Examining community-level protection from Alaska Native suicide: An Indigenous knowledge-informed extension of the legacy of Michael Chandler and Christopher Lalonde

The Alaska Native Community Resilience Study (ANCRS): Deeper description and measurement of dimensions of community-level influence

Exploring the emic meanings and processes associated with cultural continuity, ANCRS constructs new survey measures and subsequent data sets derived through direct participation of community residents in three regions of Alaska at highest need for effective, culturally congruent, and community-based suicide prevention initiatives: the Yukon-Kuskokwim, Northwest Arctic, and Bering Strait regions (Figure 1 maps their locations). ANCRS uses mixed methods to identify pathways from larger social and community-level processes down to individual-level youth experiences, with potential to inform a wide array of wellness and suicide prevention efforts. ANCRS seeks to advance understanding of relationships between: a) cultural continuity, b) community response to imposed social change, c) self-determination, d) community development dynamics, e) services, and perhaps most crucially, f) the mechanisms by which these influence individual well-being (Kirmayer et al., 2007) and protection from suicide. These mechanisms of community-level influence on risk and protection have significant potential to inform prevention and intervention efforts. As one example, one mechanism of interest includes ways community leadership works together to respond to community members’ perceived needs in an on-going, culturally resonant manner, conceived as governing responsively. Other protective factors and their associated mechanisms of influence include a community's ability to expand young peoples’ experiences and possible futures by providing opportunities, along with governing responsibly, and teaching community history and culture. Extensions of Chandler and Lalonde's work include new protective factors and their associated mechanisms associated with ways a community offers spiritual resources to its members, described as supporting spirituality, engaging young people in activities, and continuing Indigenous ceremonies. Together, these protective factors and their associated mechanisms offer families and the young people within them ways to engage with and influence collective efforts, and derive benefits through protection and enhanced well-being. For Indigenous communities that have undergone recent and rapid imposed social change, mechanisms associated with self-determination establish vital local control and governance over community institutions. These community protective factors and their mechanisms support young people as they craft their pathways into the future in ways that makes personal and collective—cultural—sense.

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Figure 1.

Alaska Native Suicide Rates by Tribal Health Region (Alaska Native Epidemiology Center, 2021).

Cultural continuity, as described by Chandler and Lalonde, is a process infused through the above described (and additional and many yet to be described) mechanisms. Delineating these mechanisms begins to trace a process of shared coherence and collective knowledge crafted by community members across time, enabling and supporting meaningful developmental or life course pathways. In this way, culture shapes personal meaning-making across the life course and provides groups with shared understandings across time collectively. ANCRS engages with community members holding various roles within the communities to understand how these multilevel systems of culture interact across their different levels of influence.

Our work emphasizes two enduring legacies of Chandler and Lalonde. First, they advanced culture, defined as collective processes shaping self-actualization, as central to theory and to interventions derived from such theory. Second, their theoretical orientation underscored the primacy of research that is responsive to the priorities, knowledge, and worldviews of its communities of concern. As such, we provide the rare opportunity to document the value-added contributions of community engagement to the quality and utility of the science and the resulting knowledge base as it is co-produced.

Contextual considerations in the development of a measure of community protection in rural Alaska Native communities

Communities in western Alaska are hundreds of miles off the contiguous road system, and accessible only by boat, small plane, or snowmachine. Ethnicity is majority AN, which in most communities exceeds 90%. The major cultural linguistic groups in this region include Inupiaq, Yup’ik, Cup’ik, and Athabascan. In contrast to the reservation system in the lower-48 states, each AN village community is a federally recognized Tribe, and some AN communities have more than one federally recognized Tribe. Residents are shareholders in their AN Regional Corporation, and their regional nonprofit health corporation provides universal access to medical care. These arctic and subarctic communities can be differentiated by coastal or riverine geography, contrasting histories, and diversities of economic development typically related to natural resources such as fisheries and mining. A subsistence economy is augmented by a limited number of tribal, state, and federal jobs, primarily in government, health care, and schools. Food is heavily dependent on local fish, birds, and land and marine mammals. Many of the current community locations are sites where early colonizing efforts required parents to relocate to settlements in order to enable their children to attend mandatory school (Wexler, 2006).

