Development of “CULTURE FORWARD: A Strengths and Culture-Based Tool to Protect Our Native Youth From Suicide”

Abstract

Objective:

Indigenous knowledge and practices promote American Indian/Alaska Native (AI/AN; Native) communities’ health and well-being. Historical losses and continued oppression have resulted in disproportionately higher AI/AN youth suicide rates. This article describes the development of a new national resource guide titled “CULTURE FORWARD” for tribal leaders and stakeholders to support youth suicide prevention efforts through cultural strengths.

Method:

The CULTURE FORWARD guide was developed over 6 months through a community-engaged process. We conducted nine roundtables and eight interviews with a wide variety of community members, leaders, and providers representing 36 diverse tribal communities and geographic regions. Participants discussed AI/AN youth risk and protective factors, successful community efforts to prevent suicide, and content and dissemination ideas. A comprehensive literature review complemented qualitative findings. A diverse and representative National Advisory Editorial Board guided content and design throughout development.

Results:

Qualitative data were analyzed iteratively and thematically. Across all listening sessions, culture was identified as a key protective factor against AI/AN youth suicide. Five themes related to cultural strengths informed guide chapters. Each chapter includes an introduction; how that theme helps prevent Native youth suicide; a review of academic literature, community stories and programs; action steps; and additional resources.

Conclusions:

CULTURE FORWARD honors and empowers communities by weaving strands of knowledge, stories, and practical resources highlighting Native communities’ strengths to protect against Native youth suicide. The guide is free online and print copies are being distributed nationally.

The “CULTURE FORWARD” guide was made possible in collaboration with Casey Family Programs. We express deep gratitude to Casey Family Programs, an operating foundation committed to supporting tribes in strengthening tribal nations’ capacity to keep children healthy, safe, and connected with their families, communities, and cultures. We humbly acknowledge and thank the tribal leaders, grassroots leaders, Native youth leaders, two-spirit leaders, veterans, military service members, elders, and traditional healers who participated in listening sessions that informed the development of “CULTURE FORWARD.” We also express our warmest gratitude to the National Advisory Editorial Board who provided valuable feedback and shared their wisdom to guide this project. We acknowledge and thank NUNA Consulting Group, LLC, led by Ricki McCarroll with contributions from Shon Quannie (Pueblo of Acoma/Hopi/Mexican) and Terra Branson (Muscogee [Creek] Nation), who supported the “CULTURE FORWARD” guide development and design. We want to express our heartfelt gratitude and hope to all Native communities who are honoring their ancestors by upholding their strengths and cultures, and in doing so paving the way for generations of Native youth to thrive.

This project was not human subject’s research. We requested written permission from participants in listening sessions to use anonymous quotes for the resource guide. However, participants were ensured that their data would not be shared outside of the research team and for informing the guide.

Victoria M. O’Keefe played lead role in formal analysis, investigation, methodology, project administration, writing of original draft and writing of review and editing and equal role in conceptualization and funding acquisition. Emma Waugh played lead role in data curation and project administration, supporting role in visualization and writing of review and editing and equal role in formal analysis, investigation and writing of original draft. Fiona Grubin played supporting role in data curation, formal analysis, investigation, project administration, writing of original draft and writing of review and editing. Mary Cwik played supporting role in methodology and supervision and equal role in writing of original draft and writing of review and editing. Rachel Chambers played supporting role in formal analysis, investigation and methodology. Jerreed Ivanich played supporting role in investigation and writing of original draft. Rose Weeks played supporting role in validation. Allison Barlow played supporting role in supervision and validation and equal role in conceptualization, funding acquisition and writing of review and editing.

“‘We share a sacred responsibility to our ancestors to build healthy futures for our young people today and for generations to come’ Congresswoman Deb Haaland (Pueblo of Laguna)” (Johns Hopkins Center for American Indian Health, 2021, p. 2).

Traditional knowledge and ways of living and being are strengths that have supported Indigenous communities for thousands of years (Settee, 2008). While recognizing and respecting the diversity of languages, worldviews, and teachings across communities, many tribes hold shared values that children are sacred and vital to community identity and well-being (Cajete, 2000; Ullrich, 2019). As Congresswoman Haaland’s (Pueblo of Laguna) quote states above, there exists an ongoing intergenerational responsibility to current and future generations of American Indian/Alaska Native (AI/AN) youth to promote their healthy futures. This sacred responsibility is urgent given that suicide rates among AI/AN youth ages 10–24 are nearly three times higher than their same-aged peers in the U.S. general population (Centers for Disease Control and Prevention, 2020). AI/AN youth suicide rates vary by geographic region and tribe and are driven by factors including, but not limited to, historical trauma (Brave Heart & DeBruyn,1998; Gone et al., 2019), interpersonaland systemic racism (Substance Abuse and Mental Health Services Administration, 2017), and lack of access to culturally responsive mental healthcare (Gone & Trimble, 2012). This urgent public health issue threatens the future of healthy, thriving youth, and entire communities. Reclaiming cultural strengths and knowledge is a foundation to prevent AI/AN youth suicide.

