Because We Love You (BeWeL): A protocol for a randomized controlled trial of two brief interventions focused on social and cultural connectedness to reduce risk for suicide and substance misuse in young Alaska Native people.

Background: Suicide among young people in Alaska Native (AN) communities was nearly unheard of through the establishment of statehood in 1959, but in the 1970s, AN suicide rates began to double every five years, with most of the increase due to suicide among 15 to 25-year-olds. From 1960-1995, the suicide rate increased by approximately 500% during this period of rapid, imposed social transition. For example, families were forced to live in settlements and children were sent to boarding schools. These disruptions increased conditions associated with suicide risk (e.g., substance use disorders, cultural disconnection), and challenged the community-level social safety net of youth protective factors that might have moderated effects of these traumas. The present study addresses the significant gap in culturally appropriate evidence-based programming to address suicide prevention among AN young people as part of aftercare. Our key research questions and methodology have been informed by AN stakeholders, and the intervention approach is Indigenous-led. Methods: Our interventions are targeted toward Alaska Native young people ages 14-24 who present with suicide attempt, ideation, or associated risk behaviors, including alcohol-related injury in the Yukon-Kuskokwim region or the Interior. In a randomized controlled trial, 14-24-year-old AN individuals will receive either BeWeL (n = 185), which comprises a 45-minute virtual cultural talk addressing family and ancestral strengths and increasing protective factors, or BeWeL plus motivational interviewing with social networks, which includes an additional 15 minutes focused on discussion of the individual's social networks (n = 185). We will evaluate intervention effects on primary outcomes of suicide-intent risk, depression, anxiety, frequency of alcohol use, and alcohol consequences. Some of our secondary outcomes include individual and community protective factors, social networks, and awareness of connectedness. Discussion: This project has the potential to expand the range and effectiveness of suicide prevention services for AN young people and will help meet the need in Alaska to link clinical behavioral health services to AN community-based networks, and to engage local cultural resources in aftercare for individuals at risk for suicide. Findings have potential to provide practical information to advance the field of suicide prevention and enhance protective factors and resiliency among this population. Trial registration: ClinicalTrials.gov Identifier: NCT05360888.

Centering Community Strengths and Resisting Structural Racism to Prevent Youth Suicide: Learning from American Indian and Alaska Native Communities.

The persistence of extreme suicide disparities in American Indian and Alaska Native (AI/AN) youth signals a severe health inequity with distinct associations to a colonial experience of historical and on-going cultural, social, economic, and political oppression. To address this complex issue, we describe three AI/AN suicide prevention efforts that illustrate how strengths-based community interventions across the prevention spectrum can buffer suicide risk factors associated with structural racism. Developed and implemented in collaboration with tribal partners using participatory methods, the strategies include universal, selective, and indicated prevention elements. Their aim is to enhance systems within communities, institutions, and families by emphasizing supportive relationships, cultural values and practices, and community priorities and preferences. These efforts deploy collaborative, local approaches, that center on the importance of tribal sovereignty and self-determination, disrupting the unequal power distribution inherent in mainstream approaches to suicide prevention. The examples emphasize the centrality of Indigenous intellectual traditions in the co-creation of healthy developmental pathways for AI/AN young people. A central component across all three programs is a deep commitment to an interdependent or collective orientation, in contrast to an individual-based mental health suicide prevention model. This commitment offers novel directions for the entire field of suicide prevention and responds to calls for multilevel, community-driven public health strategies to address the complexity of suicide. Although our focus is on the social determinants of health in AI/AN communities, strategies to address the structural violence of racism as a risk factor in suicide have broad implications for all suicide prevention programming.

Structural violence of racism and colonization are social determinants of suicide.Collaborative and power-sharing implementation strategies can disrupt oppression.Strengths-based collectivist strategies can buffer structural suicide risk.

Supporting Traditional Foodways Knowledge and Practices in Alaska Native Communities: The Elders Mentoring Elders Camp.

