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. Author manuscript; available in PMC: 2010 Jul 1.
Published in final edited form as: J Ethn Subst Abuse. 2009 Jul 1;8(3):283. doi: 10.1080/15332640903110476

The Community Pulling Together: A Tribal Community-University Partnership Project to Reduce Substance Abuse and Promote Good Health in a Reservation Tribal Community

Lisa R Thomas 1, Dennis M Donovan 2, Robin LW Sigo 3, Lisette Austin 4, G Alan Marlatt 5
PMCID: PMC2821063  NIHMSID: NIHMS173868  PMID: 20157631

Abstract

Alcohol and drug abuse are major areas of concern for many American Indian/Alaska Native communities. Research on these problems has often been less than successful, in part because many researchers are not sensitive to the culture and traditions of the tribes and communities with which they are working. They also often fail to incorporate tribal customs, traditions, and values into the interventions developed to deal with substance abuse. We describe the use of Community-Based Participatory Research (CBPR) and Tribal Participatory Research (TPR) approaches to develop a culturally sensitive substance abuse prevention program for Native youth. This project, The Community Pulling Together: Healing of the Canoe, is a collaboration between the Suquamish Tribe and the Alcohol and Drug Abuse Institute at the University of Washington.

Keywords: American Indian, Alaska Native, Community Based Participatory Research, Tribal Participatory Research, Health Disparities, Substance Abuse, Youth


American Indian and Alaska Natives (AI/AN) people comprise less than two percent of the US population (Ogunwole, 2002), yet they continue to suffer unacceptably high and persistent health disparities. These health disparities include lack of access to effective, culturally appropriate care; poorer health outcomes; and alarmingly high rates of mental health and substance abuse problems (Beals et al., 2005; Beauvais, Jumper-Thurman, Helm, Plested, & Burnside, 2004; B. Duran et al., 2005; E. H. Hawkins, Cummins, & Marlatt, 2004; Rodenhauser, 1994; Steenhout, 2002; United States Government Accountability Office, 2005; Walters, Simoni, & Evans-Campbell, 2002).

Substance abuse, in particular, is of great concern to AI/AN communities. However, there is increasing evidence that many AI/AN's do not drink or drink moderately (May & Gossage, 2001; Mohatt, Rasmus et al., 2004; Office of Applied Studies: Substance Abuse and Mental Health Services Administration, 2007). In addition, very little is known about strengths and resources in AI/AN communities, including community-based programs, to address issues related to substance abuse (Lafromboise, Hoyt, Oliver, & Whitbeck, 2006; Mohatt, Hazel et al., 2004; Silmere & Stiffman, 2006). However, and most importantly, there is increasing evidence that prevention, intervention, and treatment programs that emerge from, and are culturally relevant to, target communities are more feasible and effective (Allen et al., 2006; Fisher & Ball, 2002; Hazel & Mohatt, 2001; Holkup, Tripp-Reimer, Salois, & Weinert, 2004; May & Moran, 1995; Whitbeck, 2006).

Research on these issues has often been less than successful, in part because of researchers who were not sensitive to the culture and traditions of the Tribes and communities with which they were working (Beals, Manson, Mitchell, & Spicer, 2003; E. Duran & Duran, 1995; Foulks, 1989; Manson, Garroutte, Goins, & Henderson, 2004; Norton & Manson, 1996; Smith, 1999; Sue & Dhindsa, 2006; Taualii, 2006; Whitbeck, 2006). Many researchers have also failed to understand Tribal sovereignty, respect the diversity of the AI/AN communities, understand specific sociopolitical and historical contexts, build on Tribal strengths and resources, or incorporate Tribal customs, traditions, and values into interventions developed to address health disparities, including substance abuse. (Burhansstipanov, Christopher, & Schumacher, 2005; Caldwell et al., 2005; Foulks, 1989; Whitbeck, 2006). Finally, it is important to point out that most evidence-based practices regarding substance abuse prevention and treatment have not been tested with urban, rural, or reservation AI/AN communities (Miranda et al., 2005; University of Washington Alcohol and Drug Abuse Institute, 2006).