Additionally, enactment of self-determination in an AN context is distinctive. For instance, in response to the devastating impact of alcohol, a majority of these communities have used the Alaska local option law to declare themselves dry—making importation and possession of alcohol illegal. These contextual and historical factors required community collaboration and adaptation of the original concepts and factors explored by Chandler and Lalonde to fit rural AN community contexts and values.

The impacts of colonial intrusion on Alaska Native peoples

This description of the Alaska work opens with a portrayal of the impacts of colonial intrusion on AN people. This shared experience of intergenerational trauma, colonial suffering, and cultural violence sets the stage for understanding why a theory of cultural continuity has been so resonant in the field of Indigenous suicide research. Chandler and Lalonde's theory powerfully links the individual experience of trauma to strengths-based communal processes of resistance. These community-level processes function as culture-specific adaptive strategies creating protection for young people from suicide.

Alaska is the rightful homelands to Indigenous people who are now the 229 U.S. federally recognized Tribes that spread across all of the 424.5 million acres of this largest state in the union. The Indigenous peoples of Alaska are distinct and resilient. The diverse Indigenous cultures, languages, and ways of living in Alaska are central to AN communities. These lifeways support distinctive social patterns that are protective for children and young people as they grow up and learn how to navigate life and its challenges. For young AN people, engagement in subsistence and ceremonies, cultural rites of passage, and self-determined governance and leadership provide clear pathways toward accessing traditional resiliencies and strengths (Rasmus et al., 2019).

Forced disruptions by the colonial intrusions into Alaska's Indigenous ancestral homelands commenced in the 17th century. These incursions drastically changed the social, political, educational, and economic landscapes, and with this, the modes of living in AN communities (Chance, 1990; Fienup-Riordan, 1991). Through this process, the capacity for developing Indigenous cultural and community strengths was forcibly unsettled. Resource extraction, air travel, media, and western schooling only intensified assaults on these capacities (Evans-Campbell, 2008). Because Alaska is so vast and its land's geographic remoteness and climate posed challenges for those not born to them, some areas did not experience an onslaught of intrusion and extraction of resources from outsiders until the late 19th and early 20th centuries. The impacts of colonial racism and structural violence set upon AN people are ongoing and lasting, with the outcomes of such traumas over generations and single lifetimes manifesting in high rates of suicide, rising most sharply and shockingly among young AN people (Allen et al., 2011; Berman, 2014; Hull-Jilly & Saxon, 2019; Leavitt et al., 2018; Skewes et al., 2020; Wexler & Gone, 2012).

In most contemporary AN Elders’ memories, the death of a younger person by suicide was almost unknown (Ayunerak et al., 2014). Rates remained stable until 1965, when the suicide rate among AN people was observed to double by 1970, with all the increase accounted for by increased rates of suicide among 15–25 year olds (Kraus, 1974). This staggering growth rate continued to double every five years until the 1990s, when these unacceptably high rates plateaued (Allen et al., 2011; Brems, 1996). These rates have now persisted over the past 35 years in rural Alaska, while in some regions, including the three regions collaborating in the ANCRS research, rates have continued to increase, although at a slower pace than the previous century (Alaska Department of Health and Social Services, 2020).

One explanation for this trend highlights the numerous ways cultural disruptions are associated with acculturation stress and identity struggles among young Indigenous people ages 14 through 18 years (Brave Heart & DeBruyn, 1998). Earlier research on the dramatic rise in suicide among AN people, particularly among young men, shows how the rising death rates parallel the accelerated rates of change taking place within AN communities, transforming or suppressing Indigenous systems and factors within them that contribute to protection, particularly for young people as they grow into adulthood (Rasmus et al., 2014; Wexler et al., 2015).

In one poignant example of these changes, Ayunerak et al. (2014) describe the forcible abandonment of the communal qasgiq or men's house structures, in Yup’ik communities. This was an historically rapidly unfolding major event in a society that coincided with the precise time period when suicide began doubling in rates in AN communities. During the winter months, men traditionally lived and worked in the qasgiq, boys would receive education and instruction, and entire extended family kinship structures would gather there for ceremonial song and dance. However, the qasgiq also served as much more than a physical structure. As a social institution, it provided the collective organizing, governing, and spiritual system within which the community lived. Missionaries actively discouraged the qasgiq system, dispersing the men, and along with them these communally based extended family kinship-based networks into more isolated nuclear family households. This suppressed and fragmented the power structures in the communities and along with these, the educational structures for young people. This destruction of the qasgiq coincides with the accelerating suicide rates in young people, and in young men in particular.

