The study, led by researchers at Tabriz University of Medical Sciences, set out to answer a question that has lingered in the chronic disease literature for years: does patient empowerment improve medication adherence directly, or does it work through an intermediate psychological mechanism? Drawing on Social Cognitive Theory, the team hypothesized that cardiac self-efficacy — a patient’s specific confidence in their ability to manage their heart condition, from controlling symptoms to maintaining daily function — serves as the essential bridge between feeling empowered and actually adhering to a medication regimen. The distinction matters enormously for clinical practice, because the two explanations call for very different interventions.

To test the model, the researchers recruited adults with confirmed coronary artery disease attending routine follow-up appointments, excluding anyone who had experienced an acute cardiac event within the previous 30 days. Participants completed three validated instruments: the 25-item Coronary Artery Disease Empowerment Scale, which measures self-determination, emotional self-regulation and personal competence; Sullivan’s 13-item Cardiac Self-Efficacy Scale, covering symptom control and maintaining function; and the widely used 8-item Morisky Medication Adherence Scale. All scales demonstrated good to excellent internal consistency in this sample, with Cronbach’s alpha values ranging from 0.75 to 0.92. The final sample of 266 complete responses exceeded the minimum of 259 participants required by an a priori power analysis.

The participants, whose mean age was 53.56 years and a slight majority of whom were women, were taking an average of just over four cardiovascular medications daily, most commonly antiplatelets, lipid-lowering agents and antihypertensives. Their average adherence score fell in the medium range, a pattern familiar to clinicians everywhere. On average, patients reported a total empowerment score of 97.71 out of a possible 125 and a cardiac self-efficacy score of 50.12 out of 65. Spearman’s correlations confirmed that all three key variables moved together: empowerment, self-efficacy and adherence were each positively and significantly associated with the others, with the strongest link appearing between self-efficacy and adherence.

The statistical heart of the study was a path analysis that modelled the three empowerment sub-dimensions as predictors of the two self-efficacy sub-dimensions, which in turn predicted medication adherence. The model fit the data remarkably well, with a chi-square to degrees of freedom ratio of 1.354, a Comparative Fit Index of 0.998 and a root mean square error of approximation of 0.037 — figures that comfortably exceed conventional thresholds for an excellent-fitting model. Because medication adherence is an ordinal measure, the team also ran a Bayesian estimation using Markov Chain Monte Carlo methods as a sensitivity check; the results were highly comparable, and convergence diagnostics confirmed the stability of the estimates.

The findings were striking in their specificity. Self-determination — the sense of autonomy and personal choice in managing one’s illness — emerged as the strongest predictor of both self-efficacy components, with standardized coefficients of 0.25 for symptom control and 0.33 for maintaining function. Emotional self-regulation also contributed significantly to maintaining function. But the personal competence sub-dimension, which captures knowledge and skills, failed to predict either component of self-efficacy. In other words, simply knowing what to do and how to do it did not build the confidence needed to do it. Bootstrap analysis with 1000 resamples confirmed that the indirect effects of self-determination and emotional self-regulation on adherence, transmitted through self-efficacy, were statistically significant, while the indirect effect of personal competence was not.

Perhaps the most consequential result came from the ordinal logistic regression. When both empowerment and self-efficacy were entered as predictors of adherence, self-efficacy remained a powerful and significant predictor — each one-unit increase in self-efficacy score was associated with a 9 percent increase in the odds of belonging to a higher adherence category — while total empowerment lost its significance entirely. The pattern suggests that the apparent relationship between empowerment and adherence reported in earlier studies may have been an artefact of failing to model self-efficacy simultaneously. Empowerment, in this model, does not act on behaviour directly; it acts by building the belief that action is possible.

This finding carries real theoretical weight. It lends empirical support to a long-standing critique in the empowerment literature, articulated by scholars such as Halvorsen and colleagues, that empowerment is too often reduced to a paternalistic process of transferring knowledge and skills. The Iranian data suggest exactly the opposite: the dimension associated with a genuine redistribution of power — self-determination — was the one that built self-efficacy, while the dimension resembling conventional patient education did not. The result also aligns neatly with Self-Determination Theory, which holds that supporting autonomy is the key to internalising motivation. Notably, the study found a much stronger correlation between empowerment and cardiac-specific self-efficacy than earlier work had found with general self-efficacy, underscoring the value of disease-specific measurement.

