Building on strengths in Naujaat: the process of engaging Inuit youth in suicide prevention

ABSTRACT

Death by suicide and attempted suicide among Inuit youth is now considered a public health emergency of epidemic proportion, with rates among the highest worldwide. A strong sense of cultural identity and pride, as well as social capital, has been identified as being protective against suicide. The Canadian Institute for Health Research (CIHR) Guidelines for Health Research Involving Aboriginal People call for communities to be included in the conception, planning and implementation of research. The authors took first steps towards sharing the responsibility of designing a community initiative with the youth of Naujaat, Nunavut, a community located directly on the Arctic Circle. With the objectives of promoting open listening and exploration of community needs and enhancing self-determination and sustainability, we postulated a youth resiliency project that will be co-authored by the community. This paper describes the joint work process. We recount how Inuit youth take ownership of the project with the guidance of Ms. Elizabeth Haqpi, a Naujaat Elder. The article will particularly reflect on the process of balancing the different perspectives and expectations while enjoying the richness of mutual learning through keeping each other accountable.

KEYWORDS:

• Inuit youth resilience
• community-based participatory research
• Indigenous youth initiative
• youth suicide prevention
• qualitative research
• Canada

Introduction

High rates of suicide and attempted suicide among Inuit youth are now considered a public health emergency of epidemic proportion [1]. Rates in Nunavut are 10 times higher than in the general Canadian population, with males aged 15–29 at highest risk [2]. Among Circumpolar regions, Nunavut has the third highest suicide rate following Chukotka Autonomous Region and Greenland [3]. Inuit Health Survey found that 48% of Inuit adults in Nunavut seriously considered suicide at some point in their lifetime, and 29% survived a suicide attempt [4]. Youth (18–29 years old) were more likely than other age groups to report suicidal ideation in the past 12 months [4]. Individual risk factors affecting the general population have been studied extensively and include mental or physical illness, addictions, legal or financial stress and having a history of suicide attempts [5]. Family- and community-level factors have also been described including individual risk factors in other family members and suicide in peers [5]. It is worth noting that suicide risk factors found specifically for the Inuit population in Nunavut do not differ from the risk factors in the general North American population [6]. Individual mental health factors, including depressive symptoms, impulsiveness and level of aggression, were correlated with suicidality along with history of childhood sexual abuse, family history of death by suicide and comorbidity with substance abuse [6].

The high rates of death by suicide and attempted suicide among Inuit youth call for population level approaches [1,2,7]. Kirmayer postulates a connection between community-level autonomy and protective factors for suicide and provides an opportunity to understand Inuit youth suicide in a context that takes power relations, inequity, and social and political oppression into account [8]. Cultural continuity factors including self-government, band control of education and health services and involvement with land claims were shown to contribute to healthier communities [9]. In Nunavut, well-being has been linked to talking, visiting, spending time with family and experiences on the land [10].

For the purpose of contributing to a decrease in suicide rates, we deemed it useful to shift our perspective from historical multigenerational trauma to community adaptation and resistance as sources of resilience [11]. Such an approach is supported by the Promising Case Studies as summarised by the Arctic Council Sustainable Development Working Group, which recommends targeting youth with culturally rooted, community specific, strength-based interventions as the future direction for both clinicians and researchers [12]. Strengthening resilience in Indigenous Peoples encompasses connection to the land and a sense of place, recuperation of tradition and language, storytelling, and political activism as a source of individual and collective agency [13]. In the context of Indigenous health, leveraging community resilience can be formulated as a complex transformation and redistributing of resources between networks of relationships, events and settings. It is a longitudinal dynamic process [14]. Parents, extended family and school among many other complex and atypical variables can contribute to both strengths and vulnerability of Indigenous youth [15]. Further social and cultural resources that provide support – yet potentially also distress – to Indigenous youth in the Arctic include reliance on sharing, living off the land, kinship-based peer networks, fluid households and speaking the native language [15].

