An Exploratory Pilot Qualitative Study That Explores the Influences on Mental Health and Well-Being in Indigenous Youth and Young Adults

Abstract

Background: Suicide is the second leading cause of death among American Indian (AI) adolescents and young adults in the 15- to 24-year-old age group and is the third leading cause of death in the 10- to 14-year-old age group. Methods: Key informant interviews were conducted with AI youth (n = 10) ages 12–18, and young AI adults (n = 10) ages 19–24 to gather input on activities and programs to decrease AI suicidal-related behaviors in Nebraska. These interviews were 45 min in length at maximum. Themes were created once the interviews were completed. Results: The overarching theme was creating and implementing more suicide prevention programs and cultural activities for these age groups. Respondents identified three important characteristics that they believe all programs should have: (1) positive reinforcement, (2) culturally-centered activities, and (3) strength-based approaches that are not from a negative or punitive viewpoint. Conclusion: The results from these interviews can be used to build strengths-based approaches to promoting positive mental health in Indigenous communities and can lead to other successful programs and activities.

1. Introduction

According to the 2020 United States (US) Census, 3.7 million people self-identified as American Indian and Alaska Native (AIAN) alone, and 5.9 million identify as AIAN with one race or more (Rushing et al. 2021). In all, a total of 9.7 million people in the US identify as AIAN. The AIAN population represents 2.9% of the US population. In 2017, the AIAN population was 1% of the total Nebraska state population (Rushing et al. 2021). There are 574 federally recognized AIAN Tribal Nations throughout the US. AIAN populations are culturally diverse, with distinct languages, cultural practices, ceremonies, traditions, and histories (Rushing et al. 2021). They reside in all US geographic regions and show various degrees of assimilation into society (Warne et al. 2017). This diversity can lead to inaccuracies when health data are reported in aggregate for AIAN from different regions (Warne et al. 2017). Approximately 80% of the AIAN live in urban settings instead of on reservations.

AIAN teenagers and young adults are disproportionately affected by stress, depression, and suicide (Rushing et al. 2021). As a population, AIAN individuals experience substantial behavioral health needs compounded by limited access to mental health professionals and services (Rushing et al. 2021). Differences in risk behavior and health outcomes among AIAN teenagers and young adults have been linked to poor economic and social conditions and historical trauma stemming from colonization (Rushing et al. 2021) Combined with chronic underfunding of the Indian Health Service, these conditions mean that many AIAN teenagers and young adults do not have sufficient access to health services (Rushing et al. 2021).

AIANs in the United States experience a persistent and disproportionate burden of numerous health problems, including drinking, post-traumatic stress disorder, and suicide (Holm et al. 2010). AI reservations and communities typically suffer from high rates of adverse social conditions, including poverty, unemployment, and low high school graduation rates, known risk factors for behavioral health conditions (Holm et al. 2010). AI communities also contend with historical and intergenerational trauma from decades of traumatic losses and forced assimilation (Holm et al. 2010). Most AI community members demonstrate high resilience, resourcefulness, and adaptability to overcome adverse circumstances and survive the social and economic challenges of living on a reservation (Holm et al. 2010). Existing evidence suggests that adverse childhood experiences and social conditions in AI communities contribute to poor health outcomes for Ais (Holm et al. 2010).

One Indigenous understanding of suicide is that it is the consequence of a loss of balance and obliteration of cultural ways resulting from colonization (Ehlman et al. 2022). The recent emergence of the term historical outcomes prevention trauma has offered new concepts to characterize intergenerational grief processes and adverse health outcomes of the legacy of European contact and colonization. Historical trauma can be understood as consisting of three primary elements: a “trauma” or wounding; a trauma that is shared by a group of people, rather than an individually experienced; a trauma that spans multiple generations, such that contemporary members of the affected group may experience trauma-related symptoms without having been present for the past traumatizing event(s) (Mohatt et al. 2014). Understanding intergenerational trauma and its impact on mental health is complex and “requires a broader view of identity, community, adaptation, and resistance as forms of resilience” (Ehlman et al. 2022). Negative health outcomes, including depression, substance abuse/dependence, domestic violence, and suicide, have been theoretically linked to internalize not only oppression from genocidal acts committed against AIAN populations at the time of European contact but also ongoing marginalization, oppression, and adversity within Indigenous communities at present (Ehlman et al. 2022).

