Introduction
Despite decades of research focused on American Indian and Alaska Native health inequities, these groups continue to have a reduced life expectancy compared to other racial and ethnic groups and are disproportionately affected by chronic diseases (Espey et al., Reference Espey, Jim, Cobb, Bartholomew, Becker, Haverkamp and Plescia2014; Gone & Trimble, Reference Gone and Trimble2012). These health inequities are a product of colonization by European countries starting in the 16th century and the collective traumas and atrocities that were inflicted on these groups (Gone et al., Reference Gone, Hartmann, Pomerville, Wendt, Klem and Burrage2019). American Indians and Alaska Natives have endured a history of ethnic and cultural genocide (Heart et al., Reference Heart, Chase, Elkins and Altschul2011) including massacres of communities, forced relocation, genocidal policies, forcibly removing children from their families and placing them into boarding schools, and loss of culture and language due to government enforced prohibition (Thornton, Reference Thornton1997). Beyond the immediate loss of life and land, colonization contributed to many downstream outcomes with important implications for health. Specifically, colonization is linked to historical trauma, or “the cumulative emotional and psychological wounding over the lifespan and across generations, emanating from massive group trauma” (Brave Heart, 2003).
For American Indians and Alaska Natives, historical trauma manifests in high incidence of future trauma exposure (Beals et al., Reference Beals, Manson, Shore, Friedman, Ashcraft, Fairbank and Schlenger2002; Manson et al., Reference Manson, Beals, Klein and Croy2005; Robin et al., Reference Robin, Chester, Rasmussen, Jaranson and Goldman1997), intergenerational trauma (Cromer et al., Reference Cromer, Gray, Vasquez and Freyd2018) and is further compounded by experiences of ongoing racism and discrimination (Akinade et al., Reference Akinade, Kheyfets, Piverger, Layne, Howell and Janevic2023; Herron & Venner, Reference Herron and Venner2022; Solomon et al., Reference Solomon, Starks, Attakai, Molina, Cordova-Marks, Kahn-John, Antone, Flores and Garcia2022). Historical trauma is also related to a constellation of psychological, biological, physiological, and behavioral outcomes, named as the historical trauma response (Brave Heart, Reference Brave Heart1998), which contributes to inequities in mental and physical health (Gone et al., Reference Gone, Hartmann, Pomerville, Wendt, Klem and Burrage2019, John-Henderson & Ginty, Reference John-Henderson and Ginty2020; John-Henderson et al., 2020, 2022a, Reference John-Henderson, Oosterhoff, Kampf, Hall, Johnson, Laframboise, Malatare, Salois, Carter and Adams2022b). Based on these relationships, health interventions rooted in culture have been suggested and utilized to address the health consequences of historical trauma (Gone & Calf Looking, Reference Gone and Calf Looking2011; Gone, Reference Gone2013; Pomerville & Gone, Reference Pomerville, Gone, Fleming and Manning2019).
Despite an environment and context with potentially elevated levels of stress and adversity, American Indians and Alaska Natives demonstrate tremendous resilience (Hartmann et al., Reference Hartmann, Wendt, Burrage, Pomerville and Gone2019; Oré et al., Reference Oré, Teufel-Shone and Chico-Jarillo2016; Reinschmidt et al., Reference Reinschmidt, Attakai, Kahn, Whitewater and Teufel-Shone2016; Teufel-Shone, Tippens, et al., Reference Teufel-Shone, Tippens, McCrary, Ehiri and Sanderson2018). Resilience has been previously defined as “the capacity of a system to adapt successfully to disturbances that threaten the viability, function or development of the system.” (Masten, Reference Masten2014). This definition is applicable to a wide range of dynamic systems, including biological systems within the human body (e.g., cardiovascular system), individuals, communities, and societies (Masten et al., Reference Masten, Lucke, Nelson and Stallworthy2021). Resilience has been central to the survival of American Indian and Alaska Native people, and this resilience has been demonstrated across the lifespan (Oré et al., Reference Oré, Teufel-Shone and Chico-Jarillo2016), including youth (Gilgun, Reference Gilgun2002; Henson et al., Reference Henson, Sabo, Trujillo and Teufel-Shone2017; Lafromboise et al., Reference LaFromboise, Hoyt, Oliver and Whitbeck2006; Stumblingbear-Riddle & Romans, Reference Stumblingbear-Riddle and Romans2012), young adults (Nikolaus et al., Reference Nikolaus, Sinclair, Buchwald and Suchy-Dicey2021), and older adults (Kahn et al., Reference Kahn, Reinschmidt, Teufel-Shone, Oré, Henson and Attakai2016; Reinschmidt et al., Reference Reinschmidt, Attakai, Kahn, Whitewater and Teufel-Shone2016). Although the resilience observed in these groups is a response to challenges rooted in long and ongoing history of cultural loss and degradation, and continued discrimination, what remains less clear are the multi-level factors underpinning resilience, and how these factors relate to positive physical and mental health outcomes. Over the past three decades, there has been a growing movement toward strength-based approaches to understanding health and resilience across racial and ethnic groups (Tse et al., Reference Tse, Tsoi, Hamilton, O'Hagan, Shepherd, Slade, Whitley and Petrakis2016). While resilience was once conceived as something remarkable and only observed in some individuals, it is now seen as something that is accessible and inherent to basic human adaptational systems (Masten, Reference Masten2001). As such, identification of resilience factors linked to positive health is an important step in addressing persistent health inequities.