The transmission of generational knowledge in Alaska Native communities has been disrupted by colonization and led to declining health among Alaska Natives, as evidenced by the loss of knowledge regarding traditional foods and foodways and increasing rates of cardiometabolic disorders impacting Alaska Natives. Elders play a central role in passing down this generational knowledge, but emerging Elders may have difficulty in stepping into their roles as Elders due to the rapid social and cultural changes impacting their communities. The Center for Alaska Native Health Research (CANHR) and the Denakkanaaga Elders Program are partnering with the Center for Indigenous Innovation and Health Equity to uplift and support traditional food knowledge and practices to promote health in Alaska Native communities. Guided by a decolonizing and Indigenizing framework, researchers at CANHR are working with Athabascan Elders in the Interior of Alaska to strengthen and protect the intergenerational transmission of cultural knowledge and practices for emerging Elders. This community-academic partnership will implement and evaluate an Elders Mentoring Elders Camp to focus on repairing and nurturing relationships through the practice and preservation of cultural knowledge and practices, including traditional foodways. This initiative contributes to the intergenerational transmission of knowledge, which is necessary to keep culture alive and thriving.

Culturally grounded strategies for suicide and alcohol risk prevention delivered by rural Alaska Native communities: A dynamic wait-listed design evaluation of the Qungasvik intervention.

We examined the effectiveness of the Qungasvik (Tools for Life) intervention in enhancing protective factors as a universal suicide and alcohol prevention strategy for young people ages 12-18 living in highly affected rural Alaska Native communities. Four communities were assigned to immediate intervention or to a dynamic wait list. Outcomes were analyzed for 239 young people at four time points over two years of community intervention. Outcomes assessed two ultimate variable protective factors buffering suicide and alcohol risk, and three intermediate variable protective factors at the individual, family, and community level. Dose dependent intervention effects were associated with growth in ultimate but not intermediate variables. This evaluation of the Qungasvik intervention provides support for the effectiveness of its Indigenous strategies for suicide and alcohol misuse prevention in this rural Alaska Native setting. Though findings did not provide support for a theory of change where growth in ultimate variables is occasioned through effects on intermediate variables, research designs focused on young people who enter intervention at lower levels of preexisting protection hold promise for better understanding of intervention change processes. The Qungasvik intervention is responsive to an acute public health need for effective rural Alaska Native suicide and alcohol risk prevention strategies.

Protective Factors as a Unifying Framework for Strength-Based Intervention and Culturally Responsive American Indian and Alaska Native Suicide Prevention.

The ongoing challenge of American Indian and Alaska Native (AIAN) youth suicide is a public health crisis of relatively recent historical origin inadequately addressed by contemporary prevention science. A promising development in AIAN suicide prevention highlights the role of protective factors. A protective factor framework adopts a social ecological perspective and community-level intervention paradigm. Emphasis on protection highlights strength-based AIAN cultural strategies in prevention of youth suicide. Attention to multiple intersecting levels incorporates strategies promoting community as well as individual resilience processes, seeking to influence larger contexts as well as individuals within them. This approach expands the scope of suicide prevention strategies beyond the individual level and tertiary prevention strategies. Interventions that focus on mechanisms of protection offer a rigorous, replicable, and complementary prevention science alternative to risk reduction approaches. This selected review critically examines recent AIAN protective factor suicide prevention science. One aim is to clarify key concepts including protection, resilience, and cultural continuity. A broader aim is to describe the evolution of this promising new framework for conducting primary research about AIAN suicide, and for designing and testing more effective intervention. Recommendations emphasize focus on mechanisms, multilevel interactions, more precise use of theory and terms, implications for new intervention development, alertness to unanticipated impacts, and culture as fundamental in a protective factors framework for AIAN suicide prevention. A protective factor framework holds significant potential for advancing AIAN suicide prevention and for work with other culturally distinct suicide disparity groups, with broad implications for other areas of prevention science.

Strengths-Based Assessment for Suicide Prevention: Reasons for Life as a Protective Factor From Yup'ik Alaska Native Youth Suicide.