Suicide and suicide-related behaviors are very concerning among AIAN adolescents. Suicide is the second leading cause of death among AIAN adolescents and young adults in the 15- to 24-year-old age group and is the third leading cause of death in the 10- to 14-year-old age group (Goldsmith et al. 2002). Suicidal behaviors increase with age in this population until age 45, which resembles the general US population (Goodkind et al. 2012). AIANs experience greater use of substance abuse risks such as drinking at a younger age, drinking more heavily, using drugs with alcohol, and experiencing negative life consequences from drinking as well as a higher prevalence of alcohol abuse and dependence and psychiatric disorders (Borowsky et al. 1999).

It is estimated that there are about 13 suicide attempts for every completed suicide in the AIAN population. O’Keefe et al. (2018) estimated that more than 40% of adolescents who die by suicide have made previous attempts, and those who attempt are 20 to 50 times more likely to die by suicide than peers without a history of attempts (O’Keefe et al. 2018). Suicide attempts are associated with depression, substance use, loss of a family member or friend to suicide, availability of firearms, female sex, and a history of physical or sexual abuse (O’Keefe et al. 2018). Some of the risk factors identified in the previous statement for suicide attempts among adolescents in the general population have been found for AIAN youth populations (O’Keefe et al. 2018).

O’Keefe et al. (2018) identified the need to (1) address the role of historical trauma and internalized oppression in shaping divisions within a community and affecting a community’s readiness for change, (2) the importance of extensive community mobilization efforts to address community politics, factions of the community, and organizational alliances, (3) the need to honor locally meaningful conceptualizations of mental health and wellness, and (4) the need for community-based and culturally-relevant clinical services and programs (West et al. 2012). Goodkind et al. (2015) support the importance of addressing AIAN mental health by understanding cultural losses due to colonization and engaging in cultural reclamation (Goodkind et al. 2015). At the same time, researchers and practitioners should question the primacy given to Western mental health prevention and treatment practices that are frequently and implicitly considered to be universal, legitimate, and better because they are based on the knowledge of the dominant group in the United States (Debebe 2012). There has also been notable studies conducted in Canada with the First Nations (FN). One of these studies indicated that while several younger participants found dominant approaches like social support and mental health services helpful, most others sought cultural teachings to first find and then understand their identities as FN people (Isaak et al. 2015). Although, there is significant diversity within the FN communities regarding the degree to which traditional Aboriginal teachings are known, being taught, or practiced (Manning 2013). The participants drew from within themselves, as well as their belief in something larger than themselves, using sacred teachings, spirituality, and forgiveness which has been previously linked with healing, resilience and positive mental health well-being (Manning 2013). In reviewing the mental health services, there are findings that suggest that health systems and clinicians working with AIAN people with suicide risk should work toward developing a heightened awareness of how suicide impacts family members and communities (Shaw et al. 2019). De Schweinitz et al. (2017) their findings also suggest that there is a need for increasing suicidal individuals’ sense of social belonging and connectedness (Shaw et al. 2019). In a rural community in Alaska, individuals emphasized the importance of culture and traditions and noted cultural loss as a significant contributing factor to suicide and a priority for their community to address (De Schweinitz et al. 2017).

The Winnebago Tribe of Nebraska (WTN) is home to 2737 residents. Of those residents, 64.8% (n = 1775) are enrolled WTN members. The WTN reservation is located in the northern half of Thurston County in northeast Nebraska and spans nearly 120,000 acres. A small parcel of land in western Iowa’s Woodbury County is part of the WTN Reservation. The reservation is approximately 20 miles south of Sioux City, IA, and 80 miles north of Omaha, NE, the nearest urban area.

