Introduction

“This project seems to have opened up a place that once was closed.”

The quote that opens this paper comes from an Elder who is a member of a Yup’ik Alaska Native community that engaged with university researchers to plan, develop and deliver an intervention to reduce the prevailing disparities in suicide and substance abuse devastating this region of Alaska (Allen et al. 2011; Hagan and Provost 2009). The Elder was interviewed as part of an evaluation, reported here, describing process outcomes from the implementation of a community based participatory research (CBPR) approach to intervention development that took place over a three-year period in the indigenous community context of a remote, Yup’ik community in southwest Alaska. CBPR is fast becoming best practice for conducting research with indigenous and other historically marginalized and oppressed populations (Holkup et al. 2004; LaVeaux and Christopher 2009; Wallerstein and Duran 2006). But what do community members think about it? How do community member participants and co-researchers describe the effects of the strategy? This evaluation of the Elluam Tungiinun (Towards Wellness) Project (hereafter ET) aimed to explore the experience of a community engaged within a CBPR process. The evaluation aimed to understand how a CBPR approach to intervention development could contribute to achieving desired community-level outcomes such as capacity building, social network strengthening, partnership development and ownership. The goal was to identify how the CBPR implementation contributed to the opening-up of this community for change and healing.

The community engagement components of CBPR approaches are now routinely identified as particularly well-suited for research with American Indian and Alaska Native populations, many of which have experienced long histories of disempowerment and marginalization as a result of colonial interactions with the predominately Western cultures of contact (Smith 2012; Mohatt et al. 2004; Quigley 2006). The legacy of these colonial interactions has created a unique set of challenges for the implementation of conventional Western scientific approaches in the study of health and well-being interventions with indigenous populations. It is not uncommon for members of American Indian and Alaska Native groups today to express distrust and reticence about participating in research, and in becoming involved in programs that come from outside of the community (Duran and Duran 1995; Mohatt et al. 2004; Thomas et al. 2009).

Changing a community’s collective experience with research is a critical outcome that the implementation of a CBPR approach has the potential to achieve. But how can we know for sure that our efforts are contributing in a positive and beneficial way to the collective community experience of research? It is more common now for CBPR studies to include process along with program evaluation components to determine outcomes from both the research design implementation and relationship work that is essential to carrying out CBPR (Sandoval et al. 2012). Process evaluations of CBPR within indigenous community contexts remain limited, and tend to focus more closely on the process work required to design and implement research informed or guided by indigenous community constructs and practices (Thomas et al. 2009). When community member perspectives are reported they tend to focus on individual-level outcomes such as personal satisfaction, individual growth or gains through participation in the research (Goodman et al. 2012). For example, one study found that youth participants in a CBPR HIV/AIDS prevention program, perceived the research experience positively stating the benefits of “being heard” and having others “finally listen” (Flicker 2008, p. 76). In another CBPR process evaluation study, community member participants reported experiencing: (1) an increase in self-competence (2) development of a critical awareness of their environment, and (3) development of “resources for social and political action as an outcome of their involvement in the research” (Foster-Fishman et al. 2005, p. 283). The latter finding points to an area where potential outcomes of CBPR move beyond those personally experienced, and suggest broader impacts for communities shaping the collective experience of the process.

Studies that do address community-level outcomes of CBPR often use “ownership” of the project as a primary construct, and identify factors such as community member attendance in meetings and roles in project decision-making to establish achievement of this goal (Suarez-Balcazar and Harper 2003; Wandersman et al. 2005). These are important areas to explore as part of CBPR process evaluation; however, there are other potential contributions that community members can make to an understanding of community-level outcomes of CBPR. For example, community members are rarely asked how they feel the research was affected or impacted by their involvement, or how the research promoted community change beyond the specific aims of the CBPR research and the intervention program it studies. Additionally, community members are rarely asked to share their perspectives of how the researchers may have changed through the process. Community member observations of research represent additional sources of data on program impact at the local level, and in particular, can yield potentially important information community-level process and outcomes that would have otherwise gone unexplored.

