Inspiring hope through sources of strength among predominantly Pacific Islander communities

Abstract

Suicide death rates for Indigenous Hawaiians and other Pacific Islanders are amongst the highest in the world for youth, taking a tremendous toll on local communities (Else et al., 2007; Goebert, 2014). Comprehension of community perspectives of suicide and well-being can enhance suicide prevention interventions. This community-initiated project aimed to culturally adapt the components of an evidence-based youth suicide prevention intervention and refine the intervention methodology to align with these adaptations. Formative qualitative work was conducted with community members to obtain information on community strengths and program fit. Narrative analyses were emergent and emphasized components for suicide prevention, incorporating cultural auditing to ensure information reflected group views. Participants highlighted cultural aspects pertaining to the program philosophy, the importance of cultural protocol, local innovation in suicide prevention, and culturally grounded advancements that give back to their community. This insight was applied to two adjacent but distinct communities to integrate suicide prevention in a sustainable way by culturally adapting the program. Effective suicide prevention for rural and Indigenous youth requires a broad-based community commitment, connection, and network.

Introduction

Rates of Suicidality Among Youth

Suicide death rates for Indigenous peoples have been increasing for over a hundred years and are now among the highest in the world for youth, taking a tremendous toll on local communities (Else et al., 2007; Goebert, 2014). Over the last few decades, suicide death rates in Hawai‘i and the U.S. have significantly increased, particularly among Indigenous groups (D. Galams, presentation to Prevent Suicide Hawai‘i Task Force, February 18, 2021; Curtin et al., 2016). Native Hawaiian and other Pacific Islander adolescents self-report among the highest rates of suicide-related behaviors, including depression, suicide ideation, planning, attempts, and attempts requiring medical attention (Matsu et al., 2013; Subica & Wu, 2018; Wong et al., 2012), In 1999, Native Hawaiian and Other Pacific Islanders in Hawa‘i were 1.8 times more likely to attempt suicide than White students (14.4% vs. 8.0%); in 2009, they were 3.1 times more likely (23.3% vs. 7.4%); and in 2019, they were 1.5 times more likely (12.2% vs. 8.0%; CDC, 2020). For every life lost to suicide, approximately 135 individuals are affected (Cerel et al., 2018).

Risk and Protective Factors

Risk factors associated with youth suicide in Hawai‘i include previous attempts, sexual minority identification, anxiety and depressive symptoms, substance use, incarceration, foster care, death of a parent, violence, and historical trauma (Goebert & Sugimoto-Matsuda, 2017). Native Hawaiians and other Pacific Islander youth report more risks than their non-Indigenous counterparts, yet most youth do not develop suicidality or other behavioral problems (Carlton et al., 2006; Hishinuma et al., 2017; Goebert & Sugimoto-Matsuda, 2017). Native Hawaiian youth demonstrate resilience and have a strong sense of community and hope for the future. Efforts to assess protective factors and foster a strength-based approach to prevention and intervention are expanding. Several protective factors have been identified for preventing suicidality, including family and community connectedness (Antonio et al, 2020; Else et al., 2007; Goebert et al., 2018; Medeiros & Tibbetts, 2008; Yahata & Kaninau, 2009). Additionally, schools can foster a positive climate to enhance the collective sense of connection and care (Goebert et al., 2010).

Integrated, Multi-Faceted Suicide Prevention Strategies

Suicide is affected by diverse factors at multiple levels of influence, so suicide prevention interventions benefit from combining various approaches. Communities that implement gatekeeper training experience fewer suicide deaths among youth ages 10 to 24 years than matched controls (1.33 fewer deaths per 100,000; Walrath et al., 2015). Furthermore, communities that implement integrative suicide prevention strategies such as gatekeeper training, awareness, screening activities, improved community partnerships, and linkages to services are more likely to demonstrate lower suicide attempt rates among youth than comparison communities (4.9 fewer attempts per 1,000 youth; Godoy et al., 2015). Research among local community members engaged in youth suicide prevention showed that youth-led suicide prevention programs enhance youth participation and lead to improved self-concept, connectedness, and improved mental health and wellness (Antonio et al., 2020). Comprehension of local and Indigenous perspectives of suicide and well-being enhances the ability to develop better suicide prevention programs and services (Goebert et al., 2018).