However, to date, by and large, the narrative of the American Indian and Alaska Native health inequities literature has centered on risk factors, and more specifically on biological and behavioral risk factors. This deficit approach to research can reinforce feelings of hopelessness and self-blame (Wood et al., Reference Wood, Kamper and Swanson2018). Furthermore, there is limited incorporation of Indigenous perspectives and voices in this work, which can lead to a paternalistic narrative focusing exclusively on weaknesses (O’Neill et al., Reference O’Neill, Reading and Leader1998). Emphasizing risk factors rather than resilience factors fails to acknowledge the tremendous resilience of American Indian and Alaska Native people which was acknowledged here previously. As stated by James Clairmont, a Lakota spiritual elder, the concept of resilience is inherent to tribal culture, “The closest translation of ‘resilience’ is a sacred word that means ‘resistance’…. resisting bad thoughts, bad behaviors. We accept what life gives us, good and bad, as gifts from the Creator. We try to get through hard times, stressful times, with a good heart. The gift [of adversity] is the lesson we learn from overcoming it” (Graham, Reference Graham2001, p. 1).
Since American Indian and Alaska Native health inequities are a product of current environments and circumstances, along with the stress and trauma associated with historical and current atrocities and hardships, research which aims to understand and address these health inequities without integration of these factors and experiences is problematic and incomplete (de Leeuw et al., Reference De Leeuw, Maurice, Holyk, Greenwood and Adam2012). The importance of historical and current context in this work is the primary reason for focusing exclusively on American Indians and Alaska Natives in the current work. While there are certainly shared experiences and cultural values between these groups and other Indigenous groups, we chose to focus this effort exclusively on these two groups to maximize shared context and histories. Furthermore, in prior research it is commonplace for American Indians and Alaska Natives to be grouped together in analyses (Godfrey et al, Reference Godfrey, Cordova-Marks, Jones, Melton and Breathett2022; Henson et al., Reference Henson, Sabo, Trujillo and Teufel-Shone2017; Kruse et al., Reference Kruse, Lopez-Carmen, Jensen, Hardie and Sequist2022).
There are existing reviews which summarize the work on resilience in Indigenous youth (i.e., American Indians and Alaska Natives) (Heid et al., Reference Heid, Khalid, Smith, Kim, Smith, Wekerle, Hill, General, Green, Harris, Jacobs, Jacobs, Kim, Horse, Martin-Hill, McQueen, Miller, Noronha, Smith, Thomasen and Wekerle2022; Wexler, Reference Wexler2014), in Canadian Indigenous youth (Toombs et al., Reference Toombs, Kowatch and Mushquash2016), and in Arctic indigenous youth (Ulturgasheva et al., Reference Ulturgasheva, Rasmus, Wexler, Nystad and Kral2014). However, the focus of these reviews is on the factors that promote general resilience in these groups (i.e., strength, purpose fortitude), with less emphasis on how resilience factors are linked to downstream health outcomes, and with focus on one specific age group. A previous review focused on identifying themes of American Indian and Alaska Native resilience highlighted the needs for more efforts to link resilience factors with health outcomes to maximize the efficacy of health promotion efforts for these populations (Teufel-Shone et al., Reference Teufel-Shone, Schwartz, Hardy, de Heer, Williamson, Dunn, Polingyumptewa and Chief2018).
The primary purpose of the current review is to synthesize research documenting links between American Indian and Alaska Native resilience factors and health outcomes so that these findings can be useful toward future health promotion efforts. As a construct, resilience has been defined in many ways, however, for the purpose of this review, resilience is conceptualized according to the following definition, “the process of harnessing biological, psychosocial, structural and cultural resources to sustain well-being” (Panter-Brick & Leckman, Reference Panter-Brick and Leckman2013). While well-being can also be defined in many ways, in the current scoping review, we focus on mental and physical health outcomes as indices of well-being. The conceptual model for this review is based on prior theoretical work and is depicted in Figure 1. To begin with, the model recognizes the context of colonization and downstream consequences of colonization including historical trauma, childhood trauma, psychological stress, and cultural degradation and discrimination. While our model acknowledges the significant body of work indicating a relationship between the consequences of colonization and poor health, here we place emphasis on the resilience factors which are linked to positive health outcomes. We also include arrows in our model stemming from the consequences of colonization to the resilience factors, because although this is not the focus of the current review, we posit that these adverse and challenging experiences may contribute to or promote these resilience factors.
Conceptual model including context of colonization and downstream consequences and related health risk factors.