Scientific research is catching up to what Native communities have inherently known that there appears to be greater impact by focusing on strengths and protective factors compared with focusing on health disparities, risk factors, illness, and disease (Henson et al., 2017; Illuminative, 2018; Mackin et al., 2012; Sheldon & King, 2001; Stewart & McWhirter, 2007; Wexler et al., 2015). Protective factors identified in Indigenous suicide prevention research have spanned individual-level factors such as hope, future aspirations, personal wellness, self-efficacy, and cultural and spiritual identity (Chandler et al., 2003; Garroutte et al., 2003; Henson et al., 2017; O’Keefe & Wingate, 2013), family-level influences including participation in cultural traditions (Cwik et al., 2015; Strickland et al., 2006), and community- and macrolevel factors such as tribal leader support, holistic connectedness to self-family-community-land, self-governance, and cultural continuity (Chandler & Lalonde, 1998; Mohatt et al., 2011; Pharris et al., 1997). One of the greatest advantages of shifting foci from deficits to strengths is that many of these strengths already exist within Native communities and, once engaged and promoted, can accelerate efforts to prevent suicide.

Increasingly, research with Native communities is showing approaches focused on strengths are more effective in preventing and treating certain health and mental health concerns (Henson et al., 2017; Layous et al., 2014; Sheldon & King, 2001) than approaches focused on decreasing risk, including for suicide (Allen et al., 2022; Borowsky et al., 1999; Mackin et al., 2012; Wexler et al., 2015). As this work continues, it is paralleled by growing advocacy by AI/AN communities to increase culturally based solutions and redefine concepts of mental health and wellness from within communities (Gone & Trimble, 2012). Suicide prevention research with and conducted by AI/AN communities is increasingly guided by cultural strengths and with decolonizing and Indigenous research methodologies (e.g., Rasmus et al., 2019; Wexler et al., 2015, 2020). It is important to share and disseminate such knowledge across communities aligning with community-based participatory and decolonizing research approaches that promote self-determination and community change (Cooper & Driedger, 2018; Rasmus, 2014; Wallerstein & Duran, 2006; Wexler et al., 2015, 2016).

In January 2018, Casey Family Programs commissioned the Johns Hopkins Center for American Indian Health (JHUCAIH) to create a national Native youth suicide prevention resource tool for tribal leaders and other community stakeholders. Following a community-engaged process to develop this resource, the keystones of cultural strengths swiftly emerged. The resulting resource tool is a 56-page illustrated guide called, “CULTURE FORWARD: A Strengths and Culture-Based Tool to Protect our Native Youth From Suicide.” CULTURE FORWARD aims to elevate Indigenous knowledge and practices and put forth accessible state-of-the-science strengths- and culture-based approaches with AI/AN communities to reduce and prevent suicide. The purpose of this article is to describe our participatory research approach and collective process to develop and disseminate CULTURE FORWARD with diverse AI/AN stakeholders.

Method

In the current project, we combined participatory and Indigenous research approaches to inform our qualitative processes for content and design development, alongside a literature review to guide analysis and selection of research and programs included in the guide. Broadly, Indigenous and decolonizing approaches prioritize Indigenous communities’ needs and recognize and incorporate Indigenous ways of knowing (Rix et al., 2018). In addition, participatory research approaches empower Indigenous peoples to guide inquiry and lead efforts to prevent suicide in their communities, ultimately leading to more sustainable and ethical solutions (Blair & Minkler, 2009; Wilson, 2008). Using these two approaches recognizes and affirms Indigenous rights to self-determination and sovereignty, as well as supports Indigenous leadership in the interpretation and dissemination of findings (Braun et al., 2014).

We took a community-based approach to the current project through engaging a diverse stakeholder group (age, geographic region, tribal affiliation, gender, community, and/or professional role) in listening sessions to gather input to set the objectives of the guide, determine what content should be included to be most valuable and useful to audiences, and identify the best dissemination strategy (see Data Collection section below). Dissemination and knowledge translation in partnership with Indigenous communities is critical to research (Cooper & Driedger, 2018) and our listening sessions guided the research team in this process. The final content, design, and structure of CULTURE FORWARD was further directed by a National Advisory Editorial Board (NAEB; described further below). The resulting CULTURE FORWARD guide exemplifies knowledge sharing across community networks for the collective benefit of Indigenous communities (see Smith, 2012).