Fortunately, there are two promising approaches to working with AI/AN communities to conduct scientifically sound and culturally competent research: Community Based Participatory Research (CBPR) and Tribal Participatory Research (TPR). CBPR is a research methodology in which the research institution and the community or agency are fully partnered in every aspect of the research process, from determining research questions to analyzing, interpreting, and disseminating research findings. TPR is similar in that it is a full partnership between the research institution and the AIAN community or agency and extends the collaborative agreements to issues unique to AIAN communities; both are described more thoroughly below. CBPR and TPR are particularly appropriate methodologies as they provide a mechanism for understanding the complexities of conducting scientifically sound and respectful research with Tribal communities. For example, there are more than 560 federally recognized Tribes that are geographically, culturally, historically, and sociopolitically unique. Both CBPR and TPR provide methods for conducting research that is respectful of this diversity (Caldwell et al., 2005; Christopher, 2005).

This paper will describe the use of a CBPR/TPR approach in an ongoing project funded by the National Institutes of Health's National Center on Minority Health and Health Disparities NCMHD) to develop a culturally grounded prevention program for AI/AN youth. This project, Healing of the Canoe: the Community Pulling Together, is a collaborative effort between a rural, reservation Tribe in the Pacific Northwest and the Alcohol and Drug Abuse Institute at the University of Washington. Specifically, this paper will: (a) describe essential principles of CBPR/TPR, (b) describe the Healing of the Canoe youth substance abuse prevention project, an ongoing CBPR/TPR project; (c) discuss the future of the project; and (d) describe lessons learned to date.

Principles of CBPR and TPR

Our work in developing the Healing of the Canoe: the Community Pulling Together project has been guided by a set of principles that define community-based participatory research in general and its application to AI/AN communities more specifically. First and foremost, CBPR-based research represents a full partnership between researchers and the community in which it is conducted (Viswanathan et al., 2004). Unlike much research in the past, this approach is not an imposition of academicians and their interests onto a community. Instead it is an invitation from the community to trusted researchers to enter into a research partnership. The implication is that there will be an ongoing, collaborative process that determines the proposed focus of the research, research process and data collection methodology, interpretation of the data in the context of the community's understanding of it, and joint involvement in dissemination of the findings. Furthermore, there is an equitable sharing of funding and resources between the community and researchers.

Using CBPR the researcher's focus is more responsive to issues of concern to the target community, addresses needs of the community, and takes into account the community's strengths and resources. This often requires the development and implementation of a needs and resources assessment, either to identify and prioritize community needs or to refine researcher and community understanding of the nature and scope of a previously defined concern (DeWit & Rush, 1996). Needs and resources assessments must be sensitive to the unique cultural factors of the community and its people (Okamoto, et al., 2006). Rather than focusing only on the community's “problem,” which often leads unintentionally to a pathologizing process, the needs and resources assessment builds on what is currently already “working” in the target community. This approach is consistent with approaches that take into account the risk and protective factors that exist in communities (J. D. Hawkins, Arthur, & Catalano, 1995).

Once the needs, concerns, strengths, and resources have been identified, the researcher needs to develop and use assessments and interventions that are culturally appropriate and relevant. While a goal in this process is to use available instruments with known psychometric properties and empirically-supported interventions, this is not always possible or culturally appropriate. Often measures and interventions need to be adapted to the specific needs of a project and to the traditions, culture, and values of the community. This process also applies to defining “meaningful” outcomes. What might be viewed as meaningful to the community may be quite different from what researchers might suggest based on prior evidence and/or theory which requires an ongoing balancing act between scientific rigor and empiricism on the one hand and the use of local cultural knowledge on the other (Fisher & Ball, 2005; Whitbeck, 2006). This balancing act sets up a dynamic that requires ongoing communication among all parties; CBPR is an iterative process that often involves changes in plans and methods as the project progresses, evolves, and is informed by input from the community. This communication process also leads to another important aspect of CBPR, namely that it is meant not only to provide scientific data, but also to provide information that can enhance the community's ability to more successfully reduce health disparities and promote health.