In contrast to dominant notions of health, Indigenous models of health are holistic and emphasize the interconnectedness of multiple domains of one’s life and experiences (Ahenakew, Reference Ahenakew2011). In line with this approach to health, in the current scoping review, we will include resilience factors across multiple domains which are linked to health outcomes. These domains will be identified based on the empirical evidence that emerges in the scoping review. As depicted in our model, these resilience domains could have direct effects on health, or may affect health indirectly, by moderating the degree to which the consequences of colonization negatively impact health resilience.
Once the domains of resilience are identified based on the review of the existing literature, we will summarize the existing literature for each domain. Within each domain, we will report findings across developmental periods if applicable. In our figure, we also note that age, biological sex, trauma exposure, and place of residence (i.e., tribal reservation vs. urban residence) could act as moderators of the proposed model. Some of these moderators are considered in the research included in this review, while others should be explored in future research. Finally, based on the synthesized literature, we propose future directions for promoting health and wellness and improved understanding the mechanisms through which resilience factors may contribute to American Indian and Alaska Native health.
Method
We conducted a scoping review following the methods and approach outlined by Arksey & O’Malley (Reference Arksey and O'Malley2005) in their methodological paper on scoping studies. Scoping reviews are utilized to examine the range of research on a given topic, to synthesize and share findings, and to identify current gaps in the literature (Arksey & O’Malley, Reference Arksey and O'Malley2005). In the current scoping review, the goal was to answer the following research question: “What are the identified resilience factors linked to positive health outcomes in American Indians and Alaska Natives?” Next, we identified relevant studies using a variety of approaches. In April of 2023, we used electronic databases PUBMED-MEdline and Psycinfo. Different combinations of search terms were utilized including protective factors, resilience, health, health outcomes, American Indians, health resilience, health disparities, health inequities, inequity, disparity, mental health, physical health, social, cultural, socio-cultural, psychological, biopsychosocial, and spiritual. We searched for articles with these terms in the subject heading, title, abstract, or keyword section. We also reviewed reference lists from existing reviews of American Indian and Alaska Native health to identify additional articles. From these searches, a total of 71 articles emerged ranging from the year 1997–2023. The authors reviewed the collection of articles collaboratively and excluded any articles that were theoretical (i.e., lacking empirical data), articles that used a deficit approach, and articles that did not focus exclusively on American Indian or Alaska Native samples or communities. After this process, 34 articles remained, and three health protective domains emerged: social protective factors, psychological factors, and cultural/spiritual factors. The findings from work within each of these domains are presented below.
Results
Social protective factors (N = 13)
The link between social factors, experiences, environments, and health has been well-documented in many racial and ethnic groups. In general, while social connectedness is linked to positive health outcomes (Barger, Reference Barger2013; Berkman et al., Reference Berkman, Glass, Brissette and Seeman2000; Fothergill et al., Reference Fothergill, Ensminger, Robertson, Green, Thorpe and Juon2011), social isolation relates to compromised health and mortality (Holt-Lunstad et al., Reference Holt-Lunstad, Smith, Baker, Harris and Stephenson2015). Qualitative research in American Indian and Alaska Native communities indicates that families and the individuals who make up their social network are important sources of strength and direction (McMahon et al., Reference McMahon, D. and Carter2013). In line with these relationships, there is a growing body of work specific to American Indians, indicating that social connectedness is linked to positive mental and physical health which we summarize here. Table 1 lists all studies included in the social resilience domain.
Social protective factors and mental health outcomes
Depression and anxiety are two mental health outcomes that are closely tied to the psychological traumas and stressors which contribute to American Indian health inequities (Brockie et al., Reference Brockie, Dana-Sacco, Wallen, Wilcox and Campbell2015; Kenney & Singh, Reference Kenney and Singh2016; Warne et al., Reference Warne, Dulacki, Spurlock, Meath, Davis, Wright and McConnell2017). Furthermore, depression and anxiety are linked to suicide in the general population (American Association of Suicidology, 2010), which is a leading cause of early mortality in American Indians and Alaska Natives (Indian Health Services, 2023). Similarly, American Indians diagnosed with anxiety and depressive disorders are twice as likely to experience a substance use disorder (SUD) (Riekmann et al., Reference Rieckmann, McCarty, Kovas, Spicer, Bray, Gilbert and Mercer2012), and are at greater risk for hypertension (Ho et al., Reference Ho, Thorpe, Pandhi, Palta, Smith and Johnson2015). These links between depression and anxiety and the primary causes of early mortality for American Indians and Alaska Natives provide a strong impetus to understand the resilience factors which offset risk for depression and anxiety, as well as poor mental health more broadly.
In one qualitative study, American Indian youth were asked to speak about both the challenges and positive qualities they associated with living on a tribal reservation. Many of the American Indian youth who participated in the study indicated that living on a reservation made it easier for them to access social support and allowed them to develop and nurture intergenerational relationships (Wood et al., Reference Wood, Kamper and Swanson2018). In turn, social support and positive relationships across generations allow for a sense of safety and well-being. In a separate study, social connectedness was negatively related to symptoms of depression and anxiety in Blackfeet American Indian adults (John-Henderson et al., Reference John-Henderson, Henderson-Matthews, Ollinger, Racine, Gordon, Higgins, Horn, Reevis, Running Wolf, Grant and Rynda-Apple2020b). Finally, one study reported that American Indian and Alaska Native youth who reported higher levels of family cohesion reported lower levels of symptoms of depression and anxiety (Palimaru et al., Reference Palimaru, Dong, Brown, D'Amico, Dickerson, Johnson and Troxel2022).