The Canadian scientific community has a long and infamous history of propagating Non-indigenous worldviews and notions of progress in the name of “beneficial” outcomes [7–10,14,15]. In his article on the disparities and contradictions of Indigenous and non-Indigenous perspectives and the inherent power imbalance, Cole points out: “we never had ‘rights’ before contact we had relationships we had community”[16]. Today the Canadian Institute for Health Research (CIHR) Guidelines for Health Research Involving Aboriginal People call for communities to be included in the conception, planning and implementation of research [17]. Yet, as of today, the Inuit Tapiriit Kanatami, an advocacy organisation representing Inuit interests in Ottawa, has identified lack of “input and consultation in identifying research needs and questions in designing studies”[18]. The term Community-Based Participatory Research (CBPR) has become widely used; however, fewer studies have actually discussed a partnership with the communities [19]. Instead, community involvement is often reduced to “consultation”, leaving the participants feeling exploited [20]. The appropriation of local initiatives as research projects can undermine local agency and leadership [21]. The risk of symbolic use of involvement, which does not truly reflect community voices, can be prevented by transparency, careful planning and building lasting relationships [20]. Long lasting involvement with communities has been identified as a key to a deeper understanding of Indigenous resilience at the crossroads of competing demands and expectations [22]. Finally, providing training and employment for local researchers has been suggested in a previous issue of this journal as a strategy to ensure that research findings find their way back to the community in a meaningful way [23]. Taking the above described principles to heart, the initiative introduced here consists of a long-term work process fuelled by the wishes and ideas for a better future of the youth of Naujaat. The following sections will describe this process of engaging a group of young people and a community Elder to develop a set of goals and directions to enhance youth resiliency. We propose that enhancing resiliency will help to reduce the high rates of suicidality in Inuit youth. The outcomes of the discussions with the youth will be presented in more depth in a future publication.

Methods

One of the authors (NG) suggested the use of CBPR to involve youth in design and implementation of a project that would be based on resilience and sense of ownership. CBPR is defined as a systematic approach for engaging groups of people in a process of inquiry and social change [24]. It is central to CBPR to take the dignity and autonomy of individuals who constitute a “community” as a starting point and frame of reference that guides research. “Throughout the life of the study the CBPR process is cyclical, iterative, dynamic”[24]. CBPR presented itself as a good fit due to its emphasis on the collaborative approach and mutual learning that requires flexibility and reflective professional practice [25]. As part of this approach, it was proposed among the researchers to engage a group of Inuit youth from the community to co-author the project, lead focus groups and take on a self-directed, self-sustaining initiative which would ultimately belong to the community. The initial objective of the project became to establish a partnership with a group of youth in the community.

The roots of the relationship between the people of Naujaat and the Principal Investigator (PA) go back to her first visits to Naujaat in 2012 and 2013 as a psychiatry resident. Since 2014, PA has been spending 1 week in Naujaat 3–4 times annually as part of specialist care provided by Ongomiizwin Indigenous Institute of Health and Healing (formerly J. A. Hildes Northern Medical Unit), with MB present as a psychiatry resident since 2015. The clinical experience includes stories of domestic violence, substance use, suicides, grief and loss, and trauma. Hearing these stories led us to ask the questions of the strengths and resilience that carried people through these challenging circumstances. We started to search for the broader perspective of the agency, creativity and pride of the youth in Naujaat. This led to the initial conceptualisation of the research question. Furthermore, recognising the issues of privilege and power inherent in delivering medical services in Nunavut as a non-Indigenous provider, the collaborative and responsive emphasis of CBPR was pivotal. The CBPR approach further allows integration of 2-eyed seeing into a suicide prevention study. Two-eyed seeing is concerned with using both Indigenous and Western understandings to approach mutually beneficial learning between researchers and the community [26].

Planning phase

As part of initial planning, publicly available documents and Naujaat public institutions (Royal Canadian Mounted Police office, Hamlet office, Wildlife Office, Health Centre, Arctic College, after-school programme run by the Catholic Church) were accessed to better understand the context and background of the community we were about to approach. Inuktitut is the primary language for 95% of the residents. The population of Naujaat in 1996 was 559, whereas in 2016 it reached 1082. According to 2016 census, Naujaat has the youngest population in Nunavut with the majority of Naujaat residents under the age of 24. Chesterfield Inlet Indian Residential School operated by the Catholic Church between 1929 and 1970 played a prominent role in the lives of many residents of Naujaat. Despite the cultural disruptions resulting from the colonial history and its ongoing effects on today’s generations, traditional activities including carving, sewing and providing for families by hunting and fishing “on the land” remain important to daily life. The community has approximately 140 jobs. Few government and teaching positions are filled with Inuit professionals. Jolene Itkilik, Tusarvik School Vice-Principle, is the first teacher from Naujaat to become a school administrator. In the Health Centre, nurses and doctors are Qallunaat (non-Inuit), whereas clerks, interpreters and house-keeping personnel are Inuit. Avoiding polarisation between “us” and “them” is an ongoing struggle for both Qallunaat and Inuit.