Suicide is the second leading cause of death among American Indian and Alaska Native youth, and within the Alaska Native youth subpopulation, the leading cause of death. In response to this public health crisis, American Indian and Alaska Native communities have created strategies to protect their young people by building resilience using localized Indigenous well-being frameworks and cultural strengths. These approaches to suicide prevention emphasize promotion of protective factors over risk reduction. A measure of culturally based protective factors from suicide risk has potential to assess outcomes from these strengths-based, culturally grounded suicide prevention efforts, and can potentially address several substantive concerns regarding direct assessment of suicide risk. We report on the Reasons for Life (RFL) scale, a measure of protective factors from suicide, testing psychometric properties including internal structure with 302 rural Alaska Native Yup'ik youth. Confirmatory factor analyses revealed the RFL is best described through three distinct first-order factors organized under one higher second-order factor. Item response theory analyses identified 11 satisfactorily functioning items. The RFL correlates with other measures of more general protective factors. Implications of these findings are described, including generalizability to other American Indian and Alaska Native, other Indigenous, and other culturally distinct suicide disparities groups.

Health Disparities Research with American Indian Communities: The Importance of Trust and Transparency.

American Indian and Alaska Native (AI/AN) communities experience notable health disparities associated with substance use, including disproportionate rates of accidents/injuries, diabetes, liver disease, suicide, and substance use disorders. Effective treatments for substance use are needed to improve health equity for AI/AN communities. However, an unfortunate history of unethical and stigmatizing research has engendered distrust and reluctance to participate in research among many Native communities. In recent years, researchers have made progress toward engaging in ethical health disparities research by using a community-based participatory research (CBPR) framework to work in close partnership with community members throughout the research process. In this methodological process paper, we discuss the collaborative development of a quantitative survey aimed at understanding risk and protective factors for substance use among a sample of tribal members residing on a rural AI reservation with numerous systems-level barriers to recovery and limited access to treatment. By using a CBPR approach and prioritizing trust and transparency with community partners and participants, we were able to successfully recruit our target sample and collect quality data from nearly 200 tribal members who self-identified as having a substance use problem. Strategies for enhancing buy-in and recruiting a community sample are discussed.

Global goals and suicide prevention in the Circumpolar North.

The purpose of this selective narrative review is to provide an overview of suicide and suicide prevention in the Circumpolar North and the relevance of global strategies and policies to these themes. We conducted a selective review of the English language literature on Arctic Indigenous mental health, suicide, and suicide prevention. We briefly present the social context, epidemiology, and risk and protective factors for suicide in the Arctic, with a focus on Indigenous peoples. We highlight a recent collaborative, intergovernmental response to elevated suicide rates in this region, the Reducing the Incidence of Suicide in Indigenous Groups - Strengths United through Networks Initiative, which used a consensus methodology to identify key outcomes for evaluating suicide prevention interventions in the circumpolar context. In relation to the Sustainable Development Goals, we examine recent policy developments in Indigenous-led suicide prevention and identify opportunities for strengthening policy, community interventions, and research. Globally, suicide prevention is a public health priority, and reducing the number of suicide deaths is a key target for sustainable development. Although overall and country-specific suicide rates have decreased since 1990, there remains wide variation at the regional and local level. This is particularly evident in the Arctic region known as the Circumpolar North, where Indigenous peoples experience marked disparities in suicide risk and suicide deaths compared to non-Indigenous populations. The factors that influence these variations are complex and often rooted in the social and economic consequences of colonization. The integration of science, community-based and Indigenous knowledge, and policies that address upstream risks for suicide will play an important role in suicide prevention alongside the growing number of Indigenous suicide prevention strategies tailored for specific populations.

The Development of a Measure of Alaska Native Community Resilience Factors through Knowledge Co-production.

BACKGROUND: The Alaska Native Community Resilience Study (ANCRS) is the central research project of the Alaska Native Collaborative Hub for Research on Resilience (ANCHRR), one of three American Indian and Alaska Native (AIAN) suicide prevention hubs funded by the National Institute of Mental Health. OBJECTIVE: This paper describes the development of a structured interview to identify and measure community-level protective factors that may reduce suicide risk among youth in rural Alaska Native communities. METHODS: Multilevel, iterative collaborative processes resulted in: a) expanded and refined constructs of community-level protection, b) clearer and broadly relevant item wording, c) respectful data collection procedures, and d) Alaska Native people from rural Alaska as primary knowledge-gathering interviewers. LESSONS LEARNED: Moving beyond engagement to knowledge co-production in Alaska Native research requires flexibility, shared decision-making and commitment to diverse knowledge systems; this can result in culturally attuned methods, greater tool validity, new ways to understand complex issues and innovations that support community health.