The relative dearth of direct observational data from community members involved in CBPR may be due in part to the challenges inherent in most types of long-term collaborations, particularly those involving people from diverse academic, educational and ethnic backgrounds. Researchers may hesitate to report on what could be perceived as negative outcomes from the program. There is a tendency in CBPR process and methods papers to gloss over challenges or report them in the form of a brisk closing paragraph with bulleted items typically including: challenges in keeping to research timelines, challenges in coming to consensus, challenges maintaining community member involvement over time, challenges in achieving community member representation and co-equality on the research team, and challenges integrating or honoring divergent worldviews and experiential realities (Griffin et al. 2010; Holkup et al. 2004; Thomas et al. 2009). It is important to seek out and include dissenting opinions from community members involved in a CBPR process, along with members from the community who may not have been directly involved in the research, but have been affected by the research being done in their community.

This paper describes the experience of one community involved in a CBPR intervention planning and feasibility study that has the aims of reducing health disparities related to suicide and substance abuse. The focus is on the community-level outcomes of engaging in a CBPR project. The aim is to explore how the collective experience of research at the community-level changed over time, and how this collective experience contributed to participation within the project, and community ownership of the project. Of particular interest is the potential for CBPR to change an indigenous community’s relationship to research, and identify any unexplored or unintended outcomes of CBPR. Results from in-depth interviews and focus groups with Yup’ik community members illustrate process steps towards achieving community ownership outcomes, and also reveal potential obstacles in reaching desired goals within the process. The intent is not to provide a “how-to” for implementing CBPR within an indigenous community context. Instead, the goal is to share the experiences of one indigenous, Yup’ik Alaska Native community engaged in a flexible and dynamic research relationship in a way that preserves some of the inherent mutability and complexity of doing CBPR.

Method

This paper focuses on the experience of an Alaska Native community involved in a CBPR relationship with researchers from the Center for Alaska Native Health Research at the University of Alaska Fairbanks. This relationship emerged from a longer-standing relationship the researchers had developed with Alaska Native communities as part of the People Awakening Project (Allen et al. this issue). A critical turning point in the relationship happened when members of one community approached university researchers to request help with addressing rising incidences of youth suicide in the community. Together with key leaders in the community, researchers at UAF submitted a proposal to NIH/NIMHD to implement a CBPR intervention planning and feasibility project specifically aimed at reducing a source of health disparity as identified by the community. The community identified co-occurring risk for suicide and substance abuse as the focus for their intervention.

The Elluam Tungiinun (ET; “Towards Wellness”) Project was funded and contained an external evaluation component to monitor and assess the implementation of the CBPR approach. The evaluation data collection took place in the community over the course of two weeks at two different time points. The first data collection occurred during the last year of the intervention planning and feasibility project, during intervention implementation, and focused on exploring the CBPR process. The second data collection took place two years later, and focused on exploring the collective, community experience and community-level outcomes of the CBPR process implementation. Qualitative methods were used to examine CBPR as a formative, experiential process in the community.

Setting and Participants

The evaluation took place in one Yup’ik Alaska Native community located on the Bering Sea Coast. I had lived for two years in a nearby village serving in a clinical position with the regional health corporation, and had familiarity with the pilot project community and its members. I attended weekly research team meetings for six months prior to traveling out to the community and had several teleconference meetings with the ET project leadership prior to traveling out to the community. I was provided a contact list by the ET Project Director with names of key participants active in the CBPR process and intervention. The goal for the first site visit was to interview 12 community members who had participated in the ET CBPR process and conduct two focus groups with the community planning and oversight groups. Goals for the second site visit included following-up with the same 12 individuals interviewed during the initial site visit and conducting another two focus groups with the community planning and oversight groups.

Using the contact list provided by the ET Project Director and with the assistance of a local prevention staff member, I recruited an initial twelve individuals to participate in the individual in-depth interview. Five additional interviews were conducted with individuals who either approached me and asked to be interviewed or were nominated by a community Elder as a person with a unique or important perspective. Of the seventeen individuals who agreed to participate in the individual interview for the ET evaluation two were youth, five were parents, six were Elders, three were local intervention staff members, and one was the Tribal Administrator. Follow-up interviews were conducted during the second data collection time point with nine of the original seventeen participants in the evaluation. Attempts were made to follow-up with all seventeen individuals, but four had moved out of the community and four were working in a neighboring community and could not leave work to conduct an interview.