Conceptual expansion of cultural continuity theory

We designed ANCRS to include an AN Indigenous knowledge-informed process that occupied a substantial period of the study timeline. These efforts were directed toward building a direct measure of community protective factors linked to cultural continuity that could be completed by members of the community of concern. Row 1 in Table 1 elaborates on ways in which this knowledge co-production work led to a re-envisioning of cultural continuity as an expanded set of protective factors situated within a systems process of community resilience. This reconceptualization identified additional dimensions of protection on the community level that were culture-specific or culturally mediated community practices, strengths, and resources specific to rural AN community contexts. Figure 2 outlines how this collaborative work identified new culturally salient domains that expand upon existing domains from Chandler and Lalonde's original work, while also allowing for their direct assessment by community members.

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Figure 2.

Model of Community-level Protection from Suicide Risk for Young People Living in Rural Alaska Native Communities.

In Figure 2, we list the theorized primary domains or characteristics of protective AN communities as informed by our multi-layered AN collaborator groups. In the middle column, community characteristics are defined as resources. The provision of these resources along the developmental pathways of young people has potential to be supportive of youth well-being and preventative of suicide risk. One example of the ANCRS cultural continuity theory expansion driven by ILT and RSC (Wexler et al., 2020) includes how, from an Indigenous-knowledge perspective, ‘self-determination’ is viewed as central to continuation of traditional practices in an AN community context. Through the community engagement process in the interpretation of the data, understandings of self-determination became more nuanced, and emphasized two distinct elements, responsible governance, which was effective in completing its governance responsibilities, and in addition, responsive governance. Responsive governance includes culturally salient decision-making processes that are receptive to diverse needs across the community. These processes include explicit invitation of input from multiple perspectives, and in particular, key perspectives from community Elders, into this decision-making dialogue.

Another conceptual expansion enlarged scope of cultural continuity to include community efforts to train service providers such as teachers, law enforcement personnel, and healthcare providers on the local history and culture of the community in support of culturally responsive service provision. Cultural continuity was further reimagined to include the opportunity structures in rural AN communities that support young people to: a) become involved in ceremony and traditional gatherings; b) speak their Indigenous language; c) engage in subsistence activities such as hunting, gathering, and fishing; d) spend time with Elders; and e) learn traditional song and dance. Other content identified from the literature included local community and community member input opportunities for youth jobs, sports, and recreational activities.

The RSC and the entire ANCHRR network was unified in advocating for inclusion of item content in the PCS about the nature of and access to spiritual resources in a community, and the effectiveness of these resources in contributing to social connections and supportive relations. This new content was generated out of the RSC's aim of developing a measurement tool capable of identifying a wide breadth of community-level strengths in rural AN communities. The overarching goal was to provide broader understanding of the relationship of community protective factors to individual youth well-being and prevention of suicide.

Refinement of data sources and data collection procedures

With utmost respect for the ground-breaking nature of Chandler and Lalonde's original work, the ANCRS research design team also sought to address limitations to their pathfinding discoveries. Some of these most significant limitations relate to reliance on publicly available administrative data provided by several governmental organizations that included the Federal Treaty Negotiations Office, British Columbia Treaty Commission, Indian and Northern Affairs Canada, and British Columbia Ministry of Health. Chandler and Lalonde's use of these data was in many ways as innovative as their theory, allowing the authors to, in their own words, thoughtfully “jerry-build a set of after-the-fact proxy variables meant as indirect measures of cultural continuity” (Chandler & Lalonde, 1998, p. 208). At the same time, this created significant limitations. First, the use of these proxy variables limited theory to the available pre-exiting data, and additionally to the quality and precision of these data. Second, these data, while quite novel as a data source in suicide prevention research, were by their nature fundamentally lacking in the perspectives of community members. Composed of variables devised by and then collected through methods created by national governing organizations, which had their own long histories of oppression and exclusion of Indigenous communities, resulted in an approach that introduced much potential for cultural misunderstanding and bias.