Growing from Our Roots: Strategies for Developing Culturally Grounded Health Promotion Interventions in American Indian, Alaska Native, and Native Hawaiian Communities.

Given the paucity of empirically based health promotion interventions designed by and for American Indian, Alaska Native, and Native Hawaiian (i.e., Native) communities, researchers and partnering communities have had to rely on the adaptation of evidence-based interventions (EBIs) designed for non-Native populations, a decidedly sub-optimal approach. Native communities have called for development of Indigenous health promotion programs in which their cultural worldviews and protocols are prioritized in the design, development, testing, and implementation. There is limited information regarding how Native communities and scholars have successfully collaborated to design and implement culturally based prevention efforts "from the ground up." Drawing on five diverse community-based Native health intervention studies, we describe strategies for designing and implementing culturally grounded models of health promotion developed in partnership with Native communities. Additionally, we highlight indigenist worldviews and protocols that undergird Native health interventions with an emphasis on the incorporation of (1) original instructions, (2) relational restoration, (3) narrative-[em]bodied transformation, and (4) indigenist community-based participatory research (ICBPR) processes. Finally, we demonstrate how culturally grounded interventions can improve population health when they prioritize local Indigenous knowledge and health-positive messages for individual to multi-level community interventions.

Promising Practices for Promoting Health Equity Through Rigorous Intervention Science with Indigenous Communities.

Research in indigenous communities is at the forefront of innovation currently influencing several new perspectives in engaged intervention science. This is innovation born of necessity, involving efforts to create health equity complicated by a history of distrust of research. Immense diversity across indigenous cultures, accompanied by variation in associated explanatory models, health beliefs, and health behaviors, along with divergent structural inequities add further complexity to this challenge. The aim of this Supplemental Issue on Promoting Health Equity through Rigorous, Culturally Informed Intervention Science: Innovations with Indigenous Populations in the United States is to highlight the promising new approaches and perspectives implemented by a group of engaged researchers and their community partners, as they seek to move intervention research forward within indigenous communities. Case studies presented are from projects led by members of the National Institutes of Health Intervention Research to Improve Native American Health (IRINAH) consortioum, investigators who conduct health promotion and disease prevention research among American Indians, Alaska Natives, and Native Hawaiians. The promising practices profiled include new strategies in (a) community partnerships, engagement, and capacity building; (b) integration of indigenous and academic perspectives; (c) alignment of interventions with indigenous cultural values and practices; and (d) implementation and evaluation of multilevel interventions responsive to complex cultural contexts. The IRINAH projects illustrate the evolution of an intervention science responsive to the needs, realities, and promise of indigenous communities, with application to health research among other culturally distinct health inequity groups.

An Intervention Science to Advance Underrepresented Perspectives and Indigenous Self-Determination in Health.

This concluding article to the Supplemental Issue on Promoting Health Equity through Rigorous, Culturally Informed Intervention Science: Innovations with Indigenous Populations in the United States draws themes and conclusions from the innovative practices implemented by the National Institutes of Health Intervention Research to Improve Native American Health (IRINAH) consortium. The IRINAH work highlights promising practices for advancing the diverse and underrepresented perspectives essential to develop and test culturally appropriate, effective health interventions in American Indian, Alaska Native, and Native Hawaiian settings. Four emergent themes appear through the IRINAH work. First, community-based participatory research (CBPR) has provided projects an intersectional worldview for bridging cultures and informing an ethics of local control. Second, culture is fundamental as a central organizing principle in IRINAH research and intervention implementation. Third, crucial demands for sustainability of interventions in Indigenous intervention science require a rethinking of the intervention development process. Finally, tensions persist in Indigenous health research, even as significant strides are made in the field. These themes collectively inform an ethical and rigorous Indigenous intervention science. Collectively, they suggest a roadmap for advancing Indigenous perspectives and self-determination in health intervention research. IRINAH studies are leading innovation in intervention science by advancing applications of CBPR in intervention science, promoting new directions in small populations health research, and demonstrating value of participatory team science.

