Health effects of Indigenous language use and revitalization: a realist review.

BACKGROUND: Indigenous populations across the world are more likely to suffer from poor health outcomes when compared to other racial and ethnic groups. Although these disparities have many sources, one protective factor that has become increasingly apparent is the continued use and/or revitalization of traditional Indigenous lifeways: Indigenous language in particular. This realist review is aimed at bringing together the literature that addresses effects of language use and revitalization on mental and physical health. METHODS: Purposive bibliographic searches on Scopus were conducted to identify relevant publications, further augmented by forward citation chaining. Included publications (qualitative and quantitative) described health outcomes for groups of Indigenous people who either did or did not learn and/or use their ancestral language. The geographical area studied was restricted to the Americas, Australia or New Zealand. Publications that were not written in English, Spanish, French, Portuguese or German were excluded. A realist approach was followed to identify positive, neutral or negative effects of language use and/or acquisition on health, with both qualitative and quantitative measures considered. RESULTS: The bibliographic search yielded a total of 3508 possible publications of which 130 publications were included in the realist analysis. The largest proportion of the outcomes addressed in the studies (62.1%) reported positive effects. Neutral outcomes accounted for 16.6% of the reported effects. Negative effects (21.4%) were often qualified by such issues as possible cultural use of tobacco, testing educational outcomes in a student's second language, and correlation with socioeconomic status (SES), health access, or social determinants of health; it is of note that the positive correlations with language use just as frequently occurred with these issues as the negative correlations did. CONCLUSIONS: Language use and revitalization emerge as protective factors in the health of Indigenous populations. Benefits of language programs in tribal and other settings should be considered a cost-effective way of improving outcomes in multiple domains.

Decolonizing Mental Health Services for Indigenous Clients: A Training Program for Mental Health Professionals.

Culturally appropriate mental health services are essential for Indigenous people who suffer the greatest mental health disparities of any ethnic group in the U.S. However, few mental health professionals receive training to work with this population. To fill this gap, a 90-minute training was created to increase knowledge of and empathy for Indigenous people and culture and therefore, improve mental health services for Indigenous patients. This training is grounded in cultural competency, cultural humility, and decolonialism. The training is presented here for mental health professionals, agencies, and administrators to use as a guide. The training aims to increase knowledge, awareness, and skills and has been implemented in a variety of settings receiving positive feedback from participants and administrators.

Visioning an Effective Health Encounter: Indigenous Healthcare Experiences and Recommendations for Health Professionals.

PURPOSE: Indigenous patients experience challenges while accessing and utilizing healthcare services that relate to worsened health experiences. Bias towards Indigenous patients is prevalent in healthcare settings and leads to poor health outcomes. The purpose of this study was to learn about the healthcare experiences, both positive and negative, of Indigenous patients and solicit subsequent recommendations to improve care delivered to this population. METHODS: This study sampled Indigenous patients (n = 20) from an Indigenous-serving health clinic to discuss participants' health experiences and elicit recommendations for improved care. Four focus groups were conducted, and template analysis was employed to analyze the data. RESULTS: A total of 15 themes were developed under the category of an effective health encounter. Highlighted themes include healthcare that is free of stigma, quality care, respecting trauma experiences, expanded integrated care and the patient-provider relationship. Based on participant recommendations, a checklist was created for healthcare professionals to improve care delivery to Indigenous patients. Results indicated that bias in healthcare settings may masquerade as poor clinical care but is really founded in biased beliefs and healthcare delivery. Alternatively, when patients received good quality care, their healthcare outcomes improved. Further, effective healthcare incorporates culture, family, tribe, and community and addresses these aspects of health in both clinical and systemic settings. CONCLUSIONS: With some of the largest proportions of health disparities and bias experiences in the US, it is critical that healthcare delivered to Indigenous patients incorporate culturally safe care to regain dignity and improve health outcomes for this population.

Effects of a Decolonizing Training on Mental Health Professionals' Indigenous Knowledge and Beliefs and Ethnocultural Empathy.

Indigenous communities suffer from the highest rates of mental health disparities of any ethnic group in the United States, as well as experience significant amounts of historical and contemporary trauma including violence, racism, and childhood abuse. Unfortunately, the mental health workforce is unprepared to effectively work with this population due to the influence of stereotypes, bias, and lack of training. A 90-minute training for mental health agency employees using decolonizing methods was delivered to improve knowledge of and empathy for Indigenous patient populations (N = 166). Results indicated that the training increased participants' Indigenous knowledge and beliefs across demographic variables and may increase aspects of empathy including awareness. This training was feasible for a wide variety of mental health employees and resulted in increased learning about Indigenous people, which is a critical starting point for mental health professionals working with this population. Suggestions are offered to train mental health providers to deliver culturally responsive care to Indigenous clients and families and for decolonizing mental health professions.

Conceptualizing Indigenous strengths-based health and wellness research using group concept mapping.

BACKGROUND: In recent years public health research has shifted to more strengths or asset-based approaches to health research but there is little understanding of what this concept means to Indigenous researchers. Therefore our purpose was to define an Indigenous strengths-based approach