Research Team

The project principal investigator was led by a Cherokee Nation/Seminole Nation assistant professor at the Johns Hopkins Bloomberg School of Public Health (JHBSPH) in the Department of International Health and JHUCAIH. She has 10 years of community-engaged research experience with tribal and urban Native communities, focused on promoting mental health and preventing suicide. A White woman research associate with 7 years of community-engaged research with Native communities and qualitative research experience coled the qualitative data analysis. Two White women JHUCAIH researchers supported qualitative data analysis as coders—one a JHUCAIH research associate with 3 years of qualitative research experience and an MPH and the other a JHUCAIH graduate research assistant with 2 years of qualitative experience. Other JHUCAIH researchers who contributed to this project included a White woman associate scientist, a man and former postdoctoral scholar (now assistant professor) and member of the Metlakatla Indian Community, a White woman research associate, and a White woman senior scientist and director of the JHUCAIH; each of these researchers have worked with Native communities for 5–30 years.

Throughout the study, the research team met to discuss the project status, goals, and reflections on data collection and analysis. Early in these discussions, it was collaboratively decided that a NAEB (described below) was needed to ensure the project was continually guided by Native voices and perspectives.

Ethical Considerations and Informed Consent

This project was deemed exempt by the Johns Hopkins Bloomberg School of Public Health Institutional Review Board, as study activities did not meet the definition of human subjects research. Nonetheless, we requested voluntary written permission in the form of a consent and/or assent from all participants (obtaining written consent from parents when participants were minors) to participate in roundtable discussions or individual interviews and to be audio recorded; participants also signed a media release form providing their permission for JHUCAIH to use anonymous quotes. Taking care to ensure informed consent/assent from participants and contributors to the guide was an important part of the community-driven process used to create CULTURE FORWARD. There were no ethical considerations relevant to prior relationships with participants.

Data Collection

Recruitment

We sought to gather input and perspectives from a diverse cohort of tribal and urban AI/AN communities representing a range of geographies and community roles. We used a combination of convenience sampling (e.g., holding roundtable discussions at conferences well-attended by tribal leaders, Native youth, grassroots leaders) and snowball sampling (e.g., asking participants and JHUCAIH contacts to refer individuals who were well-positioned to inform this project). Convenience sampling recruitment occurred primarily via email, with the principal investigator reaching out to contacts at Native-led/focused conferences to request permission to arrange for and recruit attendees who were interested in joining a roundtable discussion. With permission, recruitment flyers were posted at conference venues to garner interested participants. Snowball sampling led the principal investigator to reach out to suggested contacts via email and phone to also arrange a virtual roundtable discussion and phone interviews.

Participants

Collectively, 64 listening session participants represented 36 distinct tribal communities and diverse geographic regions across reservation, rural, and urban communities. Participants included tribal leaders (e.g., chiefs, chairpersons, council members); tribal health board directors; grassroots leaders working with Native youth in their communities; Native youth leaders; two-spirit leaders working with two-spirit youth; elders and traditional healers; and military service members and veterans. Given the immense diversity of tribal communities and geographic regions, across which suicide rates and resource needs differ significantly, gathering and representing diverse perspectives and responses was critical. With consent and permission, we integrated quotes from listening session participants to respect, honor, and privilege their voices and experiences throughout the CULTURE FORWARD guide. To express appreciation for their time and sharing during listening sessions, all participants received a cultural gift that included a sage bundle, Apache tea, and a bracelet created by a White Mountain Apache youth-owned business (Tingey et al., 2020). Data collection was halted when the research team discussed together and agreed that (a) the point of saturation appeared to have been reached (i.e., participants were not sharing new information or perspectives that had not already been captured) and (b) participants collectively represented a wide range of roles (e.g., tribal leaders, Native youth, etc.) and diverse geographic areas (i.e., participants represented all 11 regional profiles as outlined by the National Congress of American Indians [NCAI], 2020).

Listening Sessions

Seventeen listening sessions, including nine roundtable discussions (September 2018, October 2018, January 2019, February 2019) and eight individual interviews (November 2018, December 2018, February 2019), were conducted over 6 months (see Figure 1). Eight of nine roundtable discussions were held in person and one was held virtually via videoconference. Three of eight individual interviews were conducted in person and five were held via phone. Roundtable and interview guides were used to facilitate discussion and included questions on the following topics: (a) Risk and protective factors related to Native youth suicide; (b) The role of tribal leaders in Native youth suicide prevention; (c) Successful youth suicide prevention solutions and programs in their own or other Native communities; (d) Content that should be included in a Native youth suicide prevention guide; and (e) Effective ways to disseminate a new national resource guide about Native youth suicide prevention. Discussion guides were adjusted slightly to ask specifically about experiences among two-spirit community members, youth, tribal leaders, and Native military service members or veterans when respondents were well-placed to speak to these experiences. On average, roundtable discussions lasted 1–2 hr while individual interviews were 30–60 min. Roundtables and interviews were audio recorded and transcribed for analysis. All roundtable and interview participants were invited to join the NAEB to continue participating in data interpretation and iterative review of the CULTURE FORWARD guide content, format, and graphic design.

