2.4.1 Define Indigenous Health Indicators.

The goal of this component is to identify health indicators that reflect local cultural knowledge, are recognized and valued by community members, and provide a foundation for culturally meaningful monitoring, planning, and interventions.

General guidance: Before defining IHIs, determine whether the community has a set of values or guiding principles that could serve as its foundation. Many communities already have guiding principles rooted in traditional knowledge that reflect health and well-being. For example, in the Copper River region, staff drew on seven traditional Ahtna values as the foundation of local IHIs. If no such framework exists, IHIs can be developed through participatory methods such as storytelling circles, interviews with Elders or Knowledge Keepers, workshops, or photovoice.

• Community storytelling circles: Organize talking circles where community members reflect on questions such as “What does health mean to us?” or “What does a healthy community look like according to our traditions?” Circles should be facilitated by Indigenous community members, often with support by Elders, and where appropriate, research allies [30,31]. Themes emerging from these discussions can form the foundation of IHIs.
• Interviews with Elders and Knowledge Keepers: Elders hold deep knowledge about community well-being and traditional practices that sustain health [32,33]. Interviews can help identify culturally grounded measures of well-being and inform the development of indicator themes.
• Participatory workshops: Community workshops can be used to collaboratively identify what health means within the community [34]. Facilitators can guide participants in brainstorming and grouping ideas related to physical, social, cultural, and environmental well-being, followed by participatory prioritization exercises such as dot voting.
• Photovoice: Photovoice is an arts-based method in which participants use photographs to document aspects of community health or challenges to it [35,36]. Group discussions and interviews about the images can reveal themes that inform IHIs [31].

Regardless of how IHIs are identified, findings should be considered alongside existing Indigenous wellness frameworks and knowledge sources to ensure important dimensions of well-being are not overlooked. For example, the Swinomish IHI team cross-referenced interview findings with ethnographic records, published Indigenous health definitions, and prior Indigenous health frameworks to validate and enrich emerging indicators [3]. This process helps situate community-defined indicators within broader Indigenous knowledge systems.

Once draft IHIs are identified, communities can collaboratively define what each indicator means in practice by identifying key attributes or sub-components [3]. For example, “Natural Resource Security” might include resource quality (abundance and health of water and food resources), access (ability to harvest in traditional areas), and safety (resources free from pollution) [3]. Defining indicators in the community’s own words helps prevent outside misinterpretation, builds shared understanding, and makes IHIs more actionable and locally meaningful. After drafting definitions, communities can hold validation sessions to confirm that the indicators accurately reflect community values and priorities. Similar to member checking in qualitative research [20], this process helps ensure that IHIs are accurate, meaningful, and community-supported.

Copper River application: Copper River staff leveraged existing community events to gather input efficiently and inclusively. Between 22/04/2024 and 30/06/2024, regional staff hosted booths at five village health fairs and the regional youth environmental health fair. These events provided opportunities to engage community members without imposing additional travel or scheduling burdens. To guide discussions, staff highlighted the set of seven traditional Ahtna values recognized across the region. A laminated poster displayed these values, and visitors were invited to place dot stickers next to the values they felt best represented what it means to be healthy. Each participant received five dots, with different colors used to indicate age group (youth, adult, elder) and Alaska Native Tribal membership. Participation was voluntary and followed IRB-approved consent procedures described above.

After collecting initial input on the Ahtna values, the Copper River staff worked with the academic research team to plan a process for validating results with the broader community. The Copper River staff decided that a community dinner would provide an inclusive, culturally familiar setting to facilitate participation by community members of all ages from across the region. The dinner was held at a community hall and catered by a local community business. The meeting began with a presentation explaining the concept of “Indigenous Health Indicators” and sharing preliminary results from the community dot voting. Participants were invited to reflect on how results aligned with their own experiences and cultural values. Facilitators solicited feedback on preferred formats for presenting results, ensuring the community had an opportunity to validate, contextualize, and guide the presentation of their collective input.

To develop definitions for the IHIs, the Copper River staff and academic research team designed an online survey that invited community members to share their interpretations and lived experiences in relation to each IHI. Respondents were asked two open-ended questions: “What word or words come to mind when you think of [indicator] in the Copper River region?” and “Can you share an example or a story about [indicator] in your community? Or an image that comes to mind?” The responses were analyzed for common themes and culturally significant language, which were synthesized into preliminary definitions. These were shared with community members to validate their accuracy and resonance, assess whether they reflected community understanding of the IHIs, and refine the language. The feedback was used to revise the definitions.