Cultural Adaption

Several studies have found that adapting interventions for specific populations can increase their effectiveness. Cultural adaption is a promising approach for programs with Native Hawaiian youth (Hishinuma et al., 2009; Manaseri et al., 2014; Withy et al., 2007). Sorenson (2018) identified several ways to culturally adapted mental health interventions. Value adaptions included fostering a positive Indigenous identity, supporting multigenerational families, and integrating traditional practices. Approach adaptions included using metaphor and stories that encompass spiritual beliefs. Surface adaptions included changing the language to simplify the jargon, using local terms, changing visuals for cultural congruence, and removing problematic western elements. These findings align with local suicide prevention efforts, Hawai‘i’s youth suicide prevention programs have been adapted to meet community and cultural needs, emphasizing the importance of honoring community knowledge and prioritizing relationships (Chung-Do, et al., 2014; Chung-Do et al., 2016; Goebert et al., 2018).

Study Purpose

For cultural adaption to be successful, there must be a balance between fidelity for evidence-based and culturally-informed aspects of the intervention. By integrating community wisdom and best practices, youth suicide prevention efforts mitigate health disparities and improve Indigenous youth and their communities’ well-being. Our project aimed to culturally-adapt the components of an evidence-based youth suicide prevention intervention, Sources of Strength (LoMurray, 2005; Wyman et al., 2010). We provide insights into a complex phenomenon and adaptation using illustrations. Ultimately, this will help inform ways to improve program delivery to underserved populations and reduce health disparities.

Methods

Environment

This project was implemented through a large, remote, federally qualified health center, the Waianae Coast Comprehensive Health Center (WCCHC). WCCHC has three school-based satellite clinics in two adjacent communities. The health center serves two underserved communities, Wai‘anae and Nānākuli, home to approximately 43,500 residents. These communities have large numbers of Native Hawaiian families and a growing number of Pacific Island migrants. Over 51% of the residents of Wai‘anae (population approximately 31.8K) and 85% of the residents of Nānākuli (population approximately 12.7K) are Native Hawaiian or of mixed Native Hawaiian ancestry (U.S. Census, 2019). Both communities have centralized town centers with public schools, a few grocery stores, as well as many fast-food restaurants and convenience stores. Many community members live in single-family dwellings with large extended, multigenerational families.

WCCHC is an ideal venue to offer this intervention. This health center has a long history of community research that stems back to 1985. WCCHC, in collaboration with community members and health center staff, developed community-engaged research principles and guidelines to frame the research process within the community and at WCCHC (DeCambra et al., 1992). WCCHC fosters and supports community researchers, especially Native Hawaiian community members and WCCHC’s healthcare providers, who understand the strengths and challenges of the community and its residents.

In 2009, the WCCHC held a strategic planning meeting to look at research needs and priorities for the next five years. It was determined that a community assessment was needed identify community research priorities that WCCHC should address. The Youth Wellness survey was developed and conducted by graduate public health students from University of Hawai‘i (UH) and staff from the WCCHC. Youth prioritized concerns about relationship issues, stress management, and depression. The teens also selected from a list of items that they felt helped them become healthy and successful. Top ten selections included supportive family and friends, knowing how to deal with stress, and a good self-image. In 2011, WCCHC partnered with the UH to bring suicide prevention gatekeeper training to its providers in behavioral health, pediatrics, women’s health, and emergency care. Furthermore, a focus group study among local community members engaged in youth suicide prevention showed that youth-led suicide prevention programs enhance youth participation, lead to improved self-concept, connectedness, and improved mental health and wellness (Chung-Do et al., 2014). Programs must include processes that allow the thoughts, beliefs, values, and relationships as expressed in actions, words, and the intricacies of the way we live. These findings indicate that effective suicide prevention program require sufficient time to form meaningful relationships to access, exchange and transform understanding and action among program participants. This information helped to establish the guidelines for selecting an evidence-based program for local implementation, required by most funding streams.

In the year preceding program selection, the communities experienced multiple suicide deaths and attempts among their youth. In response, several community meetings, adult suicide prevention gatekeeper trainings, and a community suicide prevention task force was formed. The community was poised to work towards adapting and implementing youth suicide prevention programs.

Community Partners

The community reached out to WCCHC and UH to help address rising concerns about youth suicide. The first three authors served as the program leads—Malia Agustin, a Native Hawaiian with roots in Nānākuli and health educator with WCCHC, Blane K. Garcia-a Native Hawaiian with roots in Wai‘anae and health educator with WCCHC, and Deborah Goebert-a life-long resident of Hawai‘i and professor who maintains a long-term partnership with WCCHC, The other authors, trainees with ties to Hawai‘i, assisted with project implementation and evaluation. Our community partners provided early feedback and guidance into gatekeeper and primary prevention approaches. We met with the WCCHC Community Advisory Group and the Wai‘anae Prevent Suicide Taskforce members and partners. The WCCHC Community Advisory Group is comprised of ten individuals of various professional, and Indigenous backgrounds with indepth generational knowledge of their community and its diverse residents, community needs, and cultural protocols. In response to recent deaths, the Wai‘anae Prevent Suicide Taskforce was established to bring together members of the community to address concerns, learn and grow as gatekeepers, share aloha, help families heal, provide hope, and pass life forward with suicide prevention. Additionally, several concerned community members attended meetings regularly as supportive adults including community leaders, parents, grandparents, other relatives, and school personnel.