Figure 1.

Our Listening Process

Qualitative Data Analysis

Two research assistants completed qualitative analysis of the roundtable discussions and interview transcripts with input and guidance from the principal investigator, who led listening sessions, and another senior qualitative researcher. Analysis of the transcripts was an iterative process. The principal investigator and qualitative researcher developed a codebook of a priori codes to capture ideas and themes relevant to informing the guide. A priori codes captured themes of how suicide is distinct in tribal communities, protective factors against suicide, risk factors for suicide, ideas for how to prevent suicide, needs to support prevention efforts, tribal leaders’ role in suicide prevention, and ideas for how to develop and disseminate this resource. The two research assistants independently applied the a priori codes to three of the transcripts and then met to review the convergence in how codes were applied, discuss additions and revisions to the codebook, and agree upon clear definitions of each code. Convergence was assessed by examining each instance of a code being applied in the transcripts across both coders to determine if the same codes were being applied to the same or similar excerpts of text in the transcripts. The majority of the two coders’ applications of the codes were applied consistently across the three transcripts, and where there were discrepancies, the two coders discussed why they had coded the excerpt as they did and agreed to either delete the code, apply a different code, or keep the code and enhance the definition of the code. The final version of the codebook that was applied to all transcripts included 63 codes (most a priori and some emergent) grouped into six categories: (1) needs (resources needed at the individual, family, and community levels to support suicide prevention); (2) perceptions of suicide in tribal communities (including conceptualizations, attitudes, and impacts of suicide); (3) programs and program characteristics (descriptions of successful suicide prevention programs/efforts and what factors made them successful); (4) risk and protective factors (factors contributing to and protective against suicide); (5) tribal leaders’ perspectives (about tribal leaders’ role in suicide prevention); and (6) resource guide ideas (related to content, structure, and dissemination of the resource to be developed). We used ATLAS.ti to facilitate data organization and application of codes. Results were presented to the NAEB who provided verbal and written feedback on themes that later became chapter names in the guide, as well as content included in the guide that derived from data collection.

Literature Reviews

Following roundtable discussions and interviews, we conducted a comprehensive literature review of published academic research and white and gray literature (e.g., technical, research, and program reports) pertaining to suicide prevention in Native communities that focused on participatory strengths- and culture-based approaches. We queried research databases including PsycINFO, Pubmed, and Google Scholar employing the search terms: “American Indian or Alaska Native or Native American or Indigenous,” “suicide prevention,” “protective factors,” “strengths,” and “culture.” After gathering this literature, two project team members reviewed each article to select those deemed most useful, appropriate, and relevant for the CULTURE FORWARD guide. This literature was organized by which chapter in the guide it best informed. Three to five articles were selected that clearly demonstrated chapter themes and were summarized with community audiences in mind (i.e., avoiding use of academic jargon). We also conducted a gray and white literature search to ensure inclusion of promising programs and resources that may not appear in academic peer-reviewed literature. A research associate conducted the search on Google and used the terms “American Indian,” “Alaska Native,” “Native American,” and “suicide prevention.” Programs that targeted substance use and mental health among AI/AN communities in the U.S. were included. The gray and white literature search yielded 73 programs, websites, and other resources (e.g., published reports). The research associate reviewed each program, website, and resource, and organized relevant programs and resources into each chapter theme. Several seminal programs were highlighted in each chapter and/or cited at the end of each chapter in a “Learn More Here” section (see Table 1).

Table 1.

Components of Chapter Structure

Chapter component	Description
Section overview and introduction	Provides a summary of key points for the chapter and introduces the theme of each chapter
How does (chapter theme) help prevent Native youth from suicide?	Highlights academic resources that support the chapter’s identified protective factor
Stories about (chapter theme)	A spotlight on various suicide prevention programs that are grounded in the chapter’s theme
What can our communities do now?	Actionable steps any reader could take related to the chapter theme
Learn more	Resources and links to additional information

National Advisory Editorial Board

To ensure Native voices and perspectives drove final production, we convened a NAEB to guide and review content, format, and graphic design of the guide. To ensure diverse representation, the NAEB included 14 members from 12 tribal communities and included tribal leaders, Native youth leaders, grassroots leaders, and national and regional tribal health advocacy representatives with Native youth suicide prevention expertise. NAEB members provided individual feedback on multiple versions of the guide and met twice virtually as a group to discuss revisions, comments, and questions. NAEB members were offered compensation for sharing their time through project meetings and written feedback.