I also conducted two focus groups; one focus group was conducted with the local community planning group (CPG) that served as the primary oversight group for the project and the other focus group with a smaller local work group that had the role of developing and delivering the intervention activities. At the first data collection, the CPG focus group consisted of 15 individuals representing youth, parents, Elders, local leaders and local intervention staff. The follow-up focus group with the CPG consisted of six members representing primarily the local leaders and youth. The follow-up focus group with the work group consisted of three members of the original six interviewees. The follow-up data collection occurred two years after the NIH grant support for the intervention had ended and occurred in the middle of summer, a traditionally busy time for community members focused on subsistence activities and commercial fishing. These reasons could also account for some of the difficulties with participant retention between the initial evaluation site visit and the follow-up.

The questions guiding the individual interview were formed with input from the ET research team as well as from the CBPR evaluation literature, which emphasizes the importance of assessing ownership and decision-making at the local level (Suarez-Balcazar and Harper 2003; Wandersman et al. 2005). Separate but comparable protocols were developed for the interviews and focus groups. Each interview began with the following question: “Please tell me about your involvement with the ET project?” Other questions asked about how decisions were made in the project, the role of the university in the project, the role of culture in the project, and project benefits—what kinds of positive affects the project had on the community. Next, a set of questions explored challenges of the work in the community, and what did not go well. The focus group protocol attended to the collective process of engagement and collaboration in the community. Representative questions included: “What do you think this project has done for the community?” “How has your community participated in the project?” “Are some members more involved than others?” and “What happens if members of the CPG/work group do not agree?”

Analytic Approach

The interviews and focus groups were audio recorded and transcribed. Data from the interviews and focus groups were analyzed using a modified grounded-theory approach (Charmaz 2006). In more traditional grounded theory approaches the theory arises directly from the data. I modified this approach by querying the data to identify community member perspectives that would tell the story of community engagement in the ET intervention. I drew from these stories, themes, or local concepts that reflect community member perspectives of the research process and that indicate points where ownership of the intervention occurred and was supported by the community and university researchers. Table 1 displays the coding matrix with focused codes that arose from the data along with emergent themes that provide an organizing structure for thinking about connections between focused codes. The numbers represent the frequency with which each code and theme was applied to the data.

Table 1 Evaluation code matrix
Full size table

Results and Discussion

Results focus on four emerging themes: process development, community participation, partnership and ownership. The discussion demonstrates how ownership of the intervention arose from a translational and indigenizing process, initiated by the community, which was supported and enhanced through the implementation of CBPR. Community member perspectives of their participation in the research study reveal important process points. These stand to contribute meaningfully to implementation science regarding interventions developed by and for indigenous communities, and for other ethnic minority and culturally diverse groups.

CBPR Process Development

Community members stressed the importance of building on and enhancing local capacity and process as part of CBPR implementation. Community member participants in the evaluation provided detailed descriptions of their role in the planning and intervention development phases of the research. One of the primary themes that emerged from the data indicates the importance of having the process emerge from local contexts and practices so that the resulting research or intervention is not experienced as something imposed or introduced, but is instead experienced as a natural, “Yup’ik way” to address an issue or problem in the community. A critical process step in getting to a locally-grown and owned research study happened when university researchers from “outside” came into the community, and first asked members to identify existing strengths and resources and then offered support in building upon ongoing and existing efforts. This allowed the community to identify a local resource committee, already meeting to address serious social problems in the village, and task this group with the community planning and oversight duties for the intervention development and implementation phases of the research. As the process developed and the intervention grew, the resource committee began to be known locally as the community planning group (CPG).