Participants

All adolescents from the community were eligible to take part in the suicide prevention activities offered by the project. Community partners recruited youth in each community through their existing programs and networks to take part in the project. Efforts ensured at least 20 youth leaders were recruited from diverse sociodemographic backgrounds and representative of the different social groups. The group grew in size over the course of the program. Authors Malia Agustin, Blane K. Garcia, and Deborah Goebert served as the adult advisors for the group. Youth were asked to identify their supportive adults and they joined the program. Other members of the community that had heard about the program also came to sessions. Adult participants included family members (parents, aunties, uncles), school staff, and community leaders. Some supportive adults attended most sessions, while others attended periodically.

Approach

Using an iterative process, we conducted intervention mapping to culturally align the Building Strengths and Inspiring Hope Project with Sources of Strength by meeting with key informants in the community (Bartholomew el al., 2006). Intervention mapping entails 1) involvement; 2) needs assessment, 3) specifying program objectives, 4) selecting intervention strategies, 5) designing and organizing the program, 6) specifying adoption and implementation plans, and 6) generating an evaluation plan. This study also used a naturalistic inquiry to understand the particularities of a phenomenon from the perspective of those involved (Lincoln & Guba, 1985) using qualitative methods. This was built into the program by allowing reflection on the material, session engagement, depth of conversation, and. A safe space was created to share about aspects of the program participants liked, those that needed improvement, and those that did not resonate. The emphasis on talking in the group and creating awareness materials allowed us to understand the meaning behind the words and images. Our study explored the sources of strength among youth and their supportive adults from two adjacent communities.

Building Strengths and Inspiring Hope through Sources of Strength Program

Comprehensive and integrated approaches have been shown to be more effective in addressing youth suicide prevention. Many suicide prevention programs employ gatekeeper training strategies which educate natural helpers to recognize warning signs for suicide and know how to respond appropriately. Our Building Strengths and Inspiring Hope through Sources of Strength Program expanded upon the gatekeeper training strategies and develop a program that builds upon the strengths of Native Hawaiian youth and their respective communities. Our multi-faceted program included evidence-based suicide prevention approaches that builds on protective influences of peers and supportive adults and had the capacity to integrate cultural and community activities.

One of the few strengths-based programs that have been evaluated is Sources of Strength (SoS), a universal suicide prevention approach that builds on protective influences (Wyman et al., 2010). The program employs eight Strengths, or protective factors, to boost resilience in the lives of young people and better equipped they will be to navigate the natural ups and downs of life (LoMurray, 2005; Sources of Strength, 2021). This is accomplished by training youth as peer leaders and connecting them with adult advisors and other supportive adults in the community. Advisors work together with the youth leaders in producing and conducting well-defined messaging activities to recognize and build individual and community strengths, increase connectedness, and improve help seeking. It provides a framework for meetings and not a specific curriculum, though example agendas and sample awareness campaigns are available. While initially conducted and evaluated in the school setting, SoS has increasingly been implemented in community settings, SoS training improved peer leaders’ adaptive norms regarding suicide, their connectedness to adults, and their school and community engagement, with the largest gains for those entering with the least adaptive norms. The community has indicated its acceptability, mainly because it allows components to be culturally adapted and tailored. Specifically, SoS is a wellness program that focuses on suicide prevention based on a relational connections model that builds on peers, families, and mentors’ protective influences. Participants also identify and share community strengths through various messaging campaigns.

Our program provided multiple gatekeeper training sessions for youth and community members using the Connect Suicide Prevention Training Program (Baber, & Bean, 2009; Bean & Baber, 2011). Connect follows a community-based ecological model that aligns with local efforts. This gatekeeper training seeks to build community capacity to reduce the stigma and silence that surrounds the topic of suicide and aims to increase community members’ sense of responsibility by increasing knowledge and encouraging knowledge be put into action. These materials have already been culturally-adapted and allow for inclusion of localized delivery (Chung-Do et al., 2016). Additionally, we developed a protocol for handling crisis and connecting youth with necessary resources and referrals.