This qualitative research aimed to explore a culturally informed approach to AIAN youth suicide prevention programming for ages 12–24 living on the WTN reservation.

2. Results

Most participants (80%, n = 16) identified as female, with the remaining (20%, n = 4) identifying as male. In each group (youth and young adult), the majority identified as female (80%, n = 8), with the remaining (20%, n = 2) identifying as male. See

Table 1. AIAN demographics.

	AIAN Participants
		N		%
GENDER
Female		16		80%
Male		4		20%
AGE
12 years		1		5%
13 years		1		5%
15 years		2		10%
16 years		2		10%
17 years		4		20%
19 years		1		5%
20 years		5		25%
21 years		1		5%
22 years		1		5%
24 years		2		10%

.

2.1. Past Experience with Suicide Activities

Within the youth group, only one of the ten participants indicated that they had participated in previous suicide prevention program activities. Within the young adult group, three out of the ten participants had participated in previous suicide prevention program activities. Activities ranged from attending lock-ins and suicidal-related walks.

Results indicated that there was little variability between youth and young adults. Instead, it was clear that the youth and young adults within the WTN share interest in suicide prevention programming that incorporates culture, involves physical activity, incorporates Elder teachings, and avoids the use of peer support, stigmatizing language, and lengthy programming.

2.1.1. Incorporating Cultural Practices

Both the youth group and the young adults identified a need to integrate cultural activities throughout any local suicide prevention programming for youth and young adults in the WTN. Among the 20 interviews, 75% of the participants identified cultural practices and shared activities like cultural camps, regalia making, hand games, attending Pow-Wows, spiritual activities (sweats, Native American Church, or praying), and storytelling as crucial elements. Having food present or an incentive that would interest the youth was identified as a need by two youth. There were six participants who described the need to include history and storytelling.

“I was just thinking more traditional native stuff and how it engages kids at the school more because it is something that they know”.

These participants also identified the need to increase the number of cultural activities the youth can participate in, including a weekly round dance or a calendar that indicates the annual events.

There were ten participants that described the importance of praying and reclaiming their family traditions and stories since some youth need someone to guide them.

One of the young adults heard of a healing camp in another Tribal Nation and thought it should be something that WTN could do for our young adults:

“A Healing camp where young adults can get together and learn about historical trauma because we never discuss it. I never understood why I was so angry until I learned about it. All of our youth need to learn”.

2.1.2. Incorporating Physical Activity

All the youth and young adults felt that physical activity and being around others could help address depression by keeping those who participate in suicide prevention program activities feeling positive. The participants suggested they would enjoy the following physical activities: horse riding, nature walks, softball, basketball, and gym workouts. One youth indicated that incorporating horses would help “since the creatures are so in tune with emotions that they could help support someone during their negative thoughts”.

Some traditional activities were identified, but even just something as simple as a walk would be more manageable for anyone interested in participating. The wellness program provides physical trainers who can assist those just starting to exercise as part of a long-term process. One participant discussed needing more spaces and explained that currently only the Land of Wellness and the Whirling Thunder Wellness Program are available. Participants also shared that there is a need for more outdoor spaces that are accessible to young people. One participant discussed:

“Create a sense of belonging and add to the learning with language by incorporating the names in ho chunk throughout the walk or activity”.

One of the participants even suggested relationship building activities with animals:

“Bringing in animals such as horses, cats, and dogs during those intense hours can help through those stressful events. To have a place for a mental health check, an area where people can stop in and have someone there, or even bubble wrap (objects to keep the participants hands busy). Also, having sage, sweetgrass or hearing the songs, offering sweats so that we can be around people and not necessarily have to partake but there for people to be around each other would all be helpful”.

2.1.3. Involving Elders in Youth Suicide Prevention Activities

All but one participant indicated that having the youth and Elders work together on activities or learning from Elders should be included in the programs. One of the young adults indicated that “historical trauma is foundational knowledge that all need to understand. We must understand why we do things to make those changes and be healthier”. Participants suggested that Elders can demonstrate the resilience of the people, which can be conveyed to the young adults, sending the message that despite the negative factors that have plagued us, we can still overcome and move forward. The participants indicated they wanted to learn from the Elders’ lived experiences. A few participants acknowledged that the generational differences make it hard to relate to the Elders. Half of the participants indicated that working together on cultural projects would be ideal for Elders and youth.

