Introduction to ecological description of a community intervention: building prevention through collaborative field based research.

This special issue of the American Journal of Community Psychology is the result of a 18-year partnership with Alaska Native communities using collaborative field based research methods. Its goal is to provide a case study fulfilling the spirit of ecological inquiry, offering a detailed and nuanced description of a community intervention. The articles describe the nature of our work, including some of our successes, as well as challenges, dilemmas, and even disappointments we experienced along the way. Our primary aim was to develop and assess the feasibility of a complex, multi-level intervention to increase protective factors hypothesized to reduce suicide and alcohol abuse among rural Yup'ik Alaska Native youth ages 12-18. The articles that follow include descriptions of the cultural context, relevant literature and project history, our methods of community engagement in measurement development strategies, an empirical test of the prevention model that guided the intervention, the development and implementation of the intervention, a feasibility and impact assessment, and an evaluation of community engagement. A final article summarizes what is generalizable from the work in field based intervention research with rural and culturally distinct populations, and future prospects for decolonizing community intervention research methods. These papers raise important issues, including (1) need for deep, contextual ecological descriptions, (2) reconceptualization of time in the research relationship, (3) distinctions between populations and communities, and (4) the conflict between values of communities and intervention science.

Creating Qungasvik (a Yup'ik intervention "toolbox"): case examples from a community-developed and culturally-driven intervention.

This paper describes the development of a Yup'ik Alaska Native approach to suicide and alcohol abuse prevention that resulted in the creation of the Qungasvik, a toolbox promoting reasons for life and sobriety among youth. The Qungasvik is made up of thirty-six modules that function as cultural scripts for creating experiences in Yup'ik communities that build strengths and protection against suicide and alcohol abuse. The Qungasvik manual represents the results of a community based participatory research intervention development process grounded in culture and local process, and nurtured through a syncretic blending of Indigenous and Western theories and practices. This paper will provide a description of the collaborative steps taken at the community-level to develop the intervention modules. This process involved university researchers and community members coming together and drawing from multiple sources of data and knowledge to inform the development of prevention activities addressing youth suicide and alcohol abuse. We will present case examples describing the development of three keystone modules; Qasgiq (The Men's House), Yup'ik Kinship Terms, and Surviving Your Feelings. These modules each are representative of the process that the community co-researcher team took to develop and implement protective experiences that: (1) create supportive community, (2) strengthen families, and (3) give individuals tools to be healthy and strong.

People awakening: collaborative research to develop cultural strategies for prevention in community intervention.

The consequences of alcohol use disorder (AUD) and suicide create immense health disparities among Alaska Native people. The People Awakening project is a long-term collaboration between Alaska Native (AN) communities and university researchers seeking to foster health equity through development of positive solutions to these disparities. These efforts initiated a research relationship that identified individual, family, and community protective factors from AUD and suicide. AN co-researchers next expressed interest in translating these findings into intervention. This led to development of a strengths-based community intervention that is the focus of the special issue. The intervention builds these protective factors to prevent AUD and suicide risk within AN youth, and their families and communities. This review provides a critical examination of existing literature and a brief history of work leading to the intervention research. These work efforts portray a shared commitment of university researchers and community members to function as co-researchers, and to conduct research in accord with local Yup'ik cultural values. This imperative allowed the team to navigate several tensions we locate in a convergence of historical and contemporary ecological contextual factors inherent in AN tribal communities with countervailing constraints imposed by Western science.

Feasibility of a community intervention for the prevention of suicide and alcohol abuse with Yup'ik Alaska Native youth: the Elluam Tungiinun and Yupiucimta Asvairtuumallerkaa studies.