There has been considerable focus on the applicability of community-based participatory research with AI/AN communities (Burhansstipanov, Christopher, & Schumacher, 2005; Fisher & Ball, 2002, 2003, 2005; Holkup, Tripp-Reimer, Salois, & Weinert, 2004; Mail, Conner, & Conner, 2006; Shiu-Thornton, 2003; Strickland, 2006). CBPR provides a model that differs in many ways from more traditional approaches to research that have led AI/AN communities to be suspicious of, and resistant to, becoming involved with academic researchers and institutions (Burhansstipanov, Christopher, & Schumacher, 2005; Christopher, 2005). The Tribal Participatory Research approach (Fisher & Ball, 2002, 2003) embodies the general principles of CBPR and extends them into specific recommendations for doing research with AI/AN communities. In addition to the points noted above, TPR indicates that research should involve continual Tribal oversight of the process and project. This includes the development and implementation of Tribal Council resolutions to support the intended research and may include Tribal research codes to assure ethical behavior on the part of researchers, including appropriate respect of the culture, traditions, and values of the particular tribe. In fact, Tribal research codes are being developed in many Tribal communities to better protect Tribal interests (American Indian Law Center, 1999; Brugge & Missaghian, 2006; Martin-Hill & Soucy, 2005).

One method to insure Tribal oversight is to have a community advisory council with representation of all relevant segments of the community. This assures that assessments and interventions are culturally relevant and that they incorporate traditional practices and concepts. The advisory council also facilitates ongoing communication with community members. Another recommendation is that a “cultural facilitator” be used to act as an intermediary between project staff and the oversight committee and that the facilitator establish a culturally appropriate process for meetings of community members and researchers (Fisher & Ball, 2003). Such an individual serves as a “translator,” conveying research concepts to community leaders and members in a manner and language that is understandable to them and providing researchers with culturally relevant information that can be incorporated into research design and conduct. Another extremely important component of TPR is to employ community members as project staff, providing them with the requisite training to successfully contribute to the research team and represent their community in the process. Community staff can also provide an added bridge between the community and the research institution.

Burhansstipanov et al. (2005) noted that in order to work effectively with AI/AN communities it is necessary to work honestly and cooperatively, to work from the standpoint of respect, to spend time with communities in order to build trust and to gain Tribal support, and to ensure that Native communities are involved at all stages of the research process. To this list, Christopher (2005) has also added the need for Native communities to receive benefits from research, both in terms of employment of community members and of tangible outcomes from the research. Furthermore, researchers must place the needs of the community ahead of their own interests. The goal is that both science and community will benefit from the collaborative partnership that is the foundation of CBPR and TPR. The Healing of the Canoe: the Community Pulling Together is a good example of CBPR and TPR methodologies in practice.

Healing of the Canoe: the Community Pulling Together

History of the project

The Healing of the Canoe project evolved out of ongoing communication between the Suquamish Tribe and faculty and staff members at the Alcohol and Drug Abuse Institute (ADAI) of the University of Washington. The Suquamish Tribe is a federally recognized Tribe which resides on the Port Madison Indian Reservation in the rural, Puget Sound area of Washington State. The Suquamish Tribal enrollment is over eight hundred, with approximately 350 Tribal members living on the reservation.

The Suquamish Tribe is one of many Tribes in the Pacific Northwest and Alaska who participate in “Tribal Journeys.” Tribal Journeys is a multi-tribal cultural event that occurs annually on the waters of Puget Sound and British Columbia. Tribal Journeys is the outgrowth of a short yet historic journey of tribal canoes from Suquamish to Seattle known as the “Paddle to Seattle” that took place in 1989. During the celebration on the eve of the pull in Suquamish, a challenge was made by the indigenous people of Bella Bella, British Columbia, to travel to their village in 1994. After five years of preparation, numerous tribal Canoe Families traveled in their traditional canoes for weeks from their respective reservations and descended on Bella Bella for a cultural celebration lasting many days. Tribal Journeys has since become an annual event that is drug and alcohol free and based on ancestral traditions. Tribal Canoe Families are made up of youth, adults, and Elders who organize their respective expeditions with weeks of training in the canoe, intensive practice of their traditional songs and dances, and intensive training to learn the cultural protocol necessary for the Canoe Family to appropriately conduct themselves during the long journey.

The Suquamish Tribe has participated in all subsequent Tribal Journeys. In response to the success and importance of these cultural celebrations, the director of the Suquamish Tribe's Wellness Program expressed an interest in developing a culturally relevant substance abuse and mental health intervention that would use Tribal Journeys as a teaching tool that could be implemented and evaluated as a “best practice” in the community.