“Telling stories about the history, where we come from, and the teachings from the past. There could be little storytelling, with small break-out sessions, so it can continue to evolve. Cultural activities, such as hand games, because those are fun, and the kids would love it”.

One participant presented the idea of an Elder bench where the elderly can take turns in these specific areas, and the young people will know that it is a safe space for the youth to stop and interact or have an ear to listen to them.

2.1.4. A Space to Be Heard: A Sense of Belonging

The majority of the current activities target the youth group, but the young adults (19–24 years of age) have very little programming available to them. About half of the participants indicated a need to have space for the youth to speak and have someone listen. Providing a sense of belonging is vital to the youth and was described throughout the interviews as decreasing depression within our community. They felt it was important to acknowledge that there were some opportunities at the Behavioral Health program. However, having other areas for youth to drop in would be beneficial. Three people indicated that having a support group or a drop-in center known to the youth to provide another space area would be helpful.

2.1.5. What to Be Avoided

Most participants indicated that the activities should not be lengthy or boring. They did not want anyone to be made to feel guilty if they did have any suicidal thoughts. They did not want to be talked down to or judged for the activities or paths they had created. They wanted to make sure that the program was a positive one. They also want people “who are genuine (and not fake)” and passionate people who want to be with them and listen to them. Most participants indicated they did not like peer counseling; one indicated it was dangerous because the burden of someone else caring for a child could lead to something negative within the helping youth.

3. Methodology

3.1. Study Design

This study explored what characteristics should be included in suicidal prevention programs and activities for WTN youth, ages 12–24 years. In this qualitative study, AIAN adolescents and young adults shared their perspectives about suicide prevention through key informant interviews, which were carried out in May 2023. I focused on individual accounts of experience and conducted reflexive thematic analysis techniques for analyzing and framing the research data. The questions were designed based on the information necessary to create responsive activities for this age group’s needs. I have experience presenting suicidal-related behavior education to this age group and wanted feedback on what should be included. The University of North Dakota and the Little Priest Institutional Review Boards reviewed and approved this study. The researcher, author, is a community member and works for the Tribal Nation.

3.2. Recruitment

To be eligible to participate in the study, potential participants had to identify as a Winnebago community Indigenous (AIAN) youth, aged 12–24 years old. This would exclude anyone whose parents did not sign the permission slip, anyone older than 25 and younger than 12. Anyone who did not identify as Indigenous and did not live in Winnebago, NE, was excluded from the study. Participants were recruited through flyers which were posted at the Winnebago Public School, on social media, and sent to emails obtained through staff listings. People interested in participating were asked to contact the researcher directly via cell phone. The researcher did not recruit specific individuals within the age group. The researcher used non-probabilistic sampling methods to obtain AI youth participants (n = 10) 12–18 years of age and AI young adult participants (n = 10) 19–24 years of age. The funding for the gift cards was provided by the Winnebago Public Health Department. Recruitment ended after the conclusion of the final interviews for each of the ten respondents within the age groups.

3.3. Procedure

All adult participants provided written informed consent. All participants under the age of 19 provided parental consent and youth assent before starting the recorded in-person interview. The interviewer followed a semi-structured interview protocol, asked questions, and allowed the participants to respond and elaborate. Participants were offered a $35 gift card as an expression of gratitude, and interview times ranged from 20 to 45 min. A complete interview guide can be found in

Table 2. Interview guide questions.