Participants described how another community process group emerged from the CPG to address on a more active level the needs to localize the intervention development efforts and to above all else, maintain a process and project focus consistent with traditional Yup’ik cultural values and practices. The Resource Committee nominated six of its members to sit on a community work group that would meet weekly with the local prevention research staff and visiting university researchers to develop intervention approaches and activities for the pilot. This work group named themselves the “Indigenizing Group”Footnote 1 and met weekly over a 10-month period to develop and plan out a syncretic intervention process based on Yup’ik traditions with innovations coming from other indigenous and western-world frameworks. This group worked to ensure all aspects of the research intervention was contextualized to the community and culture. The community decision to formalize the indigenizing process is a unique feature of the pilot project CBPR implementation. The work group actively took on a role with enculturating agency in the intervention; taking on the role and responsibility to create and enact solutions for their youth based on increasing access to, and knowledge of Yup’ik cultural values, practices and processes (Bateson 2000; Odden and Rochat 2004). Participant experiences with this work group are represented in the following quote from an interview with one of the Indigenizing Group members:

It’s the Indigenizing Group that really did all the work on the modules. We met every week, sometimes more than once a week, days even, to come up with the activities. We met even when there was no university people here to watch us, we would still meet. It was so good! We felt so good about ourselves. A– and D—- would write down everything we were saying about something and then they would send it to the university and the university would give it back to us just like we told them to do it. Sometimes the university would give it back to us and it wasn’t right, it didn’t look like how we told them to do it. So then we would say no, that’s not right, it should be like this. And then the university would fix and make it just right so we could use it for our children. And the children really liked it, especially because they know it came from us. (Indigenizing Group member, elder)

Local experiences at the indigenizing stage of CBPR implementation involved; (1) an increase in communication, an “opening up” of the community and the people, (2) an increase in sharing of knowledge and feelings, (3) the utilization of traditional Yup’ik ways in research activities and meetings, and (4) persistence (continuing on) of the project during times of stress and hardship. Examples from participant statements in the evaluation demonstrate these areas.

Hearing others talk and share – that has really encouraged me to talk. The more we got involved the easier it became to speak in public. And to share my feelings and hear myself speak – it helped me to accept and go on and heal. … Through this program I learn, I share and I put it into practice.” (CPG member, parent)

The Elders and young people meeting together is the best part of this program. Young people, at the start, felt they were very far away. But we start telling about the right way to do things and it start opening things up – and it’s bringing out the Elders in a positive way. We saw a vision. We want to bring people together. And young people talk about the meetings and ask – when are we going to meet again. It’s like a net we have neglected – if it needs mending to fix the holes. This project is like a big net – we are catching people here in the community with this net – dead or alive and if dead they might come alive again – Ellangneq. It’s time to wake up. It’s time to come alive. (CPG member, local leader)

Community Participation

Community members described how this initial participation transformed into a deeper sense of involvement. Involvement in the process was described as qualitatively different from participation. A person can participate in a meeting or activity without being or feeling personally involved. Involvement is indicated when community members move from seeing themselves as passive participants in a process to active leaders of a social movement for change.

Community members interviewed for the evaluation described the involvement of Elders as a key formative process outcome of the ET project. One community member described how the CBPR process implementation “took the Elders off the shelf” and renewed their sense of purpose and power in the community. Another participant stated in an interview:

I’ve lived here over 30 years, I came from downriver, and I’ve lived here for a long time now, and it’s the hardest place I’ve lived. Other places, people share. The whole village shares. Everyone was like brother and sister or uncle and aunt. Then we moved here and it was like closed-in. And I want to say … This project seems to open up a place that once was closed. Now when I walk down the street people will say happy to meet you and smile. Children will say hi to Elders now. That opening and friendliness is different. There is more understanding now – about survival, nature and who we are and how we have to live (CPG member, local leader).

Once the Elders became fully involved in the intervention process, they began to reassert their traditional leadership role in the community. Many people saw this as an important step, central to events leading to problems with the youth decreasing, and with things getting better in the community. For example, one parent noted that her own child was opening up more at home, and was able to talk about things he never would have before. He was even able to overcome a personal crisis involving suicidal thoughts and feelings because of what he had heard from the Elders in one of the ET intervention planning group meetings. Another participant noted that since the Elder’s have started going out to meetings and activities more often, the youth have not been as loud or created as much mischief in the community. Though Elders play a central role in the life of many Alaska Native and American Indian communities, this has not been thoroughly described in terms of how elder involvement can assist with or influence CBPR process and implementation. Nearly all of the community member participants in the evaluation felt strongly that Elder involvement in the CBPR process contributed to a collective community experience of overcoming the intergenerational divide and helped build local capacity for leadership of the intervention in a traditional, Yup’ik way.