Analyses

Formative qualitative work was conducted with community members to obtain information on community strengths and program fit, incorporating cultural auditing to ensure information reflected group views during community meetings. While community partners supported the overall approach, they wanted more detail about the content and implementation. After attending the Sources of Strength Train-the-Trainer session, the authors Malia Agustin, Blane K. Garcia and Deborah Goebert were able to share the program with community partners and get approval to move forward. Additional feedback was received in the supportive adult trainings and the inaugural youth leader sessions. The adult advisors used this information to develop the agenda for the next session and the process was repeated. Community also participated in focus group sessions after one-year and surveys about suicidality and community connectedness at regular intervals (not reported herein). In the thematic content analysis of community drawings was based on previous literature on SoS and emphasized components for suicide prevention. Information from the posters were organized in excel.

Results

Culturally Aligned Considerations

Participants highlighted the cultural values in their suicide prevention and community work. Local suicide prevention task members have promoted their work as passing life forward, exemplifying cultural roots. The task force spoke of the importance of aloha, ola (life), connectivity, and relationships with the environment, family, and community. These values are described in Prevent Suicide Hawai‘i’s strategic plan (2018). While often overused, aloha is essential in the approach. Aloha means to love unconditionally, give without the expectation of reciprocity, and be empathie and compassionate. As stated in the strategic plan, “Aloha is the essence of relationships in which each person is important to every other person for collective existence. Aloha means to hear what is not said, to see what cannot be seen, and to know the unknowable.” By building and maintaining relationships and connectivity with aloha, we enhance resilience. The groups expressed a shared desire to give back to their community. For example, members of the community were the first to provide a call line to their lāhui (group of people) long before the state’s crisis line was established.

Community members required assurances that the project was being done by and for the community. They also expressed the need for sustainability. Members of the community have expressed ongoing interest in expanding suicide prevention efforts and partnering to find resources. This project is only one of many avenues explored and one of the few that involves research. These efforts continue through the suicide prevention task force. Previous projects have indicated that demonstrating a program works helps to secure ongoing local resources. Additionally, staff serving as the community coordinators for the project from the HC were trained as trainers in two suicide prevention programs. SoS was being adapted for the community and can continue to provide youth training--potentially as part of the health education curriculum via WCCHC’s school-based health centers or as an ongoing program.

Community partners frequently commented on the need for such a program focusing on strengths and connection. The community came together to address suicide from a strengths-based perspective and to be involved in community efforts. They expressed exhaustion over being identified as an at-risk community given their abundant strengths. For decades, they have supported strengths-based approaches to enhance existing assets, resiliency factors, and relationships in families and communities. The program name, Inspiring Hope through Sources of Strength, mission and approach resonated well with participants. In 2018, Nānākuli & Wai‘anae communities officially welcomed SoS and became the first community in the State of Hawai‘i to implement this suicide prevention program to inspire hope. Community members were honored by this distinction.

Another programmatic approach that attracted community members was the inclusion of supportive adults in all youth work. Social network images displayed in the orientation showed the interconnectedness of community, not only linking youth to youth but also linking youth with supportive adults. This multigenerational framework emphasizes the importance of relationships mirrored by community wisdom and practice. Youth often turn to their grandparents, parents, aunties, uncles and older siblings or cousins for support.

In the introduction to the SoS program, an image of a river becoming a waterfall is displayed. The classic public health parable of a witness seeing a child caught in a river current. The witness saves the child, only to rescue more drowning people. Others join in to help. After many have been rescued and several deaths, the community asks why so many are drowning. One day someone started to walk upstream to keep some people from falling in the river in the first place. This story illustrates the difference between systems that respond to emergencies and those that emphasize prevention. Participants are informed that suicide prevention effort, including local Hawai‘i efforts, has primarily focused on identifying and getting help for those thinking about suicide. Such efforts included gatekeeper trainings for those in frequent contact with others in their community, as well as, crisis phone and text lines. SoS moves all the way upstream, emphasizing primary prevention. After presenting this story to community groups, members commented that they like this illustration. They felt that sharing through storytelling created meaning. Additionally, they commented on the symbolism of wai (water) as the source of ola (life), Hawaiian culture shows deep respect and connectedness to ‘āina (land). Streams from their origins in the mountains shaped historical community boundaries and waiwai (wealth).

The Lōkahi wheel was brought up in all community forums when the SoS wheel was displayed and discussed. Community members felt that the emphasis on strengths mirrored this approach. The Lōkahi wheel was initially conceptualized by Kamehameha Schools Bishop Estate Extension Education Division in 1995. It is a circle divided into six domains representing balance, harmony, and unity for the self with the body, mind, and spirit. The term lōkahi is defined as “unity, agreement, accord, unison, harmony” (Pukui & Elbert, 1986), The Lōkahi wheel reflects that each domain must be treated with equal respect and energy to achieve the proper balance during daily life. Within these boundaries, harmony and unity can exist.