2.4.2 Identify indicators affected by the issue of interest.

The goal of this component is to operationalize IHIs in relation to a specific environmental, social, or programmatic issue affecting community health and resilience. Using IHIs to track challenges and improvements can help communities generate locally-grounded evidence to guide planning and decision-making.

General guidance: A variety of participatory methods can be used to understand how specific IHIs are affected by the issue of interest. These methods help connect observed environmental or social changes to community-defined indicators of well-being.

• Community observations: Gather local Indigenous knowledge about how the issue is being experienced. Indigenous communities are often the first to observe environmental and social changes, such as fish developing sores, plants failing to flower, or fewer youth speaking their language [37]. Community meetings or small-group discussions can explore questions such as: “What changes have you noticed in our environment or community?” and”How do those changes affect us?” Where possible, observations can be linked to specific IHIs. For example, “fish with sores” might relate to Natural Resource Health/Safety, while “fewer youth not speaking the language” could relate to Education/Cultural Continuity. Centering local observations in this way validates Indigenous knowledge and grounds the assessment in lived experience.
• Integrating scientific data: When technical studies or models are available, such as climate projections or pollution data, present them in accessible visual and plain-language formats. Simple charts, maps, or storyboards can help illustrate how environmental changes affect community priorities, such as traditional foods, safety, or water quality. For example, the Swinomish project used color-coded risk maps of shellfish harvesting sites to illustrate future sea-level rise impacts and facilitate a conversation about impacts to local IHIs [8]. Presenting scientific information in this way helps participants interpret data in locally meaningful terms and focus discussions on community priorities.
• Scenario-Based workshops: Facilitated storytelling or hypothetical scenarios can help participants explore how IHIs may change under future conditions. For example, participants might be asked: “What if summer temperatures rise 3°C and wildfires occur every year?” and discuss how each IHI would be affected. Coast Salish Tribes used an oil spill scenario to identify and rank which health indicators would be most impacted [6].
• Dotmocracy: Dot-voting is a simple participatory method for gauging group perspectives [38]. Participants place colored stickers next to IHIs to indicate perceived levels of impact. For example, participants might use different colors to indicate whether wildfire impacts on a given IHI are perceived as high, moderate, or low.

Copper River application: For Copper River staff, the focal issue of interest was wildfire, given the region’s increasing exposure to fire and smoke in recent years. To streamline engagement and minimize participant burden, Copper River staff combined this step with the earlier phase of defining IHIs. After participants identified the Ahtna values they felt best represented what it means to be healthy, they were asked to imagine a wildfire affecting their community and to place an additional set of five stickers next to the values they believed would be most affected. A different color scheme was used for this second set of dots to distinguish them from the earlier responses, while still differentiating participant groups by age (youth, adult, Elder) and Alaska Native identity. This visual approach helped connect community-defined indicators to a locally relevant environmental stressor.

2.4.3 Prioritize health concerns.

The goal of this component is to identify which IHIs require the most immediate attention in relation to the issue of interest. While all indicators are valued and interconnected, prioritization helps communities identify where to focus initial resources and action.

General guidance:

• Ranking: Community members can rank affected IHIs by priority using cards, numbering exercises, or facilitated group ranking activities [4]. Rankings can be aggregated to identify overall priorities and support group discussion.
• Dotmocracy: Following group discussion, participants can place a limited number of stickers next to IHIs they consider most urgent. The resulting vote distribution provides a visual summary of community priorities.
• Deliberative consensus circle: Talking circles can be used to discuss each IHI in depth and identify shared priorities through facilitated discussion [39].
• Multi-criteria decision tools: Participants can evaluate priorities using multiple criteria, such as severity, cultural importance, or number of people affected. Through discussion or scoring exercises, priorities are weighted and aggregated to identify areas for action [4]. For example, the Swinomish IHI team converted IHI ranking into weights that were used to prioritize harvest locations in a spatial planning process related to marine resources [4].

Copper River application: To identify priority areas for health and resilience planning, the academic research team supported the Copper River staff with analysis of dot voting data collected during the community health fairs. Votes were counted and organized into a dataset that included the total number of votes for each IHI, grouped by community and by demographic (age group and Alaska Native identity). Microsoft Power BI (Version 2.135.7627.0, August 2024) was used for data management, visualization, and analysis.