Results

Chapter Structure

Listening session participants provided vital feedback to guide CULTURE FORWARD content and structure. For example, one roundtable participant expressed that having an influential leader write a foreword to the guide may help increase reach. In line with this recommendation, the guide begins with a foreword by Congresswoman Deb Haaland (Pueblo of Laguna) stating the importance of cultural traditions to reclaim Native health and wellness, how CULTURE FORWARD contributes to a larger movement for thriving communities, and our collective responsibility to support healthy futures for youth. Congresswoman Haaland is notably one of the first two Native women elected to the U.S. Congress, and the first Native American to be nominated and confirmed as a Cabinet Secretary. In addition, listening session participants expressed the importance of providing updated suicide rates, trends, and patterns for tribal and other community leaders to have up-to-date information. We included this information in a preliminary chapter called “Background: What We Know about Native Youth Suicide.” Participants expressed the need to know more about innovative and successful suicide prevention programs in other communities. All groups had personal examples of a variety of suicide prevention efforts that are well-received in their communities, including school-based programs and youth activities (e.g., Boys & Girls Clubs, Youth Councils) as well as programs that integrated Western medicine and traditional healing. These examples are included throughout the guide as stories to highlight these programs and meet this need identified by the participants. See Table 1 for components included in each CULTURE FORWARD chapter.

Visual Elements

Participants in our listening sessions emphasized that the guide needed to be easy to use for tribal leaders and community program managers, who are busy and constantly managing competing priorities. This feedback, as well as input from our NAEB, guided the overall design, which incorporates numerous visual elements, small blocks of text, and stand-alone chapters. With this input, the final guide was designed by NUNA Consulting Group, LLC, a minority, woman-owned firm with expertise and a long history of serving public affairs and strategic communications with AI/AN communities. A team of AI graphic designers led the design and layout. The visual content of CULTURE FORWARD incorporates weaving to embody its themes and purpose. A quote by Congresswoman Debra Haaland (Pueblo of Laguna) included in an introductory chapter summarizes the importance of weaving to the guide’s approach:

Collectively Indigenous people share the gift of weaving as a practice that has provided us the skills that aided our survival and brought beauty into our communities. Weaving teaches us discipline, self-control, and patience in the process of creating a larger product to share that is, also utilitarian. The stories that are told to us as children are woven into our baskets, rugs, and blankets and exchanged across space and time. These weavings explain where we came from and who we are, our secrets are preserved in the practice handed down to each successive generation. We have the privilege of knowing our past, and so our children can continue to create patterns of their own. Although our weavings tell stories that are not written, they are authored by us and illustrate a story that tells us that our people are survivors and that we are resilient (NCAI, 2021).

In line with this quote, the guide is designed to weave together strands of knowledge, stories, and practical resources to promote Native communities’ strengths to protect Native youth from suicide. SeeFigure2 for the CULTUREFORWARD front cover featuring four photos depicting weaving from distinct tribal and geographic regions.

Figure 2.

Front Cover of CULTURE FORWARD

Content

Data from listening sessions were originally grouped into 10 major themes, which were condensed into five themes to form chapters in the guide for ease of reading and to eliminate content overlap. The NAEB was presented with this change and provided refinement and rewording of theme/chapter titles (see Table 2). Across all listening sessions, culture was identified as a protective factor against AI/AN youth suicide, and thus became an overarching theme for the entire guide and inspired the title, “CULTURE FORWARD.” One Native youth leader participant commented on the importance of culture, stating:

Table 2.

Chapter Summaries

Chapter	Summary
Our networks harness belonging and help keep us safe	This section highlights the inherent strengths of familial and traditional relationships within Native families, clans, and communities, as well as how these networks can be leveraged to reduce suicide
Connections to our lands and elders allow us to thrive	This section highlights the deep relationships Native communities have with environment, land, and place. It explores how connecting to these relationships, and learning/engaging with elders who hold traditional knowledge can be a powerful source of healing for Native youth
Traditional knowledge holds the keys to health and healing	This section highlights how traditional knowledge, cultural practices, and values strengthen resilience and promote well-being among youth
Native youth lead us to reclaim our autonomy and well-being	This section highlights both the importance of family-based early childhood approaches that plant the seeds of well-being for youth across the lifespan and how to promote youth leadership to support thriving futures
Self-determination empowers us to fight	This section highlights how tribal leaders can leverage tribal sovereignty to lead suicide prevention efforts locally

Being grounded in our cultural traditions and who we are as Indigenous people is the key to our wellness and survival. We know this through the resiliency of our ancestors, it’s our obligation to carry this on to the next seven generations.

Below we describe how participant input led to the creation of these five themes and corresponding chapters. We also integrate findings from our literature review that relate to each theme and chapter.