The domains of the Lōkahi wheel are kuleana (responsibility), mana‘o (mind), na‘au (emotions), kino (body), pili ‘uhane (spiritual), and ‘ohana (family). Kuleana refers to a reciprocal relationship between the person responsible and the thing they are responsible for. Kuleana also exemplifies the interconnectedness of the physical person and the environmental world. Mana’o refers to the self’s ability to think, have thoughts, ideas, beliefs, opinions, wants, desires, suggestions, and wisdom. It comes from learned experiences, knowledge passed on from ancestors, and the innate human ability to solve problems. Na‘au is the “gut” and refers to the inner feelings, mood, and affections that a person feels, e.g., “trust your gut feeling”. Native Hawaiians believed both the intellect and emotions come from the na‘au (Pukui et al., 1972). Kino refers to the body or physical self. ‘Ohana is family, including immediate family, extended family, and “adopted” family. Pili‘uhane means spiritual. It also included the emotional and spiritual links to ‘aumakua (ancestoral gods).

Strengths Posters

Two hundred seventy-nine youth and supportive adults participated in the strength poster activity during the program, with some duplication. This activity was done as the first session for the supportive adult training and the youth meetings, prior to the introduction of the SoS wheel. Youth leaders also shared this activity as part of their hō‘ike (to show or exhibit) events with family, friends, and community. The posters were anonymous containing only team names. Forty-nine teams were created with group sizes ranging from 4–8 members. Six team names (12.2%) referenced place such as Nānākuli Dreamers, Wai‘anae Strong or Rainbow Valley. Six team names contained the word mana’olana or hope; four teams included family such as ‘Ohana Sunbeams or ‘Ohana Crew, four included aloha or love, and four others included spirituality such as Amazing Grace and the Guardian Spirits.

Figure 1 displays an example of a strength poster used as data for this project. This one was done by three of the authors Malia Agustin, Blane K. Garcia and Deborah Goebert during then training. For example, the drawing of the pueo (owl) and honu (turtle) represent ancestral spirits and were coded under family and spirituality. Hula dancing was coded as family, healthy activities and spirituality. Visually, the illustrations emphasize and align with other teams/groups generated themes (i.e. - ‘ohana [family], sense of place, spirituality and ‘āina [land]). Each section of the strengths poster represents the combined strengths the authors have created and reflected on. For example, the joining of people (‘ohana), the scenery displayed (‘āina), and all the interconnectedness of ocean, plants, music, physical activity (spirituality).

Figure 1.

Strength Poster completed at Train-the-Trainer Session for Sources of Strength.

Figure 2 displays the frequencies of drawings or words in the strength posters related to each of the components of the SoS wheel. Family support was shown by 43.3% of participants and 181 drawings. The vast majority of drawings were of stick figures of different sizes, suggesting the age of children and some had gray hair to indicate grandparents. Pets were included in 28 drawings. Some were taking part in activities such as on the beach, surfing, picnicking by a tree, under a waterfall, or reading the Bible near a church. Nine posters included drawings of animals believed to be ‘aumākua (family ancestral deities). These included honu (turtle), ‘io (hawk), manō (shark), mo‘o (gecko), and pueo (owl). Some individuals wrote ‘ohana or family or spending time with family. One poster had the following written on the back of their poster: “We are watered by our friends, family, hearts, music, and talents. So many things make us… us!”

Figure 2.

Frequency of drawings or words in Strength Posters related to each of the components of the Sources of Strength Wheel by Individual Participants (N=282)

Positive friends were included by 26.9% of individuals with 79 illustrations. Most drawings indicated two or three stick figures of the same size. Some wrote friends, best or stated the names of their closest friends next to the drawing. These were used as indicators for friends. Some may have been classified as family. This is consistent with statements by both youth and supportive adults that family “are also our friends because we like to hang out together” and close friends are “the family we choose.” There were also descriptions of activities. The most common were talking, spending time, hanging out, or having fun with friends. A few showed the figures holding hands, enjoying the beach or taking walks. Mentors were the least frequently included component of the Sources of Strength Wheel (2.2%). All references were written listing mentors, teachers, or a person by name.