	Question	Answer Choice(s)
INTERVIEW QUESTIONS	Have you participated in any suicide prevention activities either through the school or the community (these could be health promotion activities or through Morningstar counseling)?	Open Answer
	Think back to a suicide prevention activity that you participated in or are aware of, and think of the top 3 things that you liked about them or would like to have included in the activity. Examples of suicide prevention activities could be cultural camp, traditional activities (softball, basketball, and volleyball), speakers and walks sponsored by the Health Promotions and Education program, or anything else outlined in the readings.	Open answer
	Think back to a suicide prevention activity that you have participated in or are aware of, and think of the top 3 things that you did not like about them. Again, some examples include speakers, presentations, culture camp, traditional activities (softball, basketball, and volleyball), and other activities sponsored by the Health Promotions and Education program or anything else outlined in the readings.	Open Answer
	What else can be performed to decrease suicide-related behaviors?	Open Answer

. In brief, interview topics included: mental health, programs, suicidal-related behaviors, and activities.

3.4. Data Analysis

The researcher audio-recorded all interviews with consent from participants. Nvivo version 12 was used to record and transcribe. All transcripts were manually checked for anonymity after transcription. Transcripts were returned to participants for comment and correction. In addition, the researcher conducted member-checking, and interviewees provided feedback on the findings. There was one coder, and due to the limited responses, only one round of open coding was needed. Once the transcription of participant narratives was completed, a thematic analysis codebook was developed. The following themes emerged: incorporating cultural practices, incorporating physical activity, involving Elders in youth suicide prevention activities, creating a space to be heard, cultivating a sense of belonging, and what should be avoided. The sample size was small, and the responses were limited, especially in the younger age group; so, the researcher went line by line to make those connections.

4. Discussions and Limitations

4.1. Discussion

This research explored insights from the youth and young adults about what should and should not be included in a suicide prevention program. The key findings suggest that a suicide prevention programming needs to be community-based. The WTN youth and young adults shared and interest in suicide prevention programming that incorporates culture, involves physical activity, incorporates Elder teachings, and avoids the use of peer support, stigmatizing language, and lengthy programming. Sjoblom et al. (2022) determined the importance of culturally grounded, community driven approaches in addressing suicide among Indigenous populations (Sjoblom et al. 2022).

A strength of this research is that data were collected directly from AIAN participants. This study provided insight into the importance of incorporating culture into the suicide prevention program. Culture was a significant theme throughout the activities needed to develop a sense of belonging. The culture was woven into physical activities and interactions with the Elders.

It is essential to entice the youth to be involved in these activities by ensuring they are short and exciting but inviting, energetic, and interactive. There was an indication that if the activity looked like it would be boring then they would not attend. The youth and young adults want a safe place to share their emotions and feelings. This environment could be similar to a drop-in center separate from a behavioral health outpatient therapy program but allows participants to be heard and not treated negatively. These activities can be developed into a specifically targeted suicide prevention program. Haroz et al. (2021) their findings identified included cultural fit of intervention approaches, buy-in from local communities, importance of leadership and policy making, and demonstrated program success as key factors (Haroz et al. 2021).

4.2. Limitations

Though this study produced valuable data, some things could be improved. First, the researcher sought a sample set that was non-probabilistic. The first 10 participants of each age group could participate; it was not based on whether the participant was from a single-parent or two-parent family, socioeconomic background, or engagement in cultural activities. As a result, the sample set was not equally distributed across these demographics. A second limitation is that many adolescents were challenged to elaborate on the activities they saw that would benefit them. Most youths had not participated in the existing suicide prevention programs and therefore had no framework to draw from. The third limitation is that this information is localized to this area and might not be reflected in other Tribal Nation children. The fourth limitation is that 80% of the respondents identified as female; the male perspective might have provided slightly different aspects.

5. Conclusions

This study has provided valuable insight into the activities and programs that should be designed for participation among this specific age group. Participants offered multiple specific activities that could be considered based on resources and feasibility: (1) the concept of a healing camp allowing young adults to transition from adolescents to young adults is an idea to incorporate into possible programming, (2) opportunities for young adults to learn about historical trauma and intergenerational trauma in a safe environment. Future research should conduct this same study after the activities have been implemented and determine if this age group has succeeded in increasing mental health and well-being. Future programming in the community should include the voices of the youth in determining the activities.