Theme #1: Our Networks Harness Belonging and Help Keep Us Safe

Participants in listening sessions often discussed the need to harness the strength of social connectedness to prevent suicide. Participants highlighted inherent strengths of Indigenous family, extended family and kinship, and community connections and the need to nurture these relationships to protect against suicide:

Communication over food and water in the home was where prevention was planted, with words of encouragement and affection. That was home-based prevention. There was pure love by our parents and grandmothers as they prepared food and they put that into the food. With that, you left your home with no intention to harm yourself knowing that your parents and grandparents armored you with love and the education that people may throw stones at you or downgrade you but that should not matter whatever you are doing in your life. (Traditional Healer)

Published literature supports the importance of Indigenous relationality, as well as research and programs that focus on connectedness to family and community to promote health and well-being and prevent suicide among AI/AN youth (Cross, 1997; Hill, 2009; Philip et al., 2016; Sarche & Spicer, 2008; Tingey et al., 2014).

Theme #2: Connections to Our Lands and Elders Allow Us to Thrive

Lack of connection to lands and elders was identified as a risk factor for suicide among Native youth. Participants illustrated how weaker social ties and connections to land contributed to feelings of apprehension about asking for help or talking with others about difficult struggles; thus, increasing suicide risk. They offered insightful, holistic descriptions of their view of connection, including connections to lands and elders.

The Elders, and those things that we take for granted, the natural gatherings. Those are prevention. These are prevention. When we walk on the land and hunt and provide, that makes you feel good. That’s spiritual …. These are natural things that we need to start to recognize and say these are interventions, these are actually preventions. (Elder)

Elders as cultural keepers hold an important role within communities to guide health and wellness initiatives grounded in local knowledge and traditions (Sam, 2008; Substance Abuse and Mental Health Services Administration, 2016). AI/AN communities have led land-based and culture-based wellness programs and there is mounting literature on research and programs that promote and evaluate these approaches to prevent Native youth suicide (Allen, 1979; Donovan et al., 2015; Rasmus et al., 2014, 2019).

Theme #3: Traditional Knowledge Holds the Keys to Health and Healing

Participants emphasized ways in which suicide prevention efforts should emphasize tribal strengths, especially Indigenous knowledge and practices.

I think that cultural component is critical in how we see this whole issue around suicide prevention … rather than looking upstream, downstream, whatever that is, we go back to that place of culture. (Tribal Leader)

Furthermore, participants tended to agree that prevention programs that aim to address determinants of suicide must incorporate traditional knowledge and practices to be successful.

That’s something that has come up with some other roundtables around suicide prevention. People have asked us to include ... doing interventions that are based in traditional culture, to include that information. Because, if there are data behind it then that also makes it powerful and can make it convincing to the funding agencies to put some money behind it, if we’re showing these things are working. (Tribal Leader)

Indigenous knowledge have been and continue to be deeply respected and honored within communities, yet there is increasing interest in centering local knowledge and traditions within health research (Rasmus et al., 2019; Walters et al., 2020). There are several examples of culturally grounded and community-driven programs being implemented across AI/AN communities to prevent youth suicide (Barnett et al., 2020; Brockie et al., 2015; Fleming, 1994).

Theme #4: Native Youth Lead Us to Reclaim Our Autonomy and Well-Being

Throughout listening sessions, we met numerous youth leaders acting as powerful change agents within their respective communities and nationally. Their inspiring voices solidified the need to have a chapter focused on Native youth as the key to reclaiming well-being. Feedback from other participants discussed the value Indigenous communities place on their youth for the well-being and future of communities:

We think of our children, the world is “wakhan,” wakhan is sacred, chosen, and we reintroduce that, that these children are sacred …. How children see the world, how we introduce the value of those elements of culture that are vital. (Tribal Leader)

Indigenous worldviews of children as sacred and traditions around caregiving that include extended family and community promote youth well-being throughout life (LaFromboise et al., 2006; Nichols, 2004; Ullrich, 2019). Our literature review results included family-based interventions that align with tribal values and practices to prevent suicide and substance use (Ivanich et al., 2020) and programs that promote Native youth leaders as natural helpers to prevent suicide (One Sky Center, n.d.).

Theme #5: Self-Determination Empowers Us to Fight

During roundtables with tribal leaders, nearly all responded that suicide prevention is a priority to them. As one tribal leader stated: “I think that all people need to feel that they’re needed and, like I said, that they feel like they’re loved by someone else.” Many listening session participants emphasized that tribal leaders play a key role in showing youth they are valued and supporting suicide prevention efforts. During youth roundtables, youth expressed hearing tribal leaders and adult community members say they care for their well-being, but that not regularly attending youth-led meetings or events weakens these statements of care. Thus, the CULTURE FORWARD guide promotes the importance of tribal and community leaders’ active engagement with youth. Several articles from our literature review featured research and programs underscoring ways that self-governance and tribal sovereignty contribute to suicide prevention in Native communities (Chandler & Lalonde, 1998, 2008; Cwik et al., 2014, 2016).