The Elluam Tungiinun and Yupiucimta Asvairtuumallerkaa studies evaluated the feasibility of a community intervention to prevent suicide and alcohol abuse among rural Yup'ik Alaska Native youth in two remote communities. The intervention originated in an Indigenous model of protection, and its development used a community based participatory research process. Feasibility assessment aimed to assess the extent to which (1) the intervention could be implemented in rural Alaska Native communities, and (2) the intervention was capable of producing measurable effects. Scales maximally sensitive to change were derived from earlier measurement work, and the study contrasted implementation process and outcomes across the two communities. In one community, medium dose response effects (d = .30-.50), with dose defined as number of intervention activities attended, were observed in the growth of intermediate protective factors and ultimate variables. In the other community, medium dose effects were observed for one intermediate protective factor variable, and small dose effects were observed in ultimate variables. Differences across communities in resources supporting intervention explain these contrasting outcomes. Results suggest implementation in these rural Alaska settings is feasible when sufficient resources are available to sustain high levels of local commitment. In such cases, measureable effects are sufficient to warrant a prevention trial.

A protective factors model for alcohol abuse and suicide prevention among Alaska Native youth.

This study provides an empirical test of a culturally grounded theoretical model for prevention of alcohol abuse and suicide risk with Alaska Native youth, using a promising set of culturally appropriate measures for the study of the process of change and outcome. This model is derived from qualitative work that generated an heuristic model of protective factors from alcohol (Allen et al. in J Prev Interv Commun 32:41-59, 2006; Mohatt et al. in Am J Commun Psychol 33:263-273, 2004a; Harm Reduct 1, 2004b). Participants included 413 rural Alaska Native youth ages 12-18 who assisted in testing a predictive model of Reasons for Life and Reflective Processes about alcohol abuse consequences as co-occurring outcomes. Specific individual, family, peer, and community level protective factor variables predicted these outcomes. Results suggest prominent roles for these predictor variables as intermediate prevention strategy target variables in a theoretical model for a multilevel intervention. The model guides understanding of underlying change processes in an intervention to increase the ultimate outcome variables of Reasons for Life and Reflective Processes regarding the consequences of alcohol abuse.

Found in translation: Decoding local understandings of genetics and heredity in a Yup'ik Eskimo community.

The Center for Alaska Native Health Research is a community-based participatory research center that conducts studies involving genetic research with Yup'ik Eskimo community members in Southwest Alaska, where Yup'ik remains the first language for most residents. Cultural equivalents are needed to communicate results of these studies among all partners and members of the participating communities, since many scientific terms have no direct translation in Yup'ik. To inform that effort, we examined local understandings of genetics and heredity in one community. Here, we report results from back-translated Yup'ik interviews, and identify working genetic concepts shared by participants from interviews and focus groups. We suggest issues involved in, and some potential steps toward, developing a concise, scientifically accurate and culturally relevant term for "genetics" and other health concepts.

Stable nitrogen and carbon isotope ratios indicate traditional and market food intake in an indigenous circumpolar population.

The transition of a society from traditional to market-based diets (termed the nutrition transition) has been associated with profound changes in culture and health. We are developing biomarkers to track the nutrition transition in the Yup'ik Eskimo population of Southwest Alaska based on naturally occurring variations in the relative abundances of carbon and nitrogen stable isotopes (δ(15)N and δ(13)C values). Here, we provide three pieces of evidence toward the validation of these biomarkers. First, we analyzed the δ(15)N and δ(13)C values of a comprehensive sample of Yup'ik foods. We found that δ(15)N values were elevated in fish and marine mammals and that δ(13)C values were elevated in market foods containing corn or sugar cane carbon. Second, we evaluated the associations between RBC δ(15)N and δ(13)C values and self-reported measures of traditional and market food intake (n = 230). RBC δ(15)N values were correlated with intake of fish and marine mammals (r = 0.52; P < 0.0001). RBC δ(13)C values were correlated with intake of market foods made from corn and sugar cane (r = 0.46; P < 0.0001) and total market food intake (r = 0.46; P < 0.0001). Finally, we assessed whether stable isotope ratios captured population-level patterns of traditional and market intake (n = 1003). Isotopic biomarkers of traditional and market intake were associated with age, community location, sex, and cultural identity. Self-report methods showed variations by age and cultural identity only. Thus, stable isotopes show potential as biomarkers for monitoring dietary change in indigenous circumpolar populations.