Healthy activities were the most frequently included component of the wheel (72.0%) with 469 items. Physical activities were common illustrations with 55 individuals illustrating sports, 46 individuals indicating ocean activities, and 23 showing outdoor activities. A variety of sports were drawn or listed including basketball, baseball, boxing, football, running or jogging, volleyball, judo, wrestling, lifting weights, and yoga. Several ocean activities were shown including bodyboarding, surfing, canoe paddling, fishing, diving, and swimming. Hiking in the mountains and walking on the beach were popular outdoor activities. Gardening and mowing the lawn were depicted as well. Fifty-one individuals displayed music including musical notes, playing ukulele, singing, musical instruments, microphone, or the word music. Twenty-five individuals showed art including drawing, painting (brush, paint and pencil), doodling, photography, crafting, and sewing. Fifteen individuals included images of hula and other dancing. Thirty-nine individuals illustrated hanging out, talking story, chillin’, cruising, driving, or camping. Food was drawn by 24 individuals with favorites like pizza, spam musubi, french fries, ice cream and candy. Eighteen individuals indicated strengths in baking, cooking or BBQing. Twenty-two individuals illustrated reading with pictures of books. An additional 10 individuals showed journaling or writing in books. Watching amine, movies or TV was depicted by 15 individuals. Thirteen individuals showed social media including memes, YouTube, and phones. Gaming was illustrated by 10 individuals including drawings of controllers or pictures/names of specific video games. Other activities listed included sleeping, robotics, babysitting, cleaning, and shopping.

Generosity was shown on 22.2% of the posters with 107 mentions. The vast majority of images for this component were of hearts to illustrate aloha and caring and ears to illustrate listening. This component was most frequently described with words including, aloha, caring, compassion, encouraging others, showing empathy, helping others, forgiveness, kindness, listening, service, volunteering, and advocating. One team wrote “It’s up to me to reach out and to give and care enough. The love in our hearts will grow stronger every day. Oh, won’t you be that light along the way.” Another poster has several phrases related to generosity including “Serving others is serving God,” “be a good listener,” and “strive to understand rather than to be understood.”

Spirituality was the second most common component of the wheel included in the posters (68.4%) with 387 illustrations. This component included three subcategories—faith (47 individuals), culture (42 individuals), and nature (42 individuals) with many individuals including drawings in all three categories. Four individuals wrote the word spirituality and two groups wrote thankful on their posters. Faith included images of crosses, churches, Bibles, and hands in prayer or the words God, Jesus, or Ke Akua (The God). Culture included images of kalo (taro), cultural patterns, , papa and pohaku (board and stone used for making poi), mele (song), hula, ‘Ōlelo Hawai‘i (Hawaiian language), ‘aumākua (family ancestrial deities), and cultural patterns/symbols (tattoo and kapa designs). The most frequent depictions of nature were the sun, mountains, ocean, trees, waterfalls, and rainbows.

Medical access was included by 4.3% of participants in 12 drawings. Five individuals wrote the word health. One individual also included the heartbeat line and one individual included fruits and vegatables. Five individuals inscribed counseling or support groups. Other depictions included a first aid bag, medical cross, medical access, and the health center.

Mental health was depicted by 27.2% of individuals with 119 illustrations. The majority contained words indicative of a positive self-image or outlook such as resilient, adaptable, good listener, big heart, honest, courage, leader, resourceful, belief in self, smart, learn from mistakes, and hard worker. Twelve indicated humor and laughter. Ten others refered to skills in reflection, meditation or mindfulness.

One novel component depicted in the posters and not on the wheel was community. Community appeared in the naming of groups, as hashtags on the poster, and in illustrations. It intersected every component of the wheel and was captured on all posters by the vast majority of the individuals in some respect. Community seemed to invoke both a sense of place and connection to people. It could be considered spiritual--a place of health and well-being. Youth and supportive adults spoke of the generosity of their communities and their kuleana (responsibility) to give back.

Program Adaptation

Each session began with a purposeful game. This was a part of the SoS agenda. It allowed youth and supportive adults to play together, building trust. It also allowed the program to start on time, even if some attendees were late. Participants especially enjoyed competitive games. The introductory game was tied to the purpose for the session, allowing for a smooth transition to the meaning for being there.

With the advice of the community, the opening protocol included an oli (chant). After considering a couple of suggestions, E Hō Mai was selected. Composed by Hawaiian cultural expert and practitioner, Edith K. Kanaka‘ole, this oli was originally performed to request knowledge and wisdom from the kupuna (ancestors) to accomplish the task at hand (Kanaka‘ole et al., 2017). Now it is mostly used to focus a group’s energy, reground and clear the minds of negativity to ultimately carry out the kuleana (responsibility) or the work for the day. The oli is repeated three times.

E hō mai ka ‘ike mai luna mai ē	Grant us the wisdom from above
‘O nā mea huna no‘eau o na mele ē	Concerning the hidden wisdom of songs, words and ideas shared
E hō mai – e hō mai – e hō mai	Grant this to us; Let us know these ideas; Grant us this knowledge

Many of the participants were already familiar with this oli and several were able to recite it without the lyrics. Participants were encouraged to remove their shoes to allow for physical contact to the ground as to root them to place. Hands are open to allow contact with those above.