The clinical implications are direct. If self-efficacy is the bridge that empowerment must cross to become behaviour, then counselling strategies built purely on information delivery are unlikely to move the needle on adherence. Instead, the authors argue, nurses and other clinicians should deploy techniques that strengthen patients’ sense of autonomy — motivational interviewing, collaborative goal-setting and individualised self-management support. Empowerment-based interventions tested in randomized trials, from haemodialysis units to liver transplant programmes, have already shown that they can raise self-efficacy; this new path model helps explain why they work and which ingredients matter most.

The researchers are careful to acknowledge the limits of their design. The cross-sectional data cannot establish causal direction — successful adherence may itself reinforce self-efficacy over time — and all measures were self-reported, without objective pill counts, pharmacy refill records or clinical biomarkers. The convenience sample from a single referral clinic may not generalise widely, and unmeasured factors such as depression or health literacy could partly explain the observed pathways. Still, the study offers something the field has lacked: an empirically validated, ordered pathway from autonomy to confidence to action, tested in a Middle Eastern population where such models have rarely been examined. Future longitudinal and interventional studies, ideally with objective adherence measures and cross-cultural samples, will be needed to confirm the pathway. For now, the message to cardiology is clear: to get patients to take their pills, stop telling them what to do and start helping them believe they can.

Subject of Research: The mediating role of cardiac self-efficacy in the relationship between patient empowerment and medication adherence in coronary artery disease patients

Article Title: Cardiac Self‐Efficacy Mediates the Relationship Between Patient Empowerment and Medication Adherence: A Path Analysis in Patients With Coronary Artery Disease ‐ Empirical Research Quantitative

Article References: Allahbakhshian, A., Hashempour, F., Saiyadani, S., Sarbakhsh, P., Mohammadnezhad, M., & Radimaher, F. (2026). Cardiac Self‐Efficacy Mediates the Relationship Between Patient Empowerment and Medication Adherence: A Path Analysis in Patients With Coronary Artery Disease ‐ Empirical Research Quantitative. Nursing Open, 13(10), Article e70837. https://doi.org/10.1002/nop2.70837

Image Credits: AI Generated

DOI: 10.1002/nop2.70837

Keywords: coronary artery disease, medication adherence, patient empowerment, cardiac self-efficacy, path analysis, Social Cognitive Theory, self-determination, nursing, patient education, motivational interviewing, chronic disease self-management, Iran

The origins of the curriculum lie in grief and resolve. Following devastating youth losses, a delegation of White Mountain Apache Tribal leaders met with the Johns Hopkins Center for Indigenous Health to expand their long-standing public health partnership into mental health. In 2001, exercising its political sovereignty, the Tribal Council passed a resolution establishing the Celebrating Life System, a tribally mandated suicide surveillance and case management system that has been linked to documented decreases in suicide deaths and attempts. Building on that foundation, an Elders’ Council formed and emphasized the importance of passing Apache language and traditions to youth as an upstream defense against suicide risk, which peaks between ages 15 and 24. The Elders chose to intervene earlier, at a developmental stage when children can comprehend and retain teachings about identity, belonging, and resilience. Since 2015 the curriculum has been delivered in reservation schools through monthly lessons that include Elders speaking Apache, sharing songs and stories, and assigning seasonal responsibilities for youth to practice with their families.

Scientifically, the study addresses a stubborn gap in prevention science. Culturally grounded interventions — those designed from the ground up with culture, values, and Indigenous worldviews at the forefront — are deeply valued by Native communities, yet they remain under-evaluated in the empirical literature. Standard Western frameworks assume a linear pipeline from intervention development to efficacy testing to scale-up, an approach rooted in Eurocentric knowledge construction that privileges cognition over lived experience, spirit, and relationality. The research team, led by Victoria M. O’Keefe of the Cherokee Nation and Seminole Nation, deliberately Indigenized this process, replacing the linear model with a relational, orbital, and iterative one. The goal was twofold: to identify the core components of the Elders’ Resilience Curriculum and the mechanisms through which it works, providing a theoretical basis for evaluation and future scaling, while safeguarding Apache teachings that have historically been shared orally and never disseminated outside the Tribe.