Reflections on a proposed theory of reservation-dwelling American Indian alcohol use: comment on Spillane and Smith (2007).

In their recent article, N. Spillane and G. Smith suggested that reservation-dwelling American Indians have higher rates of problem drinking than do either non-American Indians or those American Indians living in nonreservation settings. These authors further argued that problematic alcohol use patterns in reservation communities are due to the lack of contingencies between drinking and "standard life reinforcers" (SLRs), such as employment, housing, education, and health care. This comment presents evidence that these arguments were based on a partial review of the literature. Weaknesses in the application of SLR constructs to American Indian reservation communities are identified as is the need for culturally contextualized empirical evidence supporting this theory and its application. Cautionary notes are offered about the development of literature reviews, theoretical frameworks, and policy recommendations for American Indian communities.

Smoking, chewing, and cultural identity: prevalence and correlates of tobacco use among the Yup'ik-The Center for Alaska Native Health Research (CANHR) study.

Survey data were obtained from a large sample of Yup'ik participants residing in the Yukon-Kuskokwim Delta region of Alaska. Tobacco use, age, sex, and a variety of psychosocial variables were assessed. Over 75% of participants use tobacco; one half (57.4%) reported using smokeless tobacco (SLT) regularly; 28.2% reported smoking cigarettes regularly. Relative to women, men reported using SLT less, smoking cigarettes more, and using the combination of cigarettes and SLT more. Younger participants tended to smoke cigarettes more, and to use the combination of cigarettes and SLT more. SLT users displayed significantly greater enculturation by identifying more with a Yup'ik lifestyle and less with a White lifestyle, speaking their traditional language more frequently, and consuming more traditional food and medicine. In contrast, smokers tended to display significantly greater acculturation and reported using drugs and alcohol more to cope with stress. Discussion focuses on appreciating the influence of cultural factors on health behavior and on implications for intervention.

Suicide prevention as a community development process: understanding circumpolar youth suicide prevention through community level outcomes.

OBJECTIVES: Community-based models have become increasingly prominent in prevention, and have special relevance for suicide prevention in circumpolar Indigenous communities. It follows that outcomes from circumpolar suicide prevention programs might be more completely understood at the community level. We present here a methodology for analysis at this level. This paper seeks to understand a cultural prevention program for rural Yup'ik youth in Alaska targeting suicide and co-occurring alcohol abuse as a community development process through changes at the community level. STUDY DESIGN: Quasi-experimental design with assessment at pre- and post-intervention or at 4 time points. The community development process for this project began in October 2004. The first program baseline assessment began in November 2006, prior to prevention activities with youth and parents, and the post-intervention assessment concluded in March 2008. METHODS: Five key informants pre- and post-intervention completed a community readiness assessment, which is a structured procedure assessing a community's awareness of suicide as an issue and its, organizational readiness for prevention programming. Forty-three adult caregivers or sponsors of youth in the prevention program completed an assessment of behaviours that contributed to community protective factors from youth suicide and alcohol abuse at 4 time points before, during and after the intervention. The 54 youth who participated in the prevention program completed an assessment of community protective factors, also at 4 time points before, during and after the intervention. The community protective factors from suicide that were assessed included safety, enforcement of alcohol prohibitions, role models, support and opportunities for youth. RESULTS: Community readiness for the prevention efforts increased to new developmental stages of readiness post-intervention, and a trend in the data suggested community protective factors increased in the amount of protective behaviours performed by adults (slope estimate = 0.0162, 95% CI--0.0028-0.0351, d=.55) and in the perceptions of youth (slope estimate=0.0148, 95% CI--0.0004-0.0291, d=.45), in a dose response relationship to the number of prevention program sessions attended by adults and youth. CONCLUSIONS: Using data from a feasibility study, this paper demonstrates the feasibility and potential utility of methodological approaches that use community-level variables beyond individual level outcomes in circumpolar suicide prevention research.