The discussions between the Suquamish Tribe and ADAI had been ongoing for some time when a Request for Applications (RFA) was published by the National Institutes of Health's National Center on Minority Health and Health Disparities (NCMHD) to use CBPR methods to address issues of health disparities in communities. The RFA provided an ideal mechanism to pursue the partnership between the Tribe and University members. A series of meetings were held between key members of the evolving research team. The concept of the canoe, an important traditional component of coastal Native life and a source of cultural resurgence among West Coast Salish Tribes, was seen as the cornerstone of the proposal. The canoe concept also integrated well with the Canoe Journey/Life's Journey Manual, a life skills and substance abuse prevention curriculum for use with urban Indian youth (LaMarr & Marlatt, 2005; Marlatt et al., 2003) previously developed by some members of our research team. The manual uses the Canoe Journey as a metaphor for one's journey through life and for the skills needed to successfully navigate the journey. Many of the staff at the Tribal Wellness Program expressed an interest in partnering with ADAI to create a similar, culturally based intervention in their community.

The research team sought approval from both the Tribal Council and the Suquamish Cultural Co-Op, which has responsibility for assuring that all programs introduced in the community are respectful of Tribal traditions, culture, and values. A Tribal resolution of support for the project was developed by the Suquamish Wellness Program administrator and presented to the Tribal Council, and the Tribe agreed to participate. The expectations, scope of work, and terms of the collaborative partnership between the Tribe and the University were spelled out in a Memorandum of Understanding (MOU).

Developing the MOU was a time and labor intensive process; however, it was a crucial step in developing trust, assuring Tribal involvement from the outset, gaining support of key members of the Suquamish leadership and community, and establishing a partnership in which all parties contributed equally. For example, rather than using a boilerplate MOU generated by the University of Washington, the Suquamish Tribal attorney worked closely with the project team and the Suquamish Tribal Council to insure and protect Tribal sovereignty. This was particularly evident in the negotiations related to ownership of data and rights to publish and present. The project's principal investigator worked with the University's grants office to understand these unique requirements for working with sovereign entities and for respecting CBPR guidelines. The resulting MOU protected Tribal rights to data and the Tribe's right to review and approve publications and professional presentations. Given historical abuses of these important activities, the MOU was representative of both the Tribe's and the University's commitment to work as full partners.

Our project was one of 25 CBPR projects selected for funding nationally. All of the projects were three years in duration. The first year was specifically focused on developing the partnership, establishing relationships, and determining and prioritizing health disparities and areas of concern. The remaining two years were devoted to developing and piloting an intervention(s) to address the identified areas of concern.1

Insuring project adherence to CBPR/TPR principles

As previously noted, the Healing of the Canoe project has been guided from the outset by the basic principles of CBPR and TPR. Although it is one thing to endorse such principles, it is not always easy to actualize them in practice (e.g., Burhansstipanov, et al., 2005; Christopher, 2005; Fisher & Ball, 2005; Norton & Manson, 1996; Strickland, 2006). We have attempted to operationalize these principles in a number of ways. First, as mentioned, the development of the proposal for the project emerged out of an initial invitation from the Tribe to ADAI to partner in this project and from ongoing discussions between the Tribe and University. A Tribal Council resolution, approval by the Tribe's Cultural Co-Op, and an MOU were all mutually agreed to before the proposal could be submitted. The MOU also outlined a data sharing agreement that gave both the Tribe and University researchers access to project data and specified that all results and any dissemination of findings through professional presentations, publications, or reports would first be presented to and approved by the Cultural Co-Op and Tribal Council before dissemination.

These agreements also incorporated the Tribe's continual oversight of the process and project. All materials, such as key stakeholder interview protocols, focus group questions, assessment instruments, and the intervention curriculum, are reviewed initially by the Cultural Co-Op to assure their cultural respectfulness and appropriateness. After gaining Cultural Co-op approval, project materials can then be reviewed by the University's Human Subjects Division to assure research ethics and protection of participants' safety and rights. It is important to note that if Human Subjects review indicates that revisions need to be made in any of the materials; all changes must be reviewed and approved by the Suquamish Cultural Co-op again. Clearly, project teams must be mindful about the time it may take for this iterative process.

The Cultural Co-Op also serves as the project's Community Advisory Board. This group is composed of Elders, youth, and representatives of major Tribal agencies and constituencies. Members of the research team attend the monthly Cultural Co-Op meetings and provide quarterly updates about the project to the Tribal Council. Members of the broader community are informed about the project through articles that appear in the monthly Tribal newsletter and at quarterly Community Meetings. These meetings, held in a communal setting, include an opening blessing by a Tribal Elder, a project update with a discussion and question period, and a traditional dinner. A project poster is also displayed at the annual General Council meeting, which is attended by many of the enrolled Tribal members.