Social protective factors and suicide behavior
In other racial/ethnic groups, social relationships inform suicide risk (Chang et al., Reference Chang, Chan and Yip2017; Van Meter et al., Reference Van Meter, Paksarian and Merikangas2019). In a sample of American Indian/Alaska Native adolescents, the relationship between social relationships and suicide risk was gender specific. Specifically, for girls, positive relationships with adults at home, at school, and in the community were independently associated with lower-suicide-attempt prevalence. In contrast, among boys, only positive relationships with adults at home showed an association with lower-suicide attempt prevalence (FitzGerald et al., Reference FitzGerald, Fullerton, Green, Hall and Peñaloza2017).
A separate but related study investigated whether positive relationships with adults at home, in school, and in the community are protective for suicide among American Indian/Alaska Native, Hispanic, and non-Hispanic White adolescents. While positive relationships with adults in the home and in the community were protective for Hispanic and non-Hispanic White adolescents, only positive relationships with adults in the home were protective for American Indian adolescents (Fullerton et al., Reference Fullerton, FitzGerald, Hall, Green, DeBruyn and Peñaloza2019). A related study found that there were gender differences in the types of support were the most protective with regards to suicide risk for American Indian and Alaska Native youth. Specifically, for females, community support was the most protective for having seriously thought about committing suicide, while family support was associated with having made a suicide plan and having attempted suicide. For males, school support was the most protective for having thought about suicide, having made a suicide plan, and for having attempted suicide (Parshall et al., Reference Parshall, Qeadan, Espinoza and English2023). Finally, another study reported that general social support availability appears to affect risk for suicide in American Indian high school students, with those students who reported high levels of social support being less likely to report attempting suicide (Agyemang et al., Reference Agyemang, Madden, English, Venner, Handy, Singh and Qeadan2022). Overall, these findings indicate that there are several social protective factors which are important in reducing the risk for suicidal behavior in American Indian and Alaska Native youth.
Social protective factors and general health resilience
With regards to health resilience more generally, one study utilized a community-engaged approach to identify strategies used by American Indians to promote and maintain wellness and good health. The study included 39 American Indian adults who self-identified as resilient. The qualitative data indicated that social relationships were linked to wellness and survival. Participants spoke about the important role of supportive family members and people in their extended social networks in successfully making healthy changes. They also spoke about how the desire to serve as a role model for healthy behavior acted as an impetus for improving their own health. Finally, participants spoke about how being around others who were engaging in healthy behaviors made them more likely to do the same (Hulen et al., Reference Hulen, Hardy, Teufel-Shone, Sanderson, Schwartz and Begay2019).
Social protective factors and substance use
Recreational alcohol and other drug use was not prevalent in American Indians prior to colonization. The historical traumas which forced relocations and placement in boarding schools, as well as laws leading to cultural degradation and limited use of spiritual practices disrupted the well-being of American Indian communities and contributed to many of the currently observed health inequities, including substance use (Brave Heart, Reference Brave Heart2005; Duran & Duran, Reference Duran and Duran1995). There are known biological, psychological, and social risk and protective factors for addiction (Skewes & Gonzales, Reference Skewes and Gonzalez2013). Understanding protective factors is critical to reducing risk for SUDs.
Previous literature focusing on substance use in American Indian youth indicates that the family environment and family relationships are important in reducing risk for SUD. Social support, supportive family relationships, and positive social interactions have also been found to be protective factors for SUD in American Indian youth, in part by helping them make healthier decisions regarding substance use (Baldwin et al., Reference Baldwin, Brown, Wayment, Nez and Brelsford2011).
As noted above, social support appears to be a health resilience factor for American Indian youth in the context of SUD. Social support can be expressed in many ways, and one expression of support which appears to promote health resilience related to SUD for American Indian adults is the expression of love. A mixed-methods study collected qualitative and quantitative study collected data from two indigenous tribes measured the amount of love, verbal, and physical affection available in one’s childhood environment and in their current family environment. The study found that higher levels of love and verbal and physical affection in both one’s childhood environment and current family environment was negatively linked to alcohol abuse symptoms (McKinley & Scarnato, Reference McKinley and Scarnato2021)
Social protective factors and health in American Indian adults who experienced childhood trauma
As with other racial and ethnic groups, a positive relationship between number of adverse childhood experiences (ACEs) and depressive symptoms has been found in American Indian adults (McKinley et al., Reference McKinley, Boel-Studt, Renner and Figley2021; Roh et al., Reference Roh, Burnette, Lee, Lee, Easton and Lawler2015). However, perceived social support was found to alleviate depressive symptoms for those adults reporting ACEs (Roh et al., Reference Roh, Burnette, Lee, Lee, Easton and Lawler2015). Furthermore, in contrast to ACEs which was positively related to depressive and anxiety symptoms in American Indian adults, social support drawn from both the family and larger community was negatively related to levels of anxiety (McKinley et al., Reference McKinley, Boel-Studt, Renner and Figley2021).