The study employed a non-parallel convergent mixed methods design embedded in Indigenous Community-Based Participatory Research. Rather than treating community members as subjects, the team worked with a Community Advisory Board of ten White Mountain Apache members who reviewed the design, interpreted results, and shaped dissemination. Language itself was decolonized: partners preferred the term “youth strength factors” over “protective factors against suicide,” reframing the work as strengths-based life promotion rather than deficit reduction. The research unfolded in deliberate steps, beginning with a consensus survey completed by faculty and staff involved in the program, who rated 31 potential core components and 13 potential youth outcomes for importance. A virtual consensus meeting then resolved ambiguities, ultimately confirming 28 core components rated very important or useful, spanning program activities, format and setting, curriculum delivery, organizational support, and Elder knowledge and training.

The qualitative phases brought the community’s voice to the center of the analysis. Focus group discussions with Elders and in-depth interviews with youth, caregivers, teachers, and Tribal leaders illuminated what makes the program meaningful. Participants described the intergenerational bonds forged when Elders enter classrooms, with one Tribal leader noting that Elders carry the wisdom to navigate life’s hardships and that connection between generations is “definitely needed.” Another leader described the ripple effect of a single lesson: a student goes home, shares an Elder’s words about respect with a parent, and plants seeds of dialogue that spread through the classroom, the school, the home, and the larger community. Elders spoke of pride in carrying forward the tools their own ancestors shared with them, now teaching children how to use those tools to weather storms and solve problems.

To identify the theoretical mediators — the youth strengths the curriculum is meant to build — the team used Nominal Group Technique, a participatory method in which participants independently generate, rank, and prioritize ideas. Community mental health specialists, youth ages 11 to 13, and youth ages 14 to 17 each produced ranked lists of what keeps young people strong and connected. The final consensus identified four paramount strength factors: connection to family, connection to religion and spirituality including prayer, connection to Elders through learning from and helping them, and connection to culture, encompassing cultural history, activities, and traditional foods. Notably, youth prioritized sleep and sports, factors not currently addressed in the curriculum — an input that points toward possible new lesson topics as Elders continue iterating the program. Community members framed expected outcomes as “positive changes,” spanning mental, emotional, spiritual, and social health, academic achievement, identity, belonging, Apache language, and cultural continuity.

The study’s most innovative methodological step came with pile sorts, in which Elders, youth, and community mental health specialists sorted notecards representing core program activities, youth strengths, and potential outcomes, mapping the relationships among them. Participants consistently described the elements as interconnected rather than sequential — a reciprocal, relational web rather than a causal chain. When the research team drafted a conventional linear theoretical model showing activities producing strengths that produce outcomes, Community Advisory Board members pushed back decisively. One member explained that everything moves back and forth constantly, a give and take rather than “this causes this causes that.” The model, they insisted, had to be circular.

The community’s answer to how to visualize that circularity came from Apache teachings themselves. A community mental health specialist and artist shared that he pictured the model as a cottonwood tree, a symbol whose specific teaching cannot be written or shared outside the Tribe. In his visualization, the core components form the roots, the youth strength factors form the trunk, and the positive changes form the branches and leaves. Other specialists added that trees hold knowledge and keep growing, and that new leaves replacing old each year mirror how youth learn, grow, and gain strength. Elders on the Elders’ Council affirmed the teaching, noting that the color yellow in the artist’s painting represents life in Apache tradition. A White Mountain Apache graphic designer then digitized the model, producing a theoretical framework grounded entirely in the community’s own Knowledge System — a living, growing structure rather than a static flowchart.

The implications extend well beyond one reservation. Other American Indian and Alaska Native communities have expressed interest in adapting the curriculum, and this research offers a pathway for scaling culturally grounded programs while respecting their origins: other communities can follow the same participatory process to integrate their own languages, knowledges, and practices rather than importing Apache content. The study also carries lessons for mainstream prevention science, challenging rigid fidelity requirements and suggesting that Indigenous interventions should remain dynamic, evolving documents shaped by community experts rather than academic ones. Limitations include COVID-19 pandemic delays that forced retrospective reporting and a purposive sample not designed for generalizable statistics. Yet the strengths are substantial: the research supported the re-implementation of the curriculum in fall 2023, empowered local interpretation at every stage, and culminated in community dissemination. Ultimately, the cottonwood tree model stands as both a scientific framework and a cultural statement — evidence that suicide prevention can be rooted in sovereignty, sustained by Elders, and measured in the flourishing of the next generation.