Substance Use Research with Indigenous Communities: Exploring and Extending Foundational Principles of Community Psychology.

Many Indigenous communities are concerned with substance use (SU) problems and eager to advance effective solutions for their prevention and treatment. Yet these communities also are concerned about the perpetuation of colonizing, disorder-focused, stigmatizing approaches to mental health, and social narratives related to SU problems. Foundational principles of community psychology-ecological perspectives, empowerment, sociocultural competence, community inclusion and partnership, and reflective practice-provide useful frameworks for informing ethical community-based research pertaining to SU problems conducted with and by Indigenous communities. These principles are explored and extended for Indigenous community contexts through themes generated from seven collaborative studies focused on understanding, preventing, and treating SU problems. These studies are generated from research teams working with Indigenous communities across the United States and Canada-inclusive of urban, rural, and reservation/reserve populations as well as adult and youth participants. Shared themes indicate that Indigenous SU research reflects community psychology principles, as an outgrowth of research agendas and processes that are increasingly guided by Indigenous communities. At the same time, this research challenges these principles in important ways pertaining to Indigenous-settler relations and Indigenous-specific considerations. We discuss these challenges and recommend greater synergy between community psychology and Indigenous research.

With a Spirit that Understands: Reflections on a Long-term Community Science Initiative to End Suicide in Alaska.

This retrospective analysis of a long-term community-based participatory research (CBPR) process spans over two decades of work with Alaska Native communities. A call to action from Alaska Native leadership to create more effective strategies to prevent and treat youth suicide and alcohol misuse risk initiated a response from university researchers. This CBPR process transformed into a collaborative effort to indigenously drive and develop solutions through research. The People Awakening project started our team on this translational and transformational pathway through community intervention science in the Central Yup'ik region of Alaska. We examine more deeply the major episodes and their successes and struggles in maintaining a long-term research relationship between university researchers and members of Yup'ik Alaska Native communities. We explore ways that our CBPR relationship has involved negotiation and engagement with power and praxis, to deepen and focus attention to knowledge systems and relational elements. This paper examines these deeper, transformative elements of our CBPR relationship that spans histories, cultures, and systems. Our discussion shares vignettes from academic and community perspectives to describe process in a unique collaboration, reaching to sometimes touch upon rare ground in emotions, tensions, and triumphs over the course of a dozen grants and twice as many years. We conclude by noting how there are points where, in a long-term CBPR relationship, transition out of emergence into coalescing and transformation can occur.

The qasgiq model as an indigenous intervention: Using the cultural logic of contexts to build protective factors for Alaska Native suicide and alcohol misuse prevention.

OBJECTIVES: The foundational role culture and Indigenous knowledge (IK) occupy within community intervention in American Indian and Alaska Native (AIAN) communities is explored. To do this, we define community or complex interventions, then critically examine ways culture is translated into health interventions addressing AIAN disparities in existing programs and research initiatives. We then describe an Indigenous intervention based in the cultural logic of its contexts, as developed by Alaska Native communities. Yup'ik coauthors and knowledge keepers provided their critical and theoretical perspectives and understandings to the overall narrative, constructing from their IK system an argument that culture is prevention. CONCLUSIONS: The intervention, the Qungasvik (phonetic: koo ngaz vik; "tools for life") intervention, is organized and delivered through a Yup'ik Alaska Native process the communities term qasgiq (phonetic: kuz gik; "communal house"). We describe a theory of change framework built around the qasgiq model and explore ways this Indigenous intervention mobilizes aspects of traditional Yup'ik cultural logic to deliver strengths-based interventions for Yup'ik youth. This framework encompasses both an IK theory-driven intervention implementation schema and an IK approach to knowledge production. This intervention and its framework provide a set of recommendations to guide researchers and Indigenous communities who seek to create Indigenously informed and locally sustainable strategies for the promotion of health and well-being. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

RISING SUN: Prioritized Outcomes for Suicide Prevention in the Arctic.