Row 2 of Table 1 provides examples of the contrasting ways that the ANCRS collaboration with team members living in rural AN communities allowed development, from the ground up, of a structured interview focused on aspects of community life important to these AN stakeholders. The approach allowed for the possibility of a direct measure, through interviews conducted by community members with community members, as a tool for evaluating their own communities.

Interviewers for the study were themselves rural AN community residents from the study region. These interviewers were students in a University of Alaska rural campus located in this region, who were enrolled in a Rural Human Services Certificate or Human Services Associate Degree program. These students were enrolled by the project into an elective, paid research practicum providing credits for their degree program. This practicum included a three-day campus-based face-to-face research training seminar on research ethics, methods, interviewing skills, and study procedures. These students then joined the study research team as interviewers who conducted structured phone interviews that included the PCS items with 251 rural AN community members across the 65 participating rural communities in the three study regions.

Interviewees were identified through a purposive sampling procedure. This procedure aimed to identify between three and five long-term residents in each of these communities who were knowledgeable about youth resources in their community, and who were representative from diverse community sectors in areas such as government, education, youth services, criminal justice, and religious institutions, across each of the 65 communities in the three regions. In initial contacts by ANCRS interviewers, community members nominated potential interviewees as individuals who were particularly well informed and knowledgeable about their community, and about its formal and informal community resources for young people.

The successful implementation of this nomination process provides just one of numerous examples of the ways that the community engagement process enhanced the quality and rigor of the scientific work. This locally informed nomination procedure facilitated high-quality data from each community. Effective nomination procedures required interviewers who were known and trusted by the community, as well as who were knowledgeable about how to sensitively facilitate this nomination process in a culturally congruent manner.

These refinements to the study methods came about through RSC direction, based in their own local Indigenous knowledge on how access to community resources in their communities. Row 2 of Table 1 summarizes key elements of how this high level of community engagement, which included ILT and RSC oversight and use of local interviewers, enhanced the internal and external validity of this study.

The RSC also worked with the university investigators to devise a feasible standardization of the data collection procedures with fit to local rural AN contexts. This created uniform data collection procedures for our geographically dispersed team. These procedures were at the same time responsive to important cultural protocols on how to be respectful in these interactions. This provides an additional example of the ways that the community engagement process enhanced the quality and rigor of the scientific work. Here it maximized the quality and reproducibility of the data and its findings by ensuring the integrity of uniform data collection procedures across communities while also fostering a culturally respectful interactional style. This respect for cultural protocols and communication norms facilitated interviewing of potentially sensitive information about one's home community.

Expansion of scope and longitudinal time frame of data sources

ANCSR expands the longitudinal time frame of follow-up on community suicide death, from five years in Chandler and Lalonde's original study, to 11 years using State of Alaska Health Analytics data (2007–2017). ANCRS additionally compiled data on suicide attempt by tracking hospitalizations for self-injuries for 10 years from the Alaska Trauma Registry (ATR) of the Alaska Violent Death Reporting System (AKVDRS) at the Alaska Division of Public Health (2008–2017), along with a briefer, more comprehensive listing of inpatient and outpatient hospital discharge data for suicide attempt (10/2015–3/2018) provided by the Alaska Health Facilities Data Reporting Program (HFDR). Row 3 of Table 1 outlines how these additional data sets allow ANCRS to consider the effects of community-level protective factors on a spectrum of suicidal behavior to include death and attempt, adding to the robustness of the findings. This expanded longitudinal time frame enhances statistical power in this study of suicide, which is itself a limited base rate event, and is conducted here among a small number of existing communities, all within a small population Indigenous group.

Increased measurement and analytic precision

Chandler and Lalonde's use of proxy marker variables imposed analytic limitations. This led to the composition of dichotomous variables with limited variance, and constrained analytic techniques to basic inferential statistics such as chi square tests. Row 4 of Table 1 provides a summary from a more detailed technical description in a forthcoming paper on the measurement properties of the PCS and its association to suicide (Allen, Wexler et al., 2022).