Dissemination

Our commitment to an Indigenous community-based research process included attending to dissemination and knowledge translation during all phases of the project (Collins et al., 2018; Cooper & Driedger, 2018). As described above, we included questions in our listening sessions to codetermine an effective dissemination strategy (Collins et al., 2018) to ensure this guide reached intended audiences. We learned from listening sessions that the guide needed to be accessible for free online. Accordingly, we made the CULTURE FORWARD guide for free viewing or download via mobile phone or desktop computer on the JHUCAIH website (https://caih.jhu.edu/programs/cultureforward). Participants recommended the guide should be shared via social media platforms to help increase reach. Therefore, JHUCAIH developed a series of social media posts for Facebook, Instagram, and Twitter to help disseminate the guide. In addition to the digital guide, we also printed copies of CULTURE FORWARD to ensure it would reach communities without broadband access. We distributed print copies to all listening session and NAEB participants to allow those who participated in project activities to benefit from them, a core principle of community-based and Indigenous research (Cox et al., 2021; Holkup et al., 2004). We learned from participants that the printed guide needed to be distributed to a variety of tribal departments, including education, behavioral health, and child-serving departments. Leveraging the networks of Casey Family Programs and JHUCAIH, printed copies were mailed to tribal leaders and departments (e.g., social services, family services, behavioral health, Indian Child Welfare) across 750 tribes, villages, and urban Indian health programs, as well as national Native advocacy organizations and tribal epidemiology centers. Listening session participants also recommended distributing the guide at community events, such as pow wows. While CULTURE FORWARD has been distributed at select pow wows, the COVID-19 pandemic has limited in-person pow wows and this distribution option. Finally, we distributed the guide to congressional members serving on the U.S. Senate and House Committees on Indian Affairs, who are key to influencing policy and congressional spending to redress Native youth suicide inequities and encourage further opportunities for Indigenous-led and strengths-based research and public health practice.

Discussion

“CULTURE FORWARD:

A Strengths and Culture Based Tool to Protect Our Native Youth From Suicide” honors and uplifts Native communities by maintaining a strengths focus, incorporating traditional ways of sharing knowledge in the form of stories, and integrating powerful imagery to enhance visual engagement and accessibility by all community members. The collaborative, ground-up development of CULTURE FORWARD reflects Indigenous ways of knowing, creating, and sharing knowledge, as well as meaningfully integrating historical and cultural contexts aligning with decolonizing research approaches (Cooper & Driedger, 2018; Cox et al., 2021). Community members’ ways of knowing and being are legitimate and respected epistemologies that should be included in all phases of research and can complement Western science (Collins et al., 2018). Therefore, the CULTURE FORWARD guide is shaped by Native voices and perspectives from communities, leaders, and stakeholders with first-hand knowledge of the impacts of suicide and how we can prevent and heal from it.

The development process used to produce CULTURE FORWARD which distinguishes it from other Native-focused suicide prevention resource tools. While some other tools (e.g., Indian Health Service [IHS], 2011a; Walker et al., 2006) included input from advisory boards, none included (based on information provided) direct input from youth, community members, or members of groups most affected (i.e., two-spirit, military service members, veterans). These individuals may hold valuable knowledge pertaining to suicide (e.g., lived experience) and insights to inform resources meant to address Native youth suicide. Many other resource tools have included examples of existing suicide prevention programming designed with and for AI/AN communities (e.g., IHS, 2011a, 2011b; Walker et al., 2006). However, this valuable information is often found at the end of 100+ page documents, where busy tribal leaders or service providers may not be able to easily locate this information. Our listening sessions with tribal leaders allowed us to understand not only what content should be included in the guide, but how to present and disseminate this information. This responds to a call for better alignment between community-based participatory research (CBPR) and policymakers to ensure that policymakers have access to timely evidence to help promote health equity efforts (Cacari-Stone et al., 2014).