Subject of Research: Co-developing a theoretical model for the Elders' Resilience Curriculum, an Indigenous culturally grounded school-based suicide prevention intervention of the White Mountain Apache Tribe

Article Title: The Elders’ Resilience Curriculum: Co-developing a theoretical model of an Indigenous culturally grounded preventive intervention

Article References: O’Keefe, V. M., Goklish, N., Sinquah, F. L., Grubin, F., Haroz, E. E., Sierra, V., Cwik, M., Suttle, R., Cosen, E., Velasquez-Brawley, V., Garcia, M., Rock, H., Pablo, E., Cosen, R., Whitesell, N., Gallo, J. J., Keshen, R., & Barlow, A. (2026). The Elders’ Resilience Curriculum: Co-developing a theoretical model of an Indigenous culturally grounded preventive intervention. SSM – Mental Health, 10, Article 100701. https://doi.org/10.1016/j.ssmmh.2026.100701

Image Credits: AI Generated

DOI: 10.1016/j.ssmmh.2026.100701

Keywords: White Mountain Apache Tribe, Indigenous mental health, suicide prevention, Elders' Resilience Curriculum, culturally grounded intervention, Community-Based Participatory Research, Apache language, intergenerational connection, cultural continuity, prevention science, youth resilience, self-determination

At the heart of WARP lies the Sāmoan concept of vā, a relational epistemology describing the sacred space that exists between people, and teu le vā, the practice of nurturing that space. Teu le vā is embedded in fa’asamoa, the Sāmoan way of life, and is traditionally recognized through how relationships are tended: how people speak to one another, how food is distributed, how seating arrangements and acts of care are organized in relation to self, family, village and chief. Its foundations rest on responsibility to practice respect, reciprocity, love, inclusion, understanding, thoughtfulness, service and compassion in everyday life. The researchers argue that this worldview, far from being a cultural curiosity, is a form of Indigenous technology that educators can deploy to build genuine, healthy relationships with NH/PI students, and that relational wellbeing is the precondition for academic success, mental health and holistic wellness across the life course.

The urgency behind the framework is grounded in stark evidence. NH/PI communities are among the fastest growing in Washington state and include some of the largest Tongan, Native Hawaiian, Sāmoan, Marshallese, Chamorro and Fijian communities in the United States. Yet NH/PI students in the state’s K-12 public schools achieve much lower rates on statewide standards in mathematics, science and English language arts compared with all students. Community leaders have long attributed these gaps to structural racism and settler colonialism, forces that have produced land dispossession, displacement through gentrification, environmental racism and poverty stemming from restrictions on Indigenous political and economic self-determination across Oceania.

The new paper builds on a previously published state report, Stories of Educational Wayfinding: Supporting the Educational Voyages of Native Hawaiian and Pacific Islander Students, which documented how disconnection from teachers and peers shapes students’ daily lives. In interviews, one student described missing class for a family member’s funeral without telling the teacher, feeling no connection to the adults at school and not wanting their attention or sympathy. Another student recalled teachers joking about Sāmoans being big, strong and scary. One educator described a student who quit school after sophomore year because they could not handle the jokes and mockery. The report also documented a Chuukese family that hosted relatives for a month of mourning after a death, during which students missed substantial school, only for a teacher to complain that no one answered emails, an example the researchers cite of students being forced to choose between their identity as students and as members of their communities.

These interpersonal dynamics sit atop a long institutional history. Chamoru and Hawaiian languages were banned in schools in Guåhan and Hawai’i until 1974 and 1986 respectively, and after World War I, Chamorro children suspected of hookworm infection were forcibly institutionalized at schools and separated from their families. The authors argue that such policies, far from being isolated historical incidents, produced a continuing legacy of assimilation, identity erasure and cultural loss that still ripples through the wellbeing of Pacific communities today. Within this system, students who internalize prejudice-based beliefs about themselves face damaged self-efficacy, stereotype threat and social exclusion, all documented barriers to academic motivation and achievement.