Consistent with TPR, the project has hired community members as research staff. A Tribal member serves as one of the principal investigators on the grant, assuming responsibility and leadership for the activities that take place in the community. In addition, the project employs a youth Tribal member as the peer youth educator. The two other community-based staff are also AI/AN/Native Hawaiian. University and community research teams each meet independently twice per month and meet jointly every other month. The site of these joint meetings alternates between the University and the Tribal community. There have been a number of joint research staff retreats to build relationships and to facilitate team and project development. An important part of this process, consistent with recommendations by Davis and Reid (1999) and Holkup, Tripp-Reimer, Salois, and Weinert (2004) has been a cultural training process for members of the University research team. Through focused readings, videos, and other means (e.g., visit to the Suquamish Tribal museum, meetings with Tribal Elders), many of which were recommended or set up by Tribal partners, the University based research team is becoming more familiar with the traditions, values, and issues of concern to AI/AN communities in general, and the Suquamish Tribe in particular.

The project also benefits from having the recommended “cultural facilitator.” The overall project director, an Alaska Native, literally and figuratively serves as a “go between” between the University and the Suquamish community. She is a University research scientist with a background in AI/AN substance abuse and mental health issues. She also has considerable experience with AI/AN community-based research and lives very near the Suquamish reservation. She attends both community and University research team meetings as well as Cultural Co-Op meetings with members of the community research team, and over time has establish a trusted presence and working relationship with key members of the community and Tribal leadership.

Burhansstipanov et al (2005) outlined a number of “lessons learned” from conducting community-based participatory research in Indian County. These included (1) investing time to create the partnership team and project, (2) allocating the budget equitably among the partners, (3) developing partnerships with leaders who have decision-making responsibilities from each organization, (4) providing salaries to tribal partners and project staff, (5) implementing active, effective communication among all members of the partnership (including becoming aware of real barriers to communication and setting realistic expectations), (6) alternating meetings between academic and tribal settings, (7) sharing raw and summary data related to the CBPR project, (8) modifying standardized evaluation procedures to be culturally acceptable and respectful of the local community, and (9) following both tribal and researchers' protocols for disseminating and publishing the findings.

To date, the Healing of the Canoe project not only has espoused these goals, but also has been able to put them into practice in a way that has led to a functional, respectful campus-community partnership. This collaborative project between the Suquamish Tribe and ADAI will continue to address concerns of highest priority for the community. This collaboration also promises to result in the development and implementation of a culturally relevant substance abuse prevention program that uses the actual Tribal Canoe Journeys as a teaching tool and will effectively blend elements of empirically supported “best practices” with local cultural knowledge (Fisher & Ball, 2005).

Completed Project Tasks

In spite of some of the challenges and because of the collaborative nature of the project and the project teams, we have been able to complete many tasks in the first months of this project. As mentioned previously, one of the essential components in CBPR/TPR is building and nurturing a collaborative, trusting, and respectful relationship between the Tribal community and the research institution. Therefore, many of our first year tasks were oriented toward accomplishing this goal. Completed project tasks for year 1 include: hired the Suquamish research team, all of whom are AI/AN, two of whom are Suquamish Tribal members; hired UW research team, project director is AI/AN; held two community-wide meetings with the Suquamish Tribe; published project updates in the Suquamish monthly newsletter sent to all Tribal members; attended monthly Suquamish Co-Op meetings to give project updates and obtained input, guidance, and approval for project activities; provided Suquamish Tribal Council with quarterly project updates; submitted and obtained approval from the UW Human Subjects office for current project activities; established a regular cross-training program to build research skills and capacity in the Tribal community and to increase general and specific cultural competence on the part of the researchers; began the community needs and resources assessment by surveying services currently available to Tribal members; and conducted a review of current best practices for AI/AN communities.

Next steps – planned project activities

The project activities planned for the next two years of this three-year project will continue to support and nurture the collaborative relationship between the Tribal community and the research institution. In addition we plan to complete the needs and resources assessment as well as develop/adapt the intervention curriculum and the culturally appropriate and relevant outcome measures. The needs and resources assessment will involve key stakeholder interviews as well as focus groups; this assessment is described below. The findings from the needs and resources assessment will guide the development of the intervention, the target participants, the research methods, and the desired outcomes.