The community listening process that shaped this project with ongoing guidance from a NAEB was crucial to the development of the guide and notably brought together dozens of stakeholders who were diverse in age, gender identity, tribal affiliation, geographic region, and community or professional role. While community-based research often focuses on partnership with a single community, our collective approach across communities was intentionally broader to be responsive and useful for many AI/AN communities. Our work adds to recent literature highlighting “a process of knowledge coproduction on a broader scale” with several AI/AN communities and advances CBPR literature (Wexler et al., 2020). All project contributors shared a commitment to creating a positive future for Native youth and a sustainable foundation for strong AI/AN communities, aligning with CBPR tenets to highlight community strengths and develop pathways to responsive and positive community change (Collins et al., 2018). Key threads brought forth by these stakeholders were attention to recognizing the diversity of tribal nations, urban Native communities, and various individuals and groups who are impacted by suicide; common cultural understandings of strengths shared that inspired chapter themes; and culturally resonant visual iconography, such as different types of weaving to elucidate Indigenous ways of knowing on the topics explored. Alongside oral and visual data, we wove into the guide key findings from peer-reviewed published literature about Native youth suicide prevention and community best practices. Throughout this project, we privileged Indigenous voices, knowledge, practices, and research “for Indigenous people, by Indigenous people” (Echo-Hawk, 2019) to create a guide that could maintain relevance for current and future generations. Overall, our process privileged the responsibility researchers hold to share knowledge in ways that demystify research and are understandable across Indigenous communities (Smith, 2012). Though community-based research approaches are not new to Indigenous communities, recent literature points out that CBPR studies only make up to 0.1% of peer-reviewed publications in psychology journals (Collins et al., 2018). Therefore, this project adds to the dearth of CBPR-directed studies published in psychology journals on a priority mental health topic (i.e., suicide prevention) to AI/AN communities.

Related to dissemination, we followed principles of CBPR and considerations for knowledge translation and dissemination for Indigenous health research (Cooper & Driedger, 2018). Our listening sessions allowed a space for the research team to understand dissemination as a process to be codetermined with communities (Cooper & Driedger, 2018). We followed the guidance of stakeholders from our listening sessions that CULTURE FORWARD should be disseminated in diverse and creative ways (e.g., available online, shared on social media, and print copies) and with key audiences including relevant tribal departments, national organizations, policymakers, and with communities through local events (e.g., pow wows). CULTURE FORWARD also follows several key considerations when developing dissemination products outlined by Indigenous health researchers (Cooper & Driedger, 2018): (a) the guide is available online and can be downloaded by communities to be printed or copied and distributed; (b) there are components that do not require written literacy skills; (c) the product is strengths-based and conveys hope; (d) the guide is interactive (e.g., action steps that communities can take; providing additional resources); and (e) knowledge from participating communities and stakeholders is acknowledged within the guide. This project advances literature regarding approaches to dissemination of health research with Indigenous communities (Cooper & Driedger, 2018).

Limitations and Future Directions

There are some limitations to consider for this project. Though we were able to engage diverse AI/AN participants from 36 tribes, this is still a relatively small group compared with the diversity that exists across 574 federally recognized tribes (NCAI, 2020) and geographic regions. If we had been able to include additional participants and communities in listening sessions, we may have seen new or different themes emerge to inform chapters of the resource guide. Another limitation includes having to limit the amount of information and example programs in the guide. Our listening session participants shared with us that the guide should not be too long. Therefore, we chose to feature three community stories, research studies, or programs per chapter to balance length with illustrative content. There were numerous programs, research studies, and other stories we did not include or may not be aware of that exist within communities. Additionally, the findings from this project may not be generalizable outside of Native communities. This project focused specifically on Native youth and distinct contextual factors and solutions surrounding suicide prevention. The method and approach taken in this project may be transferable to other research and contexts, as it is important to employ a community-engaged strategy that will (a) facilitate an understanding of context-specific factors; (b) determine community needs regarding suicide prevention; and (c) disseminate suicide prevention research/programs with communities in accessible and engaging ways.

Conclusion

CULTURE FORWARD represents a critical new path for Native youth suicide prevention. Preventing suicide in any community, including among AI/ANs, must include all stakeholders. Native voices and knowledge across tribes, professional and community roles, geographies, and age groups are represented in this guide. Community readiness and action is propelled forward by a strong vision and involvement of tribal leaders—who are the focal audience for CULTURE FORWARD. This guide was intentionally designed to be a practical tool with accessible written and visual information to leverage unique strengths within tribal communities to protect youth against suicide. CULTURE FORWARD aims to change the narrative about Native youth suicide prevention from targeting an “at-risk group” to elevating tribal strengths and Indigenous knowledge as solutions toward physical, mental, emotional, and spiritual well-being. We hope that CULTURE FORWARD contributes to a national movement to advance Indigenous strengths to promote Native youth well-being.

Public Significance Statement.

Suicide among American Indian/Alaska Native youth is a priority public health issue that many communities are working urgently to address. “CULTURE FORWARD: A Strengths and Culture-Based Tool to Protect Our Native Youth From Suicide” was developed by listening to Native voices and gathering community-driven, evidence-, and practice-based solutions to prevent Native youth suicide. This practical resource provides Native community and national leaders, as well as non-Indigenous allies, with accessible written and visual information featuring research, programs, and actionable steps to empower self-determination over this public health issue and to promote the well-being of Native youth and entire communities.