In capsule summary, the ANCRS measurement development approach allowed for ordered categorical response scaling of variables. Multilevel exploratory and confirmatory factor analytic and multilevel item response theory scale development procedures provided sequential testing of parameters through increasingly stringent models. This yielded item content that tapped multiple features within each factor domain, a clear structure, and a measurement model that displayed good functioning at both individual and community levels.

Recent advances in multilevel structural equation modeling next allowed testing of relationships to suicide. Bayesian analytic techniques allowed flexibilities that increased precision with small samples and allowed use of random effects models to account for instances of within and cross-level measurement noninvariance. Estimation of Level 2 (community-level) latent variables with random intercepts could be derived from Level 1 (individual-level) manifest observed variables and their latent variables. Measurement error resulting from sampling only a finite number of items is controlled for by specifying a measurement model for each factor, while sampling error from sampling only a finite number of individuals in each community is accounted for by specifying random effects in the model.

These techniques allowed new possibilities in testing the relationship of community-level protection to suicide. While these new analytic capabilities are impressive, their effective use was possible only through the extremely high-quality community-level data the ANSRS local researcher team assembled in remote, geographically dispersed, and difficult to reach arctic and subarctic communities. Scientific integrity was a direct consequence of the depth of community engagement. The ANCRS community research teams’ commitment to the issue of youth suicide in their communities, and their hard and at times difficult work, made advanced methods possible. Too often, the value-added component of community engagement to the science itself is under-recognized; in ANCRS, engagement made the methods possible.

Enhanced interpretation processes

As part of our Indigenous knowledge-informed research process, Row 5 of Table 1 overviews how AN community members are deeply incorporated into the ANCRS analytical process on multiple levels. The university research team meets monthly with the RSC. During these meetings, preliminary findings from ANCRS are shared, interpretative possibilities are discussed on an ongoing basis, and findings are iteratively considered within the context of members’ experiences and positionality. Additionally, the rural AN interviewers who collected the PCS data are also involved in these discussions, adding context and insights from their interviewing experience to the analytical work. This engaged process incorporates perspectives of community members from across the three participating regions in organizing and making sense of research outputs. The important consequence of this is that the research findings ultimately can reflect Alaska Native worldviews and practical understandings, and in doing this, better address community priorities.

Expansion to testing a multilevel conceptual framework

The ANCSR approach builds on Chandler and Lalonde's earlier efforts establishing a relationship between proxy variables for cultural continuity with suicide in Canadian First Nations communities. Row 6 of Table 1 describes how in addition to replication and extension of these findings, ANCSR seeks mechanistic understanding of how community-level protective factors confer protection to young people. Our mixed-methods approach in upcoming work, strongly endorsed by our stakeholders, will include PCS adult community member assessment of shared community practices, resources, and structures, testing a model of their influence on youth-reported protective factors using validated measures of protective outcomes from suicide, such as Reasons for Life (Allen et al., 2021). In addition, qualitative research will be used to explore adult descriptions of how these factors came to be, are sustained, and function in their communities.

Knowledge translation and translational science efforts for community use

Following in the footsteps of Chandler and Lalonde, ANCRS is systematically building toward an applied, science-to-service translation. The ANCRS community engagement structures provide contacts and social avenues for accessible and actionable knowledge translation and dissemination of the research results to local rural AN communities and tribal health leaders and providers. Row 7 of Table 1 describes how ANCRS is developing community-level measures to suggest new strategies for effective interventions for AN communities to address a critical need by building upon strengths. The PCS identifies AN community strengths and avenues for their growth in accessible and non-stigmatizing ways. A final aim for ANCRS is to provide communities with a tool for local assessment and planning. The ongoing mixed-methods research on mechanisms of protection aims to stimulate lateral knowledge-sharing. Description of examples of protective processes and practices can be leveraged to provide strategies for suicide intervention in rural AN communities.

An intervention science approach particularly interests our team. The central goal of intervention science transcends mere testing of an intervention for efficacy and effectiveness. While outcomes findings are important goals for interventions that use strengths-based strategies informed by cultural continuity theory and community protective factors, an intervention science approach additionally allows for causal inference of their mechanistic functioning by measuring change in key variables in the theory, allowing for testing their function as a theory of change guiding intervention.