer clients to a tobacco treatment specialist or tobacco cessation program. For options, see the Regional Tobacco Cessation Programs handout.
• Work with your local school district to develop health programs to help prevent tobacco use.

Recommendations for school programs:

• Prohibit tobacco use at all schools and school events.
• Encourage students, faculty, and students' family members to quit tobacco use.
• Provide training for teachers and age-appropriate materials and instruction to students of all ages.
• Have a coordinated group that supports and delivers consistent messages about tobacco use and its harms.
• Build in community effort and reinforcement to prevent tobacco use initiation.