Existing data also highlights community ties and connection as factors capable of promoting positive health outcomes specifically for American Indians who have experienced childhood trauma. One study found that the relationship between childhood trauma and elevated levels of immune system inflammation (i.e., a marker of increased risk for inflammatory diseases) which is observed in other racial and ethnic groups, was not evident in Blackfeet American Indian adults who reported high levels of connectedness to their community as adults (John-Henderson et al., Reference John-Henderson, Henderson-Matthews, Ollinger, Racine, Gordon, Higgins, Horn, Reevis, Running Wolf, Grant and Rynda-Apple2020). These findings indicate that community connectedness may promote physiological resilience in adulthood particularly for those adults who experienced trauma during childhood. Likewise, the presence or availability of social support related to improved mental and physical health for American Indian adults with type 2 diabetes who reported ACEs (Brockie et al., Reference Brockie, Elm and Walls2018). It is posited that social support and social connectedness may allow individuals who experienced childhood trauma to acquire positive coping strategies through learning from others and that this knowledge may offer protection from the negative effects of ACEs.
Psychological protective factors (N = 5)
Psychological resilience or the ability to adapt in the face of adversity (Ong et al., Reference Ong, Bergeman, Bisconti and Wallace2006) has been negatively correlated with a range of poor mental and physical health conditions including increased depressive symptomatology, post-traumatic stress disorder, and physical disability (Burns & Anstey, Reference Burns and Anstey2010; Connor et al., Reference Connor, Davidson and Lee2003; Hardy et al., Reference Hardy, Concato and Gill2004; Mehta et al., Reference Mehta, Whyte, Lenze, Hardy, Roumani, Subashan, Huang and Studenski2008). Studies included in the psychological resilience domain are listed in Table 2. Based on these findings, the relationship between psychological resilience and mental and physical health was investigated in a sample of older American Indian adults (Schure et al., Reference Schure, Odden and Goins2013). In this study, independent of demographics and other health measures, psychological resilience was related to health resilience, with those American Indian adults who reported higher levels of psychological resilience reporting lower levels of depressive symptomatology and chronic pain, and higher levels of both mental and physical health (Schure et al., Reference Schure, Odden and Goins2013).
Another psychological factor which relates to stress resilience is personal mastery or personal sense of control over goal achievement (Pearlin et al., Reference Pearlin, Lieberman, Menaghan and Mullan1981). American Indian and Alaska Native culture is founded on collectivist principles and emphasizes reliance on one’s social group (Barnhardt & Kalagwey, Reference Barnhardt and Kawagley2005; Lafromboise, Reference LaFromboise1992). Based on the collectivist nature of American Indian culture (Lafromboise, Reference LaFromboise1992), investigators tested whether communal mastery, or a sense of shared efficacy, was more related to emotional outcomes including depressive mood relative to personal mastery in a sample of American Indian women. In this study, when faced with high stress circumstances, women who were high in communal mastery experienced a less pronounced increase in depressive mood, compared to women who were low in communal mastery (Hobfoll et al., Reference Hobfoll, Jackson, Hobfoll, Pierce and Young2002).
While it has long been widely accepted that emotions are implicated in both mental and physical health (Mayne, Reference Mayne, Mayne and Bonanno2001), and while emotions are integrated into indigenous models of health (Ahenakew, Reference Ahenakew2011), empirical data to support the role of emotions in American Indian health disparities has only recently begun to accumulate. Emotion regulation refers to efforts to influence which emotions we have, when we have them, and how we experience and express these emotions (Gross, Reference Gross1998). In other racial and ethnic groups, a relationship between emotion regulation strategy use and mental and physical health has been well-documented (Berking & Wupperman, Reference Berking and Wupperman2012; Kraiss et al., Reference Kraiss, Ten Klooster, Moskowitz and Bohlmeijer2020; Low et al., Reference Low, Overall, Chang, Henderson and Sibley2021). Until recently, the role of emotion regulation in informing physical and mental health outcomes in American Indians had not been investigated. However, a new and growing body of work highlights links between emotion regulation and health outcomes in American Indians, indicating that emotion regulation may be a source of resilience. In one prospective study, emotion regulation strategies were found to predict post-traumatic stress symptoms (PTSS) in American Indian adults. Specifically, higher use of emotion reappraisal, or changing the meaning of emotional events to alter emotional experience, predicted lower PTSS (Tyra et al., Reference Tyra, Ginty and John-Henderson2021). The findings here indicate that use of emotion reappraisal may be a source of resilience in the context of a life event and may promote positive mental health outcomes when facing a stressor.