Risk, resilience, and natural recovery: a model of recovery from alcohol abuse for Alaska Natives.

AIM: The People Awakening (PA) study explored an Alaska Native (AN) understanding of the recovery process from alcohol abuse and consequent sobriety. DESIGN: PA utilized a cross-sectional, qualitative research design and community-based participatory research methods. SETTING AND PARTICIPANTS: The study included a state-wide convenience sample of 57 participants representing all five major AN groups: Aleut/Alutiiq, Athabascan, Inupiaq, Yup'ik/Cup'ik and Tlingit/Haida/Tsimshian. Participants were nominated and self-identified as being alcohol-abstinent at least five years following a period of problem drinking. MEASUREMENTS: Open-ended and semistructured interviews gathered extensive personal life histories. A team of university and community co-researchers analyzed narratives using grounded theory and consensual data analysis techniques. FINDINGS: A heuristic model of AN recovery derived from our participants' experiences describes recovery as a development process understood through five interrelated sequences: (i) the person entered into a reflective process of continually thinking over the consequences of his/her alcohol abuse; (ii) that led to periods of experimenting with sobriety, typically, but not always, followed by repeated cycling through return to drinking, thinking it over, and experimenting with sobriety; culminating in (iii) a turning point, marked by the final decision to become sober. Subsequently, participants engaged in (iv) Stage 1 sobriety, active coping with craving and urges to drink followed for some participants, but not all, by (v) Stage 2 sobriety, moving beyond coping to what one participant characterized as 'living life as it was meant to be lived. CONCLUSIONS: The PA heuristic model points to important cultural elements in AN conceptualizations of recovery.

Stress, coping, and well-being among the Yup'ik of the Yukon-Kuskokwim Delta: the role of enculturation and acculturation.

OBJECTIVES: To report on the relationships between cultural identity and stress, coping, and psychological well-being in Yup'ik communities. STUDY DESIGN: A quantitative self-administered questionnaire. METHODS: A health and wellness survey was completed by a total of 488 Yup'ik participants (284 women and 204 men) from 6 rural villages in the Yukon-Kuskokwim Delta region. Respondents were fairly equally distributed across an age range of 14 to 94 (mean +/- SD = 38.50 +/- 17.18). RESULTS: Participants who reported living more of a Kass'aq way of life (greater acculturation) reported experiencing greater psychosocial stress, less happiness, and greater use of drugs and alcohol to cope with stress. Participants who reported identifying more with a traditional Yup'ik way of life reported greater happiness, more frequent use of religion and spirituality to cope with stress, and less frequent use of drugs and alcohol to cope with stress. CONCLUSIONS: In conjunction with previous research, the data strongly indicates that in general, Yup'ik people in the Y-K Delta tend to associate stress and negative health outcomes with the process of acculturation, and health and healing with the process of enculturation. Research that focuses on documenting the intrinsic strengths of indigenous worldviews may contribute to positive transformations in community health.

Keeping busy: a Yup'ik/Cup'ik perspective on health and aging.

OBJECTIVES: Knowledge of cultural beliefs about health and how they influence life choices and intervention is essential in forming health policy and health promotion programs to meet the growing needs of aging minority populations. This study explores cultural beliefs and practices of health and well-being of Yup'ik/Cup'ik women in two rural villages in southwestern Alaska. STUDY DESIGN: Exploratory, descriptive qualitative study. METHODS: Interviews were conducted with 15 mid-life and older women to address two key research questions: 1) How do Yup'ik/Cup'ik women define health and wellbeing; and 2) What environmental, social, and cultural factors contribute to healthy aging? RESULTS: The women in this study define health aging within the framework of subsistence living-keeping busy, walking, eating subsistence foods, and respect for elders. These beliefs and practices promote a strong, active body and mind, vital components to healthy aging. CONCLUSIONS: While many health beliefs and practices appear very different from those current in research on aging, many commonalities and similarities emerge-concern for family, importance of physical activity and healthy diet. A significant finding of this study is that traditional Yup'ik/ Cup'ik ways of living parallel that of current research findings on what constitutes healthy aging in mainstream populations.