The Arctic Council, a collaborative forum among governments and Arctic communities, has highlighted the problem of suicide and potential solutions. The mental health initiative during the United States chairmanship, Reducing the Incidence of Suicide in Indigenous Groups: Strengths United Through Networks (RISING SUN), used a Delphi methodology complemented by face-to-face stakeholder discussions to identify outcomes to evaluate suicide prevention interventions. RISING SUN underscored that multilevel suicide prevention initiatives require mobilizing resources and enacting policies that promote the capacity for wellness, for example, by reducing adverse childhood experiences, increasing social equity, and mitigating the effects of colonization and poverty.

"We Raise our Grandchildren as our Own:" Alaska Native Grandparents Raising Grandchildren in Southwest Alaska.

This study explores continuity and change in the roles of rural Alaska Native grandparents, describing their importance in contemporary Yup'ik social life and structure. The study is distinctive in its focus on the experiences of Yup'ik grandparents who are primary caregivers raising their grandchildren in Southwest Alaska. Qualitative data were gathered using a semi-structured interview from 20 Yup'ik grandparents, ages 46 to 95, who raised their grandchildren as the primary caregiver for at least one year. Content analysis was used to establish a culturally grounded understanding of the role of a grandparent raising grandchildren and meanings of these roles to Yup'ik grandparents. Findings reveal areas of continuity and change in the role and place of grandparents in Yup'ik families and communities. Important continuities persist in the role of Yup'ik grandparents, who continue to be a vital resource within their families and communities. As in the past, the grandparent role is essential in passing down cultural knowledge, upholding traditional Yup'ik values and teachings, and facilitating development of a strong and healthy cultural identity among youth. However, significant change has taken place within Yup'ik communities as a result of Western colonization. Grandparent roles are also shifting and expanding as a result of these changes, as part of an adaptive community response to ensure the safety and well-being of youth during times of great change and disruption.

Multi-Level Cultural Intervention for the Prevention of Suicide and Alcohol Use Risk with Alaska Native Youth: a Nonrandomized Comparison of Treatment Intensity.

Suicide and alcohol use disorders are primary determinants of health disparity among Alaska Native people in contrast to the US general population. Qungasvik, a Yup'ik word for toolbox, is a strengths-based, multi-level, community/cultural intervention for rural Yup'ik youth ages 12-18. The intervention uses "culture as intervention" to promote reasons for life and sobriety in young people using local expertise, high levels of community direction, and community based staff. The intervention is grounded in local practices and adaptive to local cultural differences distinctive to rural Yup'ik communities. The current study compares the effectiveness of high-intensity intervention in one community (treatment), operationalized as a high number of intervention activities, or modules, implemented and attended by youth, contrasted to a lower intensity intervention in a second community (comparison) that implemented fewer modules. A Yup'ik Indigenous theory of change developed through previous qualitative and quantitative work guides intervention. In the model, direct intervention effects on proximal or intermediate variables constituting protective factors at the individual, family, community, and peer influences levels lead to later change on the ultimate prevention outcome variables of Reasons for Life protective from suicide risk and Reflective Processes about alcohol use consequences protective from alcohol risk. Mixed effects regression models contrasted treatment and comparison arms, and identified significant intervention effects on Reasons for Life (d = 0.27, p < .05) but not Reflective Processes.

Native Transformations in the Pacific Northwest: A strength-based model of protection against substance use disorder.

This paper presents findings from the Native Transformations Project, an exploratory community-based participatory research study that aims to identify sources of strength and protection against substance use disorder in three tribal communities in the coastal Pacific Northwest. Preliminary results from the study describe the specific settings, acts, and behaviors that build strengths and provide protection at the family, community, individual, and spiritual levels within coastal Pacific Northwest local tribal cultures. Findings from this study give voice to stated community preferences for grassroots Native intervention programs based in local cultural knowledge, worldviews, values, and theories of change, that operate at the local level on their own terms.