A separate study also documented a relationship between emotion regulation and mental health-relevant outcomes in the context of the COVID-19 pandemic. This study reported that American Indian adults who experienced childhood trauma who used expressive suppression infrequently, had less of an increase in psychological stress and symptoms of depression compared to those American Indian adults who had similar levels of trauma but used expressive suppression more frequently (McCullen et al., Reference McCullen, Counts and John-Henderson2022). Finally, one study found a relationship between reported use of emotion regulation strategies and markers linked to risk for cardiovascular disease in a sample of American Indian adults living on a tribal reservation. This study reported that lower use of expressive suppression was associated with lower ambulatory pulse rate, and lower ambulatory systolic and diastolic blood pressure as monitored over a 7-day period (Tyra et al., Reference Tyra, Ginty, Johnson, Lafromboise, Malatare, Salois and John-Henderson2023).
Cultural and spiritual protective factors (N = 16)
A recurring factor in resilience research in American Indian and Alaska Native peoples is engagement in traditional cultural and spiritual practices (Allen et al., Reference Allen, Wexler and Rasmus2022; Gone & Calf Looking, Reference Gone and Calf Looking2011; Gonzalez et al., Reference Gonzalez, Sittner and Walls2022; Stumblingbear-Riddle & Romans, Reference Stumblingbear-Riddle and Romans2012; Wexler, Reference Wexler2014). The indigenous stress coping model features traditional cultural and spiritual practices as a key moderator of the relationship between trauma (i.e., childhood trauma, historical, and intergenerational) and negative health outcomes (i.e., physical and mental) and substance misuse (Walters & Simoni, Reference Walters and Simoni2002). Furthermore, recent work has supported the conceptualization of traditional culture as a social determinant of mental health and well-being (Masotti et al., Reference Masotti, Dennem, Hadani, Banuelos, King, Linton, Lockhart and Patel2020). There are many facets of traditional cultural practice which may benefit health (i.e., protective factors, resilience factors). These include family and community support, spirituality, traditional healing identity, and ceremonial practices (Fleming & Ledogar, Reference Fleming and Ledogar2008; Kirmayer et al., Reference Kirmayer, Dandeneau, Marshall, Phillips and Williamson2011; LaFromboise et al., Reference LaFromboise, Hoyt, Oliver and Whitbeck2006).
Cultural factors and health
Table 3 lists studies included in the cultural/spiritual resilience domain. Recent work has demonstrated that despite ongoing harms of colonization on American Indian and Alaska Native peoples, youth still hold perspective of hope and see reservations as places of wellness and health emphasizing the role of culture in youth resilience (Wood et al., Reference Wood, Kamper and Swanson2018). In one study, in a sample of American Indian youth living on or near reservations, engagement and in traditional cultural practices was linked to higher levels of self-esteem (Stumblingbear-Riddle & Romans, Reference Stumblingbear-Riddle and Romans2012), and self-esteem has been found to prospectively predict depression in other racial and ethnic groups (Sowislo & Orth, Reference Sowislo and Orth2013). In a separate sample of American Indian youth living in an American Indian community, those youth who felt curious about their traditional culture, ate nutritious foods more frequently. Similarly, those American Indian youth who had integrated American Indian practices into their lives, also ate nutritious foods more frequently (Lee, Reference Lee2011).
A separate study developed a culturally grounded after school program which focused on local cultural values and organized activities guided by local cultural practitioners. After 10 sessions of the program, urban American Indian youth reported higher levels of self-esteem and increased ability to build general resilience, two outcomes with likely implications for mental and physical health resilience (Hunter et al., Reference Hunter, Carlos, Muniz, Leybas Nuño, Tippeconnic Fox, Carvajal, Lameman and Yuan2022).
The “Remember the Removal” Program provides an example of how culture, history, and language can provide comprehensive health benefits to American Indian young adults. This program retraces the Trail of tears with the goal of increasing Cherokee knowledge, culture, and language. Thirty Cherokee participants (mainly young adults) completed the program and completed measures of physical, mental, spiritual and cultural health, and well-being at the start of the program, at the end of the program, and again 6 months after completion of the program. At the end of the program, participants had improved diet and exercise, improved mental health, and improved social and cultural connection. At the 6-month follow-up, participants still exhibited lower levels of depression, anger, and stronger Cherokee identity (Lewis et al., Reference Lewis, Smith, Wildcat, Anderson and Walls2022).
Among American Indian adults, traditional cultural engagement has been associated with positive mental health (Kading et al., Reference Kading, Hautala, Palombi, Aronson, Smith and Walls2015), reduced mental health problems, and trauma (i.e., historical and personal) related difficulties (Bear et al., Reference Bear, Garroutte, Beals, Kaufman and Manson2018; Shea et al., Reference Shea, Mosley-Howard, Baldwin, Ironstrack, Rousmaniere and Schroer2019;Wexler, Reference Wexler2014; Wolsko et al., Reference Wolsko, Lardon, Mohatt and Orr2007). In addition to engaging with culture, cultural connectedness has also been investigated as a resilience factor. In one study, American Indian adults were administered the cultural connectedness scale, which measures connectedness across three subscales: i) identity, ii) traditions, and iii) spirituality (Snowshoe et al., Reference Snowshoe, Crooks, Tremblay, Craig and Hinson2015) and a measure of mental health and well-being. The findings indicated a positive link between cultural connectedness and mental health and well-being, with American Indian adults who reported feeling more connected to native culture also reporting better mental-health and well-being (Masotti et al., Reference Masotti, Dennem, Hadani, Banuelos, King, Linton, Lockhart and Patel2020).