Sharing results from complex disease genetics studies: a community based participatory research approach.

OBJECTIVES: Dissemination of research results to communities builds capacity of the community to understand and utilize the results. The objective of this manuscript was to propose a culturally appropriate approach to disseminate complex disease genetics research findings in small Alaska Native communities. STUDY DESIGN: The Center for Alaska Native Health Research is a community-based participatory research project (CBPR) directed at understanding the interactions between genetic, nutritional and psychosocial risk factors for obesity, diabetes, and cardiovascular disease in Yup'ik Eskimos. METHODS: We have consulted with regional healthcare providers, tribal leaders, and university-, local-, and national-institutional review boards to identify potential mechanisms for sharing population-based genetics research results or progress. RESULTS: We propose a six step CBPR-approach to conducting genetics research in isolated identifiable communities. This CPBR-approach includes generating a common research question, determining community interest, recruitment, capacity building, sharing power and control, avoiding group harm, and development of culturally appropriate dissemination procedures. CONCLUSIONS: Research scientists and community members should both benefit from population-based genetics research. Although we are just beginning our discussions with regard to sharing genetics research progress and findings, we believe that it is essential move forward as co-researchers in the CBPR enterprise.

The Center for Alaska Native Health Research Study: a community-based participatory research study of obesity and chronic disease-related protective and risk factors.

OBJECTIVES: To describe the background, approach and general results of the Center for Alaska Native Health Research (CANHR) study. STUDY DESIGN: This was a cross-sectional Community-Based Participatory Research (CBPR) study with one tribal group to assess risk and protection for obesity and the risk factors related to chronic disease, diabetes and cardiovascular disease. METHODS: A combination of biological, genetic, nutritional and psychosocial measurements were taken on 922 Alaska Native participants in ten communities in Southwestern Alaska. The paper reports on data from 753 adult participants. RESULTS: The prevalence of type 2 diabetes is 3.3% in the sample population. Metabolic syndrome is significantly lower among the males and equal for females when compared with Caucasians in the NHANES III sample. Obesity among adults is now at the national average. Risk factors for chronic disease include a shift to a Westernized diet, stress, obesity and impaired fasting glucose and protective factors include high levels of polyunsaturated fatty acid dietary intake. Articles in this issue present specific results in these areas. CONCLUSIONS: The data strongly indicate that, in general, Yup'ik people in our study are metabolically healthy and that diet and life style provide a delicate combination of protective and risk factors. The results strongly indicate that solution focused research utilizing primary and secondary prevention strategies may provide evidence for how to intervene to prevent further increases of chronic diseases. Research that focuses on relating the intrinsic strengths of indigenous worldviews and practices with basic research may contribute to positive transformations in community health.

The tools to understand: community as co-researcher on culture-specific protective factors for Alaska Natives.

A collaborative research process engaging Alaska Native communities in the study of protective factors in Alaska Native sobriety and the design of a preventative intervention using its findings is described. Study 1 was discovery oriented qualitative research whose objectives were identification of protective factors and development of a heuristic model. Study 2 involved quantitative survey methods to develop and test ameasure of protective factors identified by the qualitative study. Empirical data from these studies is presented, and the role of Alaska Native co-researchers who did not possess specialist research training is described in the design and implementation of the study, interpretation of findings, and design of the intervention model and tools. Benefits that emerged from co-researcher involvement in this process, to the community and to the co-researchers themselves, are described.

Building a community-based participatory research center to investigate obesity and diabetes in Alaska Natives.