The initial planning stages in 2015 were focused around ongoing dialogue with the Naujaat Health Committee and the Hamlet Council. After initial presentation to the Hamlet Council, our initiative was welcomed with: “When are you coming back?” The Hamlet identified a need for increased connection among generations with 1 councillor noting “Young people don’t talk to us anymore. They just get angry”. Further, the idea of focusing on resiliency resonated strongly with council members. Agatha Crawford, Naujaat Elder, stated “Why do we talk about suicide all the time!? Let’s talk about love!” As part of this discussion, it was agreed that the Hamlet will be updated of the research process in an ongoing way. Memorandum of Understanding was signed between the researchers and the Hamlet Council outlining the intent of the study with the emphasis on resilience and community building, as well as the agreement that data from this study will belong to the community. After completing the analysis, all digital recordings will be kept as a historic document in Nunavut Research Institute in Iqaluit, with a second copy to be stored in the Naujaat Hamlet office. Maintaining sustainability of the project was emphasised by several members of the Hamlet Council as another key responsibility of the research team. Consistent with ethics approval obtained from Research Ethics Board of University of Manitoba and Nunavut Research Institute, all interviews were kept confidential, and identifying information was removed.

Getting Hamlet Council suggestions for a list of youth participants was more challenging. Hamlet Council was hesitant to single out youth for leadership roles. One of the authors (EH), who is a member of the community, explained this hesitancy: the idea of leadership is different in Inuit (as compared to Western) culture, with leadership being associated with specific tasks being accomplished rather than a particular position. Nominating someone can appear to be implying that those nominated are better than others and to be singling them out, whereas communal values of blending in and being part of society remain paramount for the Inuit [27]. We (PA and MB) approached Julia MacPherson, high-school Vice-Principal, and were provided with a list of recent and soon-to-be graduates who would potentially be interested in becoming youth researchers. As the school system remains founded on the Western values of competitiveness and individualism, it was easier for the school administration to name some recent or soon-to-be graduates who stood out as future leaders. When we read out the 8 names given to us by the school, the Hamlet Council approved the list of candidates.

We were fortunate to recruit Elizabeth Haqpi, Naujaat Elder, as a team member. Ms. Haqpi wholeheartedly embraced the idea of listening to young people to let them know that their dreams and visions count. In her experience, Inuit culture meant that young people remain silent and listen to their Elders. Encouraging youth to speak up would go against the tradition. Yet, as noted above, the need to open the intergenerational communication was explicitly formulated by the Hamlet Council.

The youth were contacted by Ms. Haqpi. All 8 candidates suggested by the high-school Vice-Principal, as well as 4 friends they brought along, came to the first meeting. After initial scepticism (questioning the motives behind the initiative, wondering if it will be yet another 1 time event, inquiring about personal gain of the researchers), the youth group demonstrated unanimous enthusiasm for moving the focus from deficits and problems leading to suicide to community strengths and assets. Regular meetings with the youth group were established during the process of obtaining the approval of Research Ethics Board, University of Manitoba, Nunavut Research Institute and Government of Nunavut.

Initial data collection

In April 2017, the authors (PA, EH, MB, EG) invited the core youth group to co-facilitate focus groups. Training of the youth group consisted of 4 sessions of mutual learning, in which we gathered youth input on how to ask questions and what areas to focus on, while sharing ethical implications of confidentiality, voluntary nature of participation, and significance of recruiting participants of diverse backgrounds. We practised the games and activities planned for the focus groups with the core youth group until they were comfortable taking on co-leadership roles. Snowball sampling was used for recruitment of focus group participants. Together we held 5 focus groups, each with 2 to 3 co-facilitators from the original youth group. The focus groups were run with a total of 36 participants in a span of 1 week, with 6 to 10 participants per group. Every participant received an honorarium of $15, every co-facilitator received $60 honorarium.