To assess the strengths and resources of the Suquamish Tribal community, the project team will use the Community Readiness (CR) Model. This innovative model was developed at the Tri-Ethnic Center at Colorado State University and is a promising assessment tool for researchers working with AI/AN communities (Oetting, Jumper-Thurman, Plested, & Edwards, 2001; Plested, Smitham, Jumper-Thurman, Oetting, & Edwards, 1999; Thurman, Plested, Edwards, Foley, & Burnside, 2003). The CR model uses interviews with key community members and cultural experts to assess the level of a community's awareness of a particular issue of concern and what resources and potential solutions currently exist in the community. Most importantly, interviews are also designed to assess the community's level of readiness to make changes to address the issue.

The Healing of the Canoe project plans to conduct interviews with key community members, including Elders, Tribal leaders, spiritual leaders, and members involved in law, health and education. The Suquamish Cultural Co-op will identify key community stakeholders and provide a list to project staff. The research team will adapt the model so that multiple areas of concern can be identified by informants and then ranked in order of importance. Once top areas of concern to the community are identified, informants will be asked standard CR questions about these issues, focusing on six dimensions: a) Existing efforts (programs, activities, policies, etc.), b) Community knowledge of efforts, c) Leadership (both appointed and influential community members), d) Community climate, e) community knowledge about the problem, and f) resources available. The Cultural Co-op will approve all interview questions before interviews are conducted.

Data collected via the CR assessment will inform the project research team about the community's priorities in regards to a research intervention and will also be used to compile a report about the Suquamish Tribe's concerns, strengths, resources and climate. This report will be presented to the community both at community meetings and through pamphlets and brochures.

After completing the CR assessment, the project plans to hold focus groups with four community subgroups: Elders, youth, service providers, and general community members. The goal of these focus groups is to gain in depth information about the top two to three identified community issues of concern. Although the Tribe has indicated that they expect issues related to substance abuse (by youth in particular) will be the issue of most concern to the community, we will not know this until we have completed our full assessment. We will employ specific procedures for conducting focus groups and needs assessments that have demonstrated success in working with Native American communities to insure appropriate sensitivity to the unique cultural and historical issues of the community (Freeman, Iron Cloud-Two Dogs, Novins, & LeMaster, 2004; Okamoto et al., 2006; Strickland, 1999a). Qualitative data collected at these focus groups will further inform the development of the project intervention (Strickland, 1999b). Although the focus of the intervention will be driven by the data gathered in the needs and resources assessment, early indications suggest that a culturally appropriate, community-based life skills intervention for Tribal youth to prevent substance abuse will be the top priority.

One promising intervention is the Canoe Journey/Life's Journey Life Skills Manual for Adolescents (LaMarr & Marlatt, 2005). The Canoe Journey/Life's Journey program content is focused on training adolescents in basic life skills that are patterned after the skills required for a Clean and Sober journey in life, including acquiring navigational coping skills, communication and lifestyle balance skills, and skills to cope with negative emotional states that might otherwise prompt some teens to give up on the journey (especially by giving into alcohol and other drug temptations). It is likely that the community will elect to adapt this manual to incorporate Suquamish Tribal values, practices, traditions, and beliefs. Outcome measures will be developed and/or adapted once the intervention is determined and will reflect outcomes that are important to the Suquamish community in addition to theory-driven outcomes. Finally, the intervention will be piloted for feasibility and potential effectiveness.

Conclusion and discussion: Lessons learned

Community and Tribally-based perspective of lessons learned – voice of the community partners

The precarious relationship between Tribes and non-native institutions is one that is well known across Indian Country. Chief Seattle (after whom the city of Seattle was named), famous leader of the Suquamish Tribe, stated in an 1854 speech, “Day and night cannot dwell together. The Red Man has ever fled the approach of the white man, as the changing mist on the mountain side flees before the blazing morning sun” (Chief Seattle, 1854).

Over 150 years later, these words and feelings still echo through the community, creating challenges that necessitate nontraditional research approaches to overcome a well-earned lack of trust with institutions and to build a bridge between varying worldviews, values, and priorities. Successful implementation of the CBPR approach requires a forthright acknowledgement of this history and the gains made at the expense of Tribal peoples. Our first challenge then becomes how to convey our intentions to work in a full partnership with the University of Washington and to trust that they would work with us in a genuine and culturally appropriate manner.