Partnership

Community members talked about partnership as a process of coming together. Relationships within the community were described as the key variable in determining the success of the CBPR process. Representatives from each of the local agencies agreed to maintain involvement in the research by coming together and meeting on a regular basis. Collaboration in the CBPR process was established through a formal partnership between the university and local resource organizations, schools and councils. A memorandum of agreement (MOA) was designed by the local community tribal administration, and included representatives from all resource organizations in the community. The university was included as a local partner with the agreement to work together to address community issues related to the well-being and health of the young people. The MOA established a partnership between various organizations both local and non-local that is described by evaluation participants by the character of the relationships achieved within the partnership.

Evaluation participants described two primary types of relationships that influenced most strongly the collaborative process at the community level. The first is the relationship between the community and the university, and the second is the relationships within the community. Community member perspectives related to the effectiveness of the university-community relationship included: (1) the length of time that the university-based project staff (particularly the Project Director) stays in the village and participates in community life; (2) the frequent visits to the community by other university-based members of the research team; (3) the new ideas that the university partners bring out to the community; (4) the funding that the university provides for local workers; (5) the motivation that the university inspires locally; and (6) the support the university representatives provide to local people.

One example of an unintended outcome of the CBPR process implementation involved the degree to which community members came to view themselves as able to influence the researchers, and how researchers themselves become more enculturated to Yup’ik ways over time. One community member described this process outcome as part of a reciprocal exchange leading to multidirectional change.

[People] come from the university and explain everything and that motivates us to want to know more. And that makes them feel so good to help out, especially doing modules. All the Elders come here and share. And when they leave here, they [the researchers] change too. They get more Yup’ik the more we tell them and what they are hearing about our way of life. Jerry [Mohatt] never try and tell us we can’t do this or we can’t do that. We do it our own way and they supported that. (CPG, Elder)

This quote is an example of the unexplored areas of CBPR, and raises new topics not currently salient in the literature, including how community members came to understand and conduct their own research on the behavior of the researchers themselves, and how researchers are changed as a function of their immersion in community activities as a part of their CBPR roles.

Ownership

Community ownership of the project was universally ascribed and affirmed by community member participants in the evaluation. When asked specifically who the project belongs to, the majority of participants stated decisively that it belonged to the people of the community. Some would also qualify that the project belonged mostly to the Elders and a few respondents stated that it belonged to both the people and the university. But the emphasis on the community’s ownership of the process and intervention was clearly stated. For example, when asked who the project belongs to, one community member stated:

It belongs to the community. This is not anyone’s work. We use to say this is “A— and D—s work” or the “University’s project” but we shouldn’t say that. It is our project, ours together. (CPG Member)

Decision-making on the project came to be, and is currently primarily assigned to the Elders. This is consistent with local cultural norms that require Elders be involved in any decisions regarding the community and the people. As in many other Alaska Native and American Indian communities, Elders are the traditional advisors of the community and their participation in community-based projects and research is essential. Day to day leadership on the project is assigned primarily to the local workers and to the CPG. The local workers are community members whose primary responsibility is to ensure that the project moves forward. The local workers make the everyday administrative decisions regarding the project, and organize meetings with the CPG for approval of these decisions and for guidance on broader process-based decisions. One community member describes the decision-making process this way—“The Elders are most involved at all levels and really want to be a part of the program to share what knowledge that they have. That is the role of culture to let Elders give the advice to the rest of the group. Elders provide the leadership and the direction and then it is up to us in the other organizations to carry things out”.