There were 3 components in each focus group: Personal Meaning Maps, collecting ideas for new projects, and “Voting with your feet”. Albeit our main goal, reducing suicidality in youth, was mentioned at the outset, we emphasised that our approach consisted of focusing on strengths and assets. Personal Meaning Maps were used to pinpoint and visually illustrate connections between “Naujaat” and activities, people and environment. Personal Meaning Maps served as a tool to visualise assets, resources and social capital. Two to three participants worked on 1 Personal Meaning Map, and then presented it to the rest of the group. On the newsprint, we collected ideas of projects that would enhance the well-being of the community. Lastly, we pointed out that each corner of the room had a sign in Inuktitut and English (“Yes/ii”, “Maybe/Amai”, “Not really/Aakkaqai”, “Not at all/Aakka”). We asked group members to rush to the corner with the “gut feeling” answer, without thinking too much about it. The questions varied from desired career choices to feeling committed to making Naujaat a better place for future generations. The goal of this activity was to combine a physical activity with some measurable outcomes of future-orientation (“Can you see yourself in 5 years from now?”), professional aspirations and community cohesiveness (“Do you feel like you belong in Naujaat?”).

The energy and dedication of the co-facilitators was impressive. The youth co-facilitators spoke with friends and family, went to the Community Hall and phoned around to recruit participants. They showed up on time, set up the room, helped to clean up afterwards, actively engaged in explaining Personal Meaning Maps during focus groups but most importantly, in the process of focus group delivery, they owned the proceedings with great pride and sense of accomplishment. With little nudges: “What else?” and laughter, with expanding the signature witnessing procedure to include every participant (as opposed to only those who prefer to give verbal consent, implicitly teaching us that our original plan would have been embarrassing to people who cannot read well), they steered the meetings past potential pitfalls and, at the same time, shared their emic knowledge with the academic team members. At the wrap-up pizza party with the youth researchers, the discussion meandered towards more private aspects of our research questions: teenage parenthood, overcrowded housing, pressure to stay at home and obstacles to obtaining post-secondary education. “When are we meeting again?” was the final question from the group.

In October 2017, 3 authors (PA, EH, MB) met with the youth to provide feedback on the list of 46 projects compiled from focus groups. The youth group voiced their preference to meet on a regular basis to discuss how to elicit further feedback from the community on these projects. The projects suggested by focus group participants evolve around 3 main topics: athletic activities and dancing (e.g. swimming pool, hockey rink), social investments (e.g. crafts centre, day care) and business ventures (e.g. hunting store, clothes store). The most salient topics that frequently came up in the conversations, however, were the need for better employment opportunities, the importance of access to college or university education, and of options to balance a career with family responsibilities. The youth-identified interventions/projects will be discussed more in detail elsewhere. Two young people accompanied us to the Hamlet Council meeting to deliver first feedback. In the process it was announced that 2 youth will be incorporated as Youth Advisory Committee in every future Hamlet Council meeting to introduce youth perspectives to the Council and learn how municipal decisions are being made.

Discussion

The goal of our initiative is to reduce suicidality among Inuit youth by strengthening their resilience. Previous review of successful resilience building projects in Circumpolar regions identified among others a wide range of themes including self-determination, community engagement, cultural competencies and sustainable funding [12]. In addition, one of the central ideas identified by multiple Naujaat residents was the troubling decline in communication between generations in the community. This notion is supported by the literature [10]. Historically, youth were expected to learn by observation and listening [27]. At present, however, given the amount of societal changes and adaptations necessary, the need to blend traditional ways with the ever changing societal demands of overlapping cultures requires different ways of engaging youth. With the community elders’ explicit backing, this initiative started out with listening to the youth and their ideas and visions for their community.

In the 3-year engagement process, we fostered respectful relationships with the core group of youth. They became the driving force behind the project; they helped access their peers and elicit their perspectives; and they shared their own challenges and visions. The need for better educational and employment opportunities emerged from our study as the youths’ central concerns. With the rapidly growing population, the community is facing an unprecedented challenge. In the next decade, the number of young people looking for work will double, and the demands for childcare, educational and employment opportunities need to be addressed. Lack of infrastructure was pointed out as a challenge for young entrepreneurs in small isolated communities [28].