Related to culture, there is growing interest in whether residing on a tribal reservation confers health benefits. While residing on a tribal reservation is associated with increased risks for some health-compromising behaviors (Sarche & Spicer, Reference Sarche and Spicer2008), it is suggested that tribal reservations can make it easier for American Indians to regularly engage in traditional ways of life, protect their cultural values, and use their tribal languages. As a result, these reservations may help to preserve American Indian identity (Thornton, Reference Thornton1997). One study utilized data from two American Indian tribes to investigate whether the length of time one spends living on a tribal reservation relates to levels of psychological distress. They found that it in both tribes, American Indian adults who had spent most of their lives living on a reservation had lower levels of psychological distress compared to those American Indian adults who spent portions of their live off the reservation (Huyser et al., Reference Huyser, Angel, Beals, Cox, Hummer, Sakamoto and Manson2018), suggesting that residing on a tribal reservation may confer benefits for health.
Similar relationships between culture and health are observed in American Indian elders and older adults. Specifically, American Indian elders have demonstrated resilience to mental health difficulties after accounting for demographics and other health measures (Schure et al., Reference Schure, Odden and Goins2013). This resilience has been inextricably linked to traditional cultural connection (Grandbois & Sanders, Reference Grandbois and Sanders2009). Engagement in traditional culture among aging American Indians has also been inversely associated with memory problems (Adamsen et al., Reference Adamsen, Manson and Jiang2021).
As noted previously, American Indians endure a disproportionately large burden of SUD (Beals et al., Reference Beals, Novins, Whitesell, Spicer, Mitchell and Manson2005; Walls et al., Reference Walls, Sittner, Whitbeck, Herman, Gonzalez, Elm, Hautala, Dertinger and Hoyt2021) highlighting the necessity of leveraging the strengths and uplifting communities to address this burden through culturally grounded intervention and prevention efforts (Soto et al., Reference Soto, West, Ramos and Unger2022). In addition to the previously noted links between Native culture and positive health outcomes, extant work indicates traditional cultural engagement and spirituality play a critical role in alcohol cessation (Gone & Calf Looking, Reference Gone and Calf Looking2011; Stone et al., Reference Stone, Whitbeck, Chen, Johnson and Olson2006). Recent work has further supported traditional cultural engagement as protective against substance misuse (Brown et al., Reference Brown, Palimaru, Dickerson, Etz, Kennedy, Hale, Johnson and D’Amico2022; Hirchak et al., Reference Hirchak, Amiri, Espinoza, Herron, Hernandez-Vallant, Cloud and Venner2021) and current efforts are seeking to establish the efficacy of traditional cultural engagement as substance use prevention among American Indian youth (D’Amico et al., Reference D’Amico, Dickerson, Rodriguez, Brown, Kennedy, Palimaru, Johnson, Smart, Klein, Parker, McDonald, Woodward and Gudgell2021).
Overall, the existing work on cultural and spiritual protective factors highlights their central role in promoting positive outcomes for American Indians and Alaska Natives across the lifespan and represent a promising avenue for future health equity research and intervention development.
Discussion
The purpose of the current work was to provide a scoping review of the existing literature on resilience factors and health outcomes in American Indians and Alaska Native peoples. This project was motivated by a recognition for the need to continue to shift focus of American Indian and Alaska Native health research from risk toward resilience. As acknowledged previously, American Indians and Alaska Natives continue to be disproportionately affected by chronic mental and physical health conditions (Espey et al., Reference Espey, Jim, Cobb, Bartholomew, Becker, Haverkamp and Plescia2014; Gone & Trimble, Reference Gone and Trimble2012). While highlighting these inequities is needed to push forward efforts to improve health for American Indians and Alaska Natives, these inequities must be contextualized in the history of colonization and oppression and should be used to motivate researchers and scholars to elucidate factors which allow American Indians and Alaska Natives to thrive and exhibit good health despite a potential underlying context of adversity and trauma. Only through improved understanding and awareness of these resilience factors can effective interventions be designed to promote optimal health and well-being.