Obstacles and Challenges

Community members shared their experiences of the challenges and obstacles encountered over the course of the project, from entry to implementation. Primary obstacles identified included language barriers, achieving community inclusiveness and maintaining community involvement. Language barriers can inhibit the teaching/learning experience. Youth in the community were most often not fluent in their native language, Yup’ik. Many of the Elders are not fluent in English and meetings that include both Elders and youth must involve a translator and bridge person. This adds several hours to the meeting or activity wherein young people can lose interest and disconnect from the process. Bridge people, those that can communicate with and connect both the youth and the Elders, are essential but sometimes difficult to locate and recruit as part of the CBPR process. The use of translating equipment likewise disconnects youth from hearing their native language spoken and learning from immersion.

Participants also described challenges related to their experience of community inclusiveness throughout the CBPR implementation and process development. The indigenizing process required consensus on what constitutes the core of Yup’ik values and traditions. To gain this consensus there needed to be inclusive representation from all segments of the community. There will always be some level of intra-cultural variation occurring within communities; some groups will be more homogenous across belief systems and social practices, and some less. Participants in the evaluation interviews shared their perspectives on ways they thought that the process could expand to include a broader representation of people in the community. For example, parents of youth who were eligible to participate in the intervention were identified as a group that could be included more in the planning and implementation activities. Including youth in meaningful and consistent ways in the process was another area identified as a challenge and solutions involved increasing incentives for youth to attend meetings and project activities and limiting the number of Elders in attendance at certain meetings to allow youth more of an opportunity to share.

Sustaining community member involvement in the project was the most commonly identified concern among community members. Participants in the evaluation endorsed high levels of initial involvement by community members at the start of the intervention planning work with participation decreasing over time. One community member in an interview stated that: “At the beginning it was good because the program was new, but participation has gone down”. The role of innovation as part of CBPR implementation is another unexplored area of CBPR that emerged from our data. Participants talked about wanting to participate at first because the new people from outside the community brought an excitement and a potential to see things differently and through a fresh perspective. This outsider effect is a common feature of CBPR projects, particularly those projects that partner with small, geographically remote communities, as is the case with Alaska Native villages and many American Indian reservations. An outsider effect can initially accelerate community engagement and participation in a research and intervention process, but is also deceptive in terms of arriving at a clearer understanding of what is actually going to be feasible and sustainable for community participation over time. An outsider effect can get people around the table does not always keep them there.

Although the role of the university was often described as the motivating force to bring local people together from the different agencies to work on social issues in the community, maintaining these relationships within the community was identified as one of the greatest challenges to the CBPR process. Participants talked about how community members can experience “burn-out” from all the meetings, and how turnover within community agencies can make it difficult for the organizations to maintain associations with the research over time. Maintaining the motivational force to continue to come together is a crucial aspect of the partnership process. Some of the reasons community members cited for decreased participation in the CBPR process over time involved: (1) increased hunting or fishing activities; (2) “bored” or “tired” with meetings; (3) university staff coming out less frequently; (4) Elders effectively taking control of the process; and (5) the community no longer being in “crisis” mode.

More specific concerns related to achieving and maintaining community member involvement had to do with recruiting parents of youth and sustaining parental involvement in the CBPR planning process and intervention. The intervention focused on youth between the ages of 12 and 18 years, and their parents. Many of the parents with children in this age group held fulltime positions in a local agency (Tribe, city, school, Headstart, clinic or store), or were the primary subsistence providers for an extended family group. Other parents in this target group were too deeply involved in dealing with their own challenges and struggles to engage productively or consistently within the CBPR process. The parents that did become involved, including the three interviewed for this evaluation, described their experience as part of the CBPR process as life-changing, and cited the timing of the project implementation and the open and supportive manner of the project partners as the reason for their sustained involvement. Several community members stated that the project came at the right time, when the community and many of its members were ready to do something together and change for the young people.

Other issues related to the logistics of maintaining CBPR partnerships were described by community members, and included: (1) the physical distance of the university researchers from the community; (2) how to promote sustainability of the intervention when people were becoming accustomed to receiving payment for attending planning and work group meetings as part of the soon to be ending NIH research; and (3) transportation issues in getting people, particularly mobility challenged Elders, to and from meetings.