To center Alaska Native perspectives, the analysis focused on votes cast by Alaska Native community members. The prioritization process was conducted for two sets of votes: 1) Votes reflecting each indicator’s contribution to overall Indigenous health, and 2) Votes reflecting the perceived impact of wildfires on each indicator. For each analysis, votes within each community were summed, and the indicators were ranked from 1 to 7, with 1 representing the indicators most frequently selected as contributing to health or most impacted by wildfire, and 7 representing relatively less frequent selections. The six community-specific ranks were then averaged to calculate a regional rank for each indicator. To make the results easier to interpret, the reciprocal of each average rank was taken, such that taller bars in the charts corresponded to indicators perceived as contributing more strongly to Indigenous health or being more affected by wildfire relative to other indicators.

2.4.4 Identify strategies to address the risk.

The goal of this component is to identify strategies that can strengthen IHIs most affected by the issue of interest. This step helps communities prioritize actions that are both meaningful and feasible within local capacity. Strategies may include direct interventions (e.g., improving emergency communication or access to traditional foods) or broader policy or planning efforts (e.g., integrating Indigenous values into hazard mitigation or health plans).

General guidance:

• World Café: World Café is a facilitated discussion method that uses rotating small-group conversations to explore community concerns, share perspectives, and generate ideas through iterative dialogue [40,41]. Discussion tables are organized around priority issues identified in earlier steps, and participants rotate among tables while building on previous conversations. After several rounds, participants reconvene to share insights and identify actionable strategies.
• Scenario Planning: Facilitated scenarios can help participants explore possible responses to future challenges. Participants may take on different community or leadership roles and collaboratively develop strategies under hypothetical conditions, such as flooding, wildfire, or infrastructure disruptions [42].
• Ranking or Voting: Communities can use ranking or voting exercises to identify the strategies they consider most important or feasible. Priorities can also be organized into short-, medium-, and long-term actions to support implementation planning [3,5,6,8].

Once the strategies are selected, communities can develop implementation plans outlining priorities, responsibilities, resources, timelines, and indicators of success [43–45]. Planning may occur during community workshops or through designated advisory groups. The goal is to create actionable plans that align with community priorities and governance processes.

Copper River application: Following the prioritization of IHIs, Copper River staff reflected on what they had learned about community values and priorities through the project. Drawing on their knowledge of ongoing conversations in the community beyond the project, staff recognized the revitalization of cultural burning practices as a strategy that could both support the values identified through the IHI process and contribute to wildfire resilience in the region. To further explore this connection, the academic research team reviewed the literature on contemporary cultural burning practices and examined how these practices could relate to the Copper River region’s IHI. This reflection and review helped link the prioritized values to actionable strategies that could inform community-led wildfire resilience planning.

Findings.

Across the five village health fairs, regional youth environmental health fair, community validation session, and follow-up survey activities, approximately 153 community members participated in at least one component of the project, representing approximately 11% of the combined population of the eight Tribal villages in the Copper River region (1,350 residents). Of these 153 individuals, approximately 30 participated in more than one activity, most commonly by voting at a village health fair and then attending the community validation dinner. Participation varied across activities and reflected voluntary engagement through existing community events and outreach efforts. Because activities were designed to support broad community participation and relationship-building rather than population-representative sampling, the findings should be interpreted as community-guided priorities and perspectives rather than statistically representative estimates.

Community members consistently engaged with all seven Ahtna values during the health fair activities, supporting their use as the foundation for IHIs in the Copper River region. Conversations during the fairs further reinforced the alignment between these traditional values and local understandings of health and well-being.