To prioritize community well-being and benefit to American Indian and Alaska Native peoples, health research in Indigenous communities must center community member voices at each stage of the research process. A leading model in ensuring appropriate and beneficial research is Community Based Participatory Research (Christopher et al., Reference Christopher, Saha, Lachapelle, Jennings, Colclough, Cooper, Cummins, Eggers, FourStar, Harris, Kuntz, LaFromboise, LaVeaux, McDonald, Bird, Rink and Webster2011; LaVeaux & Christopher, Reference LaVeaux and Christopher2010). This approach emphasizes the importance of equitable partnerships between community members, stakeholders, and researchers and the equal input and involvement of all partners in all phases of the research process. This level of collaboration may strain under resourced and overburdened American Indian community systems. As such, recent calls to action have coined the term regenerative research a term referring to the intentional design of research efforts to promote sustainability and growth of community resources through the research process, rather than only focusing on the downstream benefits of providing information from research findings (Coser et al., Reference Coser, Kominsky and White2021). Examples of such community-engaged work are widespread and growing in indigenous communities (e.g., Blue Bird Jernigan et al., Reference Blue Bird Jernigan, Salvatore, Styne and Winkleby2012; Hulen et al., Reference Hulen, Hardy, Teufel-Shone, Sanderson, Schwartz and Begay2019; Teufel-Shone, Schwartz, et al., Reference Teufel-Shone, Schwartz, Hardy, de Heer, Williamson, Dunn, Polingyumptewa and Chief2018), and should be used to guide future research efforts.
In addition to elucidating resilience factors across three identified domains (i.e., social, psychological, cultural/spiritual) and their relation to health outcomes, this review draws attention to areas in the literature which are lacking and warrant increased attention in future work. The resilience domain with the smallest number of studies was the psychological domain. This is of interest as the body of work on psychological resilience factors and health outcomes is quite robust across other racial and ethnic groups (Aspinwall & Tedeschi, Reference Aspinwall and Tedeschi2010; Park et al., Reference Park, Peterson, Szvarca, Vander Molen, Kim and Collon2014). To build knowledge in this area for American Indian and Alaska Native peoples, it will be critical to increase community-engaged research so that culturally relevant psychological factors which may be sources of resilience are measured appropriately. Furthermore, across all identified domains, there is a general lack of longitudinal research. While documenting cross-sectional relationships between resilience factors and health outcomes is an important step, it is imperative that future research utilizes longitudinal designs to understand dynamic correspondence between changes in these resilience factors and changes in health-relevant outcomes.
We acknowledge that the three individual domains of resilience factors likely interact and inform one another in complex ways. We believe that an important direction of future work should aim to understand the pathways which connect these resilience domains and to better understand interactions between factors across domains. For example, it is possible that a social protective factor such as positive social relationships impacts levels of engagement in cultural activities, and in doing so improves symptoms of depression and anxiety. It is also possible that a factor in one domain may moderate the impact of a factor in a separate domain on health resilience. For example, high levels of family support (i.e., social domain) could promote a positive health outcome (e.g., low levels of anxiety) particularly for American Indians or Alaska Natives who also frequently use emotion reappraisal (i.e., psychological domain). A more nuanced understanding of these pathways and relationships will allow for the design and employment of culturally specific and comprehensive health interventions with a greater chance of contributing to positive and enduring changes in health for American Indian and Alaska Native peoples.
Behavioral factors (e.g., physical activity, dietary intake, sleep) could act as independent resilience factors for American Indian and Alaska Native peoples which promote positive health. It is also possible that the resilience factors identified in the current scoping review may promote positive health outcomes by changing health behaviors. These potential indirect pathways should be explored in future research. Furthermore, future efforts on studying resilience and health in American Indians and Alaska Natives should aim to elucidate barriers to these resilience factors. In other words, it will be important to identify the factors which make it challenging to access or utilize these resilience factors. This information would be valuable in tailoring interventions to address these barriers or challenges to increase observed resilience and positive health outcomes. Finally, while some of the extant literature does consider resilience factors at different points in the lifespan, future studies with samples with a large age range could consider age as a potential moderator of the implications of these resilience factors for health outcomes.
Conclusion
The primary motivation for this work was to provide a synthesis of resilience factors linked to health in American Indian and Alaska Native peoples. The process of collecting work to include in this review provided further evidence of the tendency to focus on deficits rather than strengths in the American Indian and Alaska Native health inequities literature. More specifically, most of the published work in this area continues to use a risk framework to present their findings, but these findings could be presented using a resilience framework. By changing the framing or presentation of findings to highlight resilience rather than risk, researchers may be less likely to foster hopelessness and more likely to promote health behavior changes or other lifestyle changes. The current scoping review synthesizes extant work on resilience factors in American Indians and Alaska Natives and their relationships with health outcomes and calls for more health equity research which utilizes a resilience framework. Furthermore, the review highlights the need for work which considers the interactions between different domains of resilience to better inform the development of effective interventions which aim to increase resilience and consequently improve health for American Indian and Alaska Native peoples.
List of studies included in the social resilience domain
List of studies included in the psychological resilience domain
List of studies included in the cultural/spiritual resilience domain
Funding statement
Research reported in this publication was supported by the National Institute of General Medical Sciences of the National Institutes of Health (NJH, grant number P20GM103474, grant number U54GM115371, and grant number P20GM104417), and by the National Institute on Minority Health and Health Disparities of the National Institutes of Health (NJH, grant number R01MD015894). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Competing interests
The authors declare none.