The Center for Alaska Native Health Research (CANHR) is a community-based participatory research project aimed at understanding current risk factors for obesity, diabetes, and cardiovascular disease in Alaska Natives living in Southwest Alaska. We utilize a multidisciplinary approach that includes assessment of genetic, nutritional and behavioral risk factors and their interrelationships with one another in the overall development of disease. The design of the CANHR project involved community participation in the development, implementation and interpretation of research results. We have developed a participatory research program that is designed to be culturally appropriate, relevant to community needs and interests, and respectful to our participants. This manuscript describes the organizational development of our CANHR study and the procedures employed in its progression to date.

"Tied together like a woven hat:" Protective pathways to Alaska native sobriety.

BACKGROUND: The People Awakening Project (1RO1 AA 11446-03) had two purposes, completed in Phase I and Phase II of the project. The purpose of Phase I was to complete a qualitative study; the research objective was discovery oriented with the specific aim of identification of protective and recovery factors in Alaska Native sobriety. Results were used to develop a heuristic model of protective and recovery factors, and measures based on these factors. The research objective of Phase II was to pilot these measures and provide initial validity data. METHODS: Phase I utilized a life history methodology. People Awakening interviewed a convenience sample of 101 Alaska Natives who had either recovered from alcoholism (n = 58) or never had a drinking problem (n = 43). This later group included both lifetime abstainers (LAs) and non-problem drinkers (NPs). Life histories were transcribed and analyzed using grounded theory and consensual data analytic procedures within a participatory action research framework. Analyses were utilized to generate heuristic models of protection and recovery from alcohol abuse among Alaska Natives. RESULTS: Analyses generated a heuristic model of protective factors from alcohol abuse. The resulting multilevel and multi-factorial model describes interactive and reciprocal influences of (a) individual, family, and community characteristics; (b) trauma and the individual and contextual response to trauma, (c) experimental substance use and the person's social environment; and (d) reflective processes associated with a turning point, or a life decision regarding sobriety. The importance of cultural factors mediating all these protective processes is emphasized. For NPs, the resilience process drew from personal stores of self-confidence, self-efficacy, and self-mastery that derived from ability to successfully maneuver within stressful or potentially traumatizing environments. In contrast, for many LAs, efficacy was instead described in more socially embedded terms better understood as communal mastery. One style of mastery is more associated with individualistic orientations, the other with more collectivistic. Future research is needed regarding the generalizeability of this group difference. CONCLUSIONS: Results suggest that preventative interventions should focus on intervening simultaneously at the community, family, and individual levels to build resilience and protective factors at each level. Of particular importance is the building of reflexivity along with other cognitive processes that allow the individual to think through problems and to reach a life decision to not abuse alcohol.

"It's been good, not drinking": Alaska Native narratives of lifetime sobriety.

Alcohol abuse is closely connected with so much hurt and pain in northern communities that it had to be addressed in this session. Much of what is done in the way of prevention and treatment of alcohol abuse originates from outside indigenous cultures. However, many Native people have either remained sober or become sober without ever going into a formal treatment program. Ironically, until very recently, little research effort has gone into understanding the backgrounds and attitudes of this population. "The People Awakening Project," a collaborative effort between a group of Alaska Natives interested in sobriety and the University of Alaska Fairbanks, has changed that. Although the project is not finished, this presentation provides a clear sense of how the research is being conducted, what kinds of data are emerging from it, and what some of the preliminary results look like. Chase Hensel gave the original presentation in Quebec City. Svenne Haakenson and Gerry Mohatt, who are heavily involved in the project, join him in authoring this written version.

"Oh No, We are Just Getting to Know You": The Relationship in Research with Children and Youth in Indigenous Communities.

We describe important elements in the process of engagement with tribal communities in research with children and youth and their families. We believe it helpful to understand the research relationship with tribal communities through the lens of kinship relations. This calls for re-examination of the nature of research and researcher, with important implications for the research process, design and organization, recovery from errors, and dissemination of results. Implications include a re-examination of some of our canons of research methods and research ethics, along with a willingness to address new challenges, to share control of the research process, and to be open to new conceptual perspectives, including alternative research strategies. Its repercussions hold promise for a deepening of the research relationship, and the role of researcher in the community.