The seven traditional Ahtna values used as the basis for IHI development included: Respect (Respect for Environment, Respect for Food, and Respect for Family and Elders), Knowledge (Knowledge of Tradition, Knowledge of Land, and Knowledge of Yourself), Trustworthy, Caring, Sharing, Spirituality, and Honesty. All values were identified by community members as important components of health. Respect and Knowledge were consistently ranked highest across all communities and age groups, reflecting their foundational role in community well-being. Adults and Elders ranked Spirituality next, while youth ranked Honesty next. During the community validation session, participants confirmed that the indicators reflected local understanding of the relationships among individual and community health, cultural practices, and environmental stewardship. Discussions emphasized the centrality of traditional subsistence foods in fostering family connections and spiritual health. Participants repeatedly identified traditional foods as central to cultural preservation, community bonds, and mental well-being. One Kluti-Kaah Tribal Member said, “Once it’s gone, it’s gone.” The phrase resonated with others and reflected concerns about the loss of traditional food sources and cultural practices related to hunting, fishing, and gathering. Sharing also emerged as a central component of well-being. One Ahtna Elder said, “Sharing is not just giving; it’s a way of showing care, which strengthens mental and spiritual well-being.” Elders emphasized that sharing food and resources is a way of honoring ancestors and maintaining cultural values.

A small number of follow-up survey responses describing community interpretations and lived experiences related to each IHI were reviewed collaboratively by the project team and used to draft preliminary working definitions (Table 1). These draft definitions are shared as examples of how communities may translate broad values into more specific and locally meaningful indicator descriptions.

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Table 1. Preliminary working definitions of Ahtna Indigenous Health Indicators. These definitions were developed from survey responses provided by a small group of community members and are shared as an example of the IHI definition development process.

https://doi.org/10.1371/journal.pclm.0000995.t001

Copper River staff reflections.

Copper River staff reported that integrating the project into existing community events was beneficial because it reduced additional time burdens for participants already attending the event. However, staff noted that standalone events may allow participants to engage more deeply with the activities. Staff also suggested the possibility of standardizing facilitation prompts (e.g., through a script or facilitation guide) to ensure consistency across data collectors, while still allowing for flexibility based on individual participant conversations.

Findings.

When participants were asked to consider the impacts of wildfire on community health and well-being, Knowledge and Respect remained highly ranked across age groups, while Sharing became more prominent relative to the earlier prioritization exercise. This shift highlighted the importance of communal support, resource sharing, and social cohesion during environmental stressors such as wildfire and smoke exposure.

Participants frequently connected wildfire impacts not only to immediate physical threats, but also to disruptions in cultural practices, traditional foods, access to the land, and opportunities for intergenerational knowledge sharing. These discussions reinforced the interconnected nature of the IHIs and illustrated how environmental change can affect multiple dimensions of well-being simultaneously.

Copper River staff reflections.

Copper River staff noted that combining indicator identification and wildfire impact ranking in a single activity was efficient and reduced participant burden. However, they identified several areas for refinement. First, spending time as a team to align on working IHI definitions prior to data collection was helpful, and future work could benefit from a brief facilitator guide to ensure consistency across data collectors. Second, staff suggested preparing wildfire scenarios in advance rather than improvising during engagement activities, which would support clearer communication and help participants more easily envision how indicators may be affected. Finally, while the dot-voting system worked well conceptually, color coding for demographic groups was difficult to track during data entry. Staff recommended simplifying the voting approach in future rounds.

Copper River staff reflections.

Copper River staff noted that sharing prioritization results through charts and maps required substantial explanation and suggested exploring more accessible visual formats in future sessions. They recommended using visuals that communicate relative rankings more intuitively, such as icons or culturally relevant images scaled according to the number of votes received for each IHI. Staff also suggested that grounding visuals in familiar elements of place (e.g., salmon, moose, berry patches, potlatch scenes) could help community members more readily connect wildfire impacts to cultural values without extensive interpretation.

Findings.

Revitalization of cultural burning practices emerged as a promising strategy for supporting the values prioritized through the IHI process while also addressing wildfire resilience in the Copper River region. Discussions connected cultural burning to broader goals related to environmental stewardship, cultural continuity, intergenerational knowledge transfer, and community well-being, illustrating how wildfire resilience strategies may also reinforce Indigenous concepts of health.

Copper River staff reflections.

Copper River staff described this step as energizing, noting that learning about cultural burning sparked growing interest and conversation across the region. After hearing examples of cultural burning at a conference, a staff member shared the idea with colleagues and leadership, creating a ripple effect of discussion among the community. Staff emphasized that early progress has been unfolding organically through ongoing conversations led by trusted community members rather than through a formal implementation process.

Looking ahead, staff noted the importance of demonstrating broad community support for cultural burning, particularly when engaging landowners and land managers. They suggested developing visual or narrative approaches to communicate community support as planning efforts continue.