Following the chant, we used the five-finger ground rules-thumb represents fun, index finder represents responsibility for self, middle finger represents respect, ring finger represents commitment to the activities and purpose, and pinky finger represents physical and emotional safety. This had been implemented in our previous suicide prevention work with youth.

SoS structures meetings into three section including one-part fun, one-part sharing, and one-part planning and creating. Surrounding one-part sharing with activities allowed participants of all learning styles to be engaged. The first activity introduced the topic in a fun way and facilitated bonding, sharing, and created meaning. This was reinforced in the second activity with a purposeful activity linked to the day’s agenda. Everyone enjoyed the activities and felt it brought renewed energy to the end of the days, setting a positive tone. Supportive adults also felt this was critical for building trust among paiticipants though positive collective experiences.

The SoS program creates safe spaces and opportunities for participants to share their stories of strength, resilience, help and hope. Each meeting devotes time for youth and adults to talk about then’ experiences, emphasizing what helped them. The strengths wheel was used as a base to build conversations. Many discussions led to peer-to-peer supportive comments and when needed was promoted by a supportive adult with a walk into the WCCHC’s school-based health clinic and a warm hand-off to the clinical psychologist who was able to meet people more regularly. Community members highlighted the importance of storytelling, specifically talkstory, historically and culturally.

Community members felt it is important to engage youth and supportive adults together in activities to make a difference. Some of these campaigns included writing positive messages on post-it-paper pertaining to each part of the wheel that others within their community could take as they chose. They practiced gratitude by passing out valentine lollipops with positive messages of hope like “You are a great friend”, “I thank God for you”, and “You inspire hope in me.” Tables were set up during class breaks where people could paint their hand, place it on a large roll of paper and once the hand print was dry they were asked to write messages of hope on their hands. Ongoing involvement in creating ways to share strength campaigns aligns with ancestral wisdom and successful local practice. As one community member reflected “Ma ka hana ka ‘ike (In working one learns; Pukui & Varez, 1983, #2088).”

The SoS program includes a brief closing to wrap up the session to remind participants to practice their strengths, and let them know about the next meeting. Additionally, in line with community practice, we included pule (prayer) at the end of our sessions. The sharing and purpose of the group often go deep and personal. Many joined the group because they were, or knew friends or family who were struggling with their mental health. The pule is used to be thankful for everyone’s presence and participation to remind the group of the purpose and preciousness of life, and to ask Ke Akua (The God) for continued guidance.

Discussion

Effective suicide prevention among Indigenous youth in Hawai‘i requires a broad-based community commitment and connection. This project was able to successfully adapt an evidence-based program, Sources of Strength (SoS). Youth, supportive adults, and other community leaders advocated for program continuation and more opportunities for community participation. They also wanted expansion to other locations across the State. WCCHC secured funding for program continuation, led by Blane K. Garcia and Malia Agustin. Deborah Goebert volunteers, attending most sessions. They received booster training for virtual implementation and continue to adapt the process.

Local and Indigenous communities have united around programs that recognize community and cultural strengths to build resilience. Indigenous models of wellness are aligned with the SoS program’s approach and its focus on the strengths wheel. The relational worldview of Native Hawaiian health and well-being is framed from an Indigenous perspective with interdependence, relationships, harmony, and balance at the center of the sphere, encircled by ancestors, culture, environment, family, community, and nation (McCubbin et al., 2010), The core of this model is connectedness. Community connectedness is the foundation for resiliency, coping skills development, and communal problem-solving among Indigenous peoples (Casey Family Programs & the Johns Hopkins Center for American Indian Health, 2021). It promotes a sense of belongingness and safety as well as shared purpose for our youth to prosper.

Our findings emphasized the interconnectedness of strengths as illustrated by ‘aumākua, the role of the environment in activities and spirituality, family outside reading the Bible, and community group names. This multi-dimensional aspect of community connection could be incorporated by adding an outer circle to the SoS wheel. In our previous work, communities shared the ‘ōlelo noe‘au (saying to express their ancestors’ wisdom): Ike aku, ‘ike mai, kokua aku kokua mai; pela iho la ka nohana ‘ohana (Recognize others (watch), be recognized (observe), help others, be helped; such is the family/community way; Pukui & Varez, 1983, #1200). Many Native Hawaiians and others living in Hawai‘i consider everyone in their community a part of their extended family. Furthermore, everyone is considered a caretaker for their community members, environment, and history. Kana‘iaupuni and Liebler (2005) documented the role place plays in weaving together physical, spiritual genealogical and social ties into practices and responsibilities. Increasing programs highlight the importance of place in nourishing well-being and encouraging youth to become change agents in their communities through connection to place (Kana‘iaupuni & Malone, 2006; Trinidad, 2011).