This work is similar to the CBPR research project engaging Yup’ik youth in Alaska by the team of Allen and Rasmus. The process of youth engagement in generating meaningful ideas and the development of action that reflects intergenerational communication and pride are demonstrated to be important aspects of Indigenous youth well-being [29].

A big success of our initiative was the youth taking ownership of the project and group meetings taking on a regular rhythm and purpose of their own. Whether obtaining feedback from the community on the desired new projects or sharing stories about grandparents feeding the toddlers of teenage mothers too much candy, these meetings symbolise youth finding their own voices and enjoying being active citizens of their community. This way, the youth have begun to use positive dialogue and agency to promote life and prevent suicide.

One of the strengths of this initiative is the ongoing work to integrate 2-eyed seeing into suicide prevention research in the community of Naujaat. Inclusion of youth perspectives, consultation with the Hamlet Council and identifying Elders to be involved are forming the backdrop for ongoing work. In a clinical setting, it is common to hear: “How long have you been coming to Naujaat? Three years? Well, now we can talk”. These notions serve as a reminder that our relationships are still fragile and need continued nurturing. The need for ongoing connections and regular contact cannot be underestimated. The tensions arising from the process of engagement provide fertile ground for a deeper understanding and creating novel outcomes [25].

Limitations of this study are the inability to clearly enunciate parameters and objectives which are part of standard Western quantitative research expectations. We take these limitations into account in order to remain open to new emerging themes and ideas as supported by CBPR literature [24]. We found it challenging to adjust to the unpredictability of youth availability. While calling a meeting at a short notice tended to be a rule rather than an exception, it was at times difficult for youth researchers to juggle childcare responsibilities, family expectations and work commitments that arose on the spur of the moment with the group involvement.

Conclusions

“Building on Strengths in Naujaat” incorporates strategies outlined in the 2015 Summary Report of the Circumpolar Mental Wellness Symposium [30]. Arctic Council representatives and international experts in Mental Health established a foundation for improving mental well-being in Circumpolar regions that encompasses focus on children and youth, cultural continuity, re-engagement with community, strengths-based approaches and youth leadership. The population-based approach with direct community engagement in design and implementation of research appears to be a promising strategy to begin addressing the overwhelming problem of high rates of death by suicide and attempted suicide among Inuit youth. As Qallunaat we (PA, MB, EG, NG) are mindful of the ongoing position of privilege we occupy and the longitudinal course of dialogue with all generations in Naujaat that is necessary to be part of the transition. With critical support of the Naujaat Hamlet Council, a core group of Inuit youth in Naujaat, Nunavut have become engaged in CBPR project. Major themes emerging from the initial stages of the engagement process include the importance of long-term relationships built on mutual respect and trust, the minimisation of the “us” and “them” divide, and the use of stories, open communication and listening as pathways to transcultural understanding. Youth creativity and passion in the design and implementation of a collaborative research process has helped to generate knowledge and collective visions and agency for a better future; and it has the potential to anchor the initiative in the community. It may, thus in the long run, contribute to greater resilience and self-determination of Indigenous youth.

We hope to see more collaborative mutually enriching learning opportunities created in Indigenous communities. This will allow us to shift our world view from a deficit model to greater structural humility and respect while acknowledging different forms of knowledge, adaptation, resistance and strengths.

Acknowledgments

The authors would like to thank Naujaat youth researchers Brenden Angotingoar, Edmond Bruce, Lydia Haqpi, Shelley Iguptak, Cathy Katokra, Alvin Kopak, Jonathon Kopak, Nicole Nanordluk, Suzanne Putulik, Lorena Kopak, Natasha Uttak, as well as Naujaat Hamlet Council, Maria Fraser, Nurse in Charge, and Julia MacPherson, Tuugaalik High-School Vice-Principal, for their dedication to this initiative.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

This study was funded by Indigenous Initiatives Fund (2017–2018), University of Manitoba; [0004, 0003] and Ongomiizwin Indigenous Institute of Health and Healing, Rady Faculty of Health Sciences, University of Manitoba. NG’s contribution to this research has received funding from People Programme (Marie Curie Actions) of the European Union’s Seventh Framework Programme (FP7/2007–2013) under REA grant agreement no. [600209] (TU Berlin/IPODI) .