The WARP framework translates these challenges and solutions into the imagery of a va’a, an outrigger canoe, voyaging between islands across rough water. The students are the voyagers. The waves and currents pushing against the vessel represent systemic barriers, interpersonal racism and internal struggles rooted in settler colonialism. The wind that helps the canoe move past those waves represents healthy, supportive relationships with educators, relationships characterized as mentorship rather than despotism, which research links to a stronger sense of belonging, greater confidence and lower stress. Guided by the stars and ocean creatures, metaphors for ancestors and families, students remain steadfast against forces threatening to capsize their educational journeys. The authors emphasize that students continue to resist these systems, supported by genealogies of care handed down through their communities.

Concretely, the researchers argue that classrooms contain many vā: the relational spaces between student and teacher, student and peers, and student and the learning environment itself. When teachers and students co-establish mutual understanding of vā and its foundational qualities, classroom relationships begin to resemble the cultural connections that sustain Pasifika communities. The paper offers an example from the senior author’s own middle school experience, in which a Hawaiian studies course designated one day a month as unstructured time for classmates to air grievances and make their relationships right through ho’oponopono, a traditional Hawaiian practice of restoring relationships. Crucially, the authors caution that non-Pasifika educators should let students and their families guide any engagement with these practices, so that relationship building does not slide into appropriation or malpractice of sacred cultural traditions.

The paper also highlights community-led programs in Washington that already embody these principles, though the authors are careful to note that none has yet been evaluated with rigorous experimental or observational designs. UTOPIA Washington, a fa’afafine and transgender-led grassroots organization serving Queer and Transgender Pacific Islanders, runs a Mana Youth Program in partnership with three public schools, providing mentorship, cultural teaching and academic support in which educators act as aunties, uncles and elders. In the report’s interviews, students described this network as family and said the support motivated them to attend class and do well. In Eastern Washington, Marshallese families built a language and culture program that teaches mathematics, biology, ecology and physics through the parts of a canoe, assigns students to write about their jowi, or clan, and their family histories, and has been credited by a paraeducator with improving student engagement, attendance, family relationships and graduation rates. Kamehameha Schools in Hawai’i, founded in 1884 by Ke Aliʻi Pauahi Bishop, is presented as a systemic model, organizing learning outcomes around a tree metaphor that encompasses ancestral knowledge, responsibility, love of the land and learner wellbeing.

The implications extend into policy and school social work. The authors argue that diversity, equity and inclusion efforts often stop at cultural awareness without confronting the systemic racism and settler colonialism embedded in curricula, training and policy, and that teu le vā demands deeper structural change, from teacher education to school mental health services. For school social workers, whose field has been criticized for paternalism and a color-evasive lens, adopting teu le vā offers a roadmap for centering students’ agency, community assets and cultural strengths rather than hyper-independence. The stakes are high: the underlying state report found that one in five NH/PI students reported thoughts of suicide, the highest rate among all racial groups. The authors call for future research to implement and evaluate community-led initiatives, conduct needs assessments with NH/PI youth, integrate Indigenous forms of evidence into evaluation frameworks and continue disaggregating NH/PI data from Asian American data. Their conclusion is unambiguous: educational wellbeing is interpersonal and rooted in connection, and no student should have to debate which parts of themselves to sacrifice on their educational journey. When schools honor the vā between students, educators and communities, they argue, Pasifika youth can stand in their genealogies of care and carry their ancestors’ knowledge into every classroom.

Subject of Research: An Indigenous relational framework, WARP, developed to support the educational wellbeing and mental health of Native Hawaiian and Pacific Islander K-12 students in Washington state.

Article Title: Wayfinding through teu le vā: Developing an indigenous relational approach to support the success and wellbeing of Native Hawaiian and Pacific Islander students in Washington state

Article References: Beck, K. L., Camacho, S. G., Sakurai, M. J., Nguyễn, J., Seto-Myers, D. K., Cheers, J. K., Spencer, M. S., & Halvorson, M. A. (2026). Wayfinding through teu le vā: Developing an indigenous relational approach to support the success and wellbeing of Native Hawaiian and Pacific Islander students in Washington state. SSM – Mental Health, 10, Article 100700. https://doi.org/10.1016/j.ssmmh.2026.100700

Image Credits: AI Generated

DOI: 10.1016/j.ssmmh.2026.100700

Keywords: teu le vā, Native Hawaiian and Pacific Islander students, Pasifika education, relational wellbeing, Indigenous knowledge, wayfinding, self-determination, school mental health, settler colonialism, Washington state education, culturally sustaining pedagogy, SSM Mental Health