Despite the latter obstacle, Elder involvement remained the strongest and most consistent feature of the community involvement throughout the duration of the project. This finding may explain some of the drop-off in levels of community involvement in the CBPR process as related to the frequency with which community members would ascribe ownership of the process to the Elders. It would be consistent with cultural values to see a stepping-back by others in the community once the Elders have come forward to regain their traditional leadership roles.

Conclusion

Elluam Tungiinun (ET) literally means a “movement towards” a social and personal state of well-being. Aboriginally, for Yup’ik peoples, the Elder members of the community, including grandparents, parents, uncles and aunts, were responsible for overseeing progress towards achievement of well-being in the young people of the community (Fienup-Riordan 1994). The traditional roles of Elders, parents and leaders in southwest Alaskan communities were greatly affected by colonization and globalization. Rather than imposing an externally developed set of goals and activities, the CBPR team of the ET project came in with the expressed purpose of locating, supporting, and building on local indigenous participatory processes as a way of strengthening the community and accelerating community ownership of the intervention itself.

In addition to describing important processes related to ownership, the current evaluation also enlarged understanding of the unexplored and unintended outcomes of CBPR-related efforts, those not typically captured in conventional outcomes evaluations of community intervention programs. Much of what we know about outcomes from CBPR in tribal communities, including even process outcomes, involves examination of outcomes related to variables specifically targeted by the intervention, typically related to the researchers’ experiences and perspectives. However, in this evaluation we found that what community members were describing and experiencing often extended well beyond the manifest “outcome” variables related to suicide and alcohol use. Outcomes of engagement in the ET CBPR process included increases in intergenerational interaction, conflict resolution, communication in families, empowerment of the Elders, and overall contributed to a more open and connected social climate in the community. These outcomes also contributed to sustainability of the project. The importance of these outcomes, particularly those at the community level, to community members suggests the value of conceptualizing and assessing CBPR outcomes as involving effects that ripple across multiple levels and many aspects of community life.

The evaluation data describes how the CBPR process implementation coincided with and supported a grass-roots social movement already occurring in the community. The combined effect was to revive the traditional role of the Elders, and to gather the Elders around the youth to protectively care for them. This social movement, among many other things, involved the formation of a resource committee made up of concerned citizens, organizational representatives, and leaders who met once a month to problem-solve around issues related to the young people of the village. The Elders emerged as leaders of the resource committee and soon began meeting as an executive subcommittee on their own. The ET project formed around this local social movement to revive the traditional problem-solving and decision-making role of Elders in the community. This merging of the ET intervention activities within a broader set of pre-existing community level processes that predate and extend beyond the intervention, is likewise rarely documented and studied. This harkens us back to Sarason’s (1989) notions on how the prehistory in many ways predetermines the outcome in the formation of any new setting, and broadens the scope of our consideration when we attempt to understand the outcomes of community interventions. Intervention activities developed around core principles of empowerment, and in particular, with regards to empowerment of the Elders. This led to increased access for the youth to experience relationship to Elders, and to learn from the Elders in meaningful and intentional ways. In this way, the ET CBPR approach supported the local, traditional Yup’ik cultural process for intervening with youth in need of help.

The form that CBPR process implementation takes in an Indigenous community context can have serious implications for intervention outcomes and sustainability. The Indigenizing Group process, initiated and formalized by the community work group members as part of ET, worked to integrate the intervention more naturally and seamlessly into the local cultural context. This innovation of local community members of a formalized, community-directed Indigenizing stage in the CBPR process constituted a critical step in bringing about ownership of the intervention within this tribal community. The next steps for the ET CBPR process involve identifying and building upon these local, reawakened processes for community discovery, decision-making and change, and to base future research design efforts around these local processes. The final key element involves a shift of the researcher role, with its attenuating power and position, to a role with the community as true coequal partner in research design decisions. Indigenizing CBPR can simultaneously improve the quality and the external validity of CBPR research and research findings, as well as improve the lives of indigenous people, as an outcome of engagement. In addition, the approach described in this process evaluation of the ET Project has broader implications generalizable to all CBPR research that seeks to work more in accord with local community customs and cultural practices.