Our findings also suggest that the SoS wheel is similar to the Lōkahi wheel, as depicted in Figure 3, The Lōkahi wheel was designed based on a holistic worldview that the body, environment, and spiritual realm are interconnected (Kamehameha School Bishop Estate Extension Education Division, 1995). One must remember that we are never alone and must respect and maintain spiritual connectedness with nature--the ‘aina (land) and kai (ocean). It also reminds us to remain connected to and appreciate Ke Akua (the God) and ‘aumakua (ancestors). We must also maintain healthy connections with ‘ohana (family). As family members, ‘aumākua communicate loving concern for, and guidance to their descendants (Barrow, 1999; Pukui et al., 1972). Their embodiment in nature as animals (or sometimes plants or rocks) reflect the transformation of family to spirits over time and their emergence from eternity into the physical world and possessing protective powers. When ‘aumākua are seen, it can be seen as a sign to change course and be guided to safety.

Figure 3.

Components of the Sources of Strength Wheel (Sources of Strength (2021) and Lōkahi Wheel (Kamehameha Schools, 1995)

Storytelling has played an essential role in various Indigenous worlds and has persisted throughout generations. It has been explored as a culturally appropriate tool for mental health research within these populations. For at least two thousand years before western contact, stones were verbally passed down in Hawa’i (Ku‘ualoha, 2004). “Talkstory” was created by residents of Hawai‘i across multiple ethnic groups who wanted a common language in informal gatherings (Schultz et al., 2015). The use of talkstory demonstrates respect to the local culture and customs. Previous local studies have used talkstory to address primary care and prevention issues (Oneha et al., 2010; Schultz et al., 2015), Talkstory represents a means of achieving social change through collective action and empowers the individual community members.

Strengths-based suicide prevention programs such as SoS incorporate talkstory to youth and empower community members to become community leaders sharing their knowledge, experiences, wisdom, and stories. Storytelling allows the intervention to be collaborative while incorporating cultural values that are important to the community (Wexler et al., 2015). Whether it be personal stories of hope and resilience, stories can provide a framework to help people find a sense of meaning, describe how they feel, and engage one’s imagination (Jones, 2010). Storytelling can provide a bridge between program providers and communities. Appreciating these stones serves to strengthen relationships, build intergenerational bonds, and enhance resilience.

There have been several recent efforts to incorporate storytelling into promoting better mental health outcomes in Indigenous populations. For example, Beltran and Begun (2014) organized digital storytelling workshops to share historical trauma narratives within the Maori community. They found that this practice facilitated healing for youth in that it allowed them to be heard, thus offering validation to their experiences. Their experience with this modem take on storytelling was so powerful that they named it a “medicinal transformative healing tool” because it allowed the community to reclaim cultural knowledge and highlight their resiliency. The authors argue that these workshops promoted positive and healthy transformations for those involved. Similar digital storytelling efforts were also held with Alaska Native youth (Wexler et al., 2012). This project held storytelling workshops over three years to produce 500+ digital stories, combining photos, music, and voice with the intention of suicide prevention. Identified as digital “hope kits,” they became a platform for the youth to deepen their appreciation for themselves and their relationship to their culture and communities. Story telling can encourage introspection and nurtured a strengths-based approach for the youth to frame their experiences (Wexler, 2011, Wexler et al., 2013). Given that Hawaiian and Pacific Islander cultures honor storytelling, it is thought that a parallel approach with modernized storytelling could be the answer to facilitating improved mental health outcomes within this population. The strengths posters and the stories shared about the illustrations are only the beginning.

Limitations

None of the community meetings nor groups were audio recorded. Researchers had to rely on notes taken during meetings and the drawings themselves to assess cultural fit. Coding and categorizing content require a degree of subjectivity. While we followed standard content analysis procedures and used a double-coding process to check on reliability, the process yielded an exploratory versus conclusive summary of strengths. Finally, the adaptations described fit for our communities. Tailoring still needs to occur for other primarily Native Hawaiian and Pacific Islander communities.

Despite these limitations, the study provides valuable insights and a seminal point of departure for a broader rigorous systematic inquiry into adolescent suicide prevention from a cultural perspective. Integrating community wisdom into evidence-based strategies for youth suicide prevention can mitigate health disparities and improve well-being among Indigenous Hawaiian and Pacific Islander youth and their communities. Future research should examine tailoring, adaption, and culture as prevention approaches to improve well-being and decrease suicidality.