Thus the first step to overcoming this challenge was identification and recruitment of “cultural facilitators” in our Tribal community. These stakeholders bring to the project the insight to develop an outreach strategy that works with the flow of the community rather than against it, saving substantial time and resources. Cultural facilitators can be youth, adults and/or Elders but should all possess a dedication to project integrity and the ability to speak up when it is not being upheld. By providing a framework from which to conduct community outreach, cultural facilitators are able to introduce the Healing of the Canoe: Community Pulling Together Project and its teams to small groups of Tribal members. The intimacy of a small group allows Tribal members to feel more comfortable asking questions and making comments. Incorporating stakeholder's feedback into our presentations and outreach methods provides evidence to the community that this project is truly community driven.

Developing community trust is a vital objective, although it is difficult to quantify and to subject it to a time schedule. Thus the project implementation schedule is adjusted as needed with regard to the Tribal Council and advisory board meetings and the unique needs of the Suquamish community. This presents a challenge in our attempt to coordinate the Tribal review process with the University review process. Postponement of deadlines is occasionally necessary but provides the important reminder that communities are not laboratories or sterile labs, but rather are process-oriented, and we are “along for the ride.” The ability to be patient and trust the pace set by the Tribe, while still maintaining a pace consistent with grant requirements, can be a difficult balance for traditional researchers.

Building a lasting collaborative, respectful effort – lessons learned and questions for the future

Our efforts to develop collaboration, trust, respect, and true partnership are ongoing and include many lessons learned, many questions to resolve, and most importantly, many points of success. We share lessons learned as well as important questions left to resolve.

Lessons learned

  1. Be prepared for continued involvement and potential delays given the need to gain community entry, trust, and buy-in.

  2. Be prepared to provide some training to research institution-based offices regarding CBPR methods and the unique issues involved in working with tribal communities as Sovereign Nations.

  3. Be prepared to educate funding agencies regarding the importance of providing food at Tribal gatherings as part of the cultural process and the need for extended timelines.

  4. Be prepared to understand and navigate at least two cultures, that of the research institution and that of the community.

  5. Clarify and document each party's expectations and responsibilities, e.g., in an MOU

  6. Allow sufficient time for Tribal review and approval as well as University IRB review and approval of all forms, questionnaires, and procedures.

  7. Hire from within the community and be sensitive to the multiple roles that community-based project staff must navigate.

  8. Be open to input and evaluation.

  9. Be flexible.

  10. Be able to develop commitment, perseverance, and some ability to tolerate delays and discouragement.

  11. Be willing to adapt as needed.

  12. Involve a formal assessment process to evaluate the process and the status of the partnership.

  13. Develop and use assessment instruments for measuring the quality of collaborative relationships and meeting effectiveness.

Important questions to resolve

  1. How do you respect and honor Tribal sovereignty while adhering to grant expectations?

  2. When is research not research? Where is the boundary between “research” and participatory community involvement, information sharing, and project presence?

  3. Who is a subject in the context of participatory research in the community?

  4. How do you define and insure confidentiality in small, relatively closed communities?

  5. How do you define “data” and who owns the data (e.g., narratives)?

  6. How do you manage findings that may cast the community in a negative light?

While the answers to these questions are not yet clear, we believe that utilizing CBPR/TPR methodologies in substance abuse prevention projects with AI/AN communities is the best choice because it is likely to result in research that is not only scientifically sound, but also is culturally relevant and appropriate, sustainable, and able to make a positive impact in reducing health disparities and promoting good health in AI/AN communities.

Acknowledgments

This research was funded by the National Institutes of Health's National Center on Minority Health and Health Disparities, Dennis Donovan, Principal Investigator. The author also acknowledges the generous and crucial contributions of the Suquamish Tribe, collaborator on this project.

Footnotes

1

Because this is a CBPR project and the intervention as well as related methods (e.g. participants, sample size, recruitment strategies, outcomes, etc.) will be determined based on the results of the needs and resources assessment we cannot describe them in this paper. They have subsequently been determined and developed and will be the focus of a future publication.

Contributor Information

Lisa R. Thomas, University of Washington, In collaboration with the Suquamish Tribe

Dennis M. Donovan, University of Washington, In collaboration with the Suquamish Tribe

Robin LW. Sigo, Suquamish Wellness Program, In collaboration with the Suquamish Tribe

Lisette Austin, University of Washington, In collaboration with the Suquamish Tribe.

G. Alan Marlatt, University of Washington, In collaboration with the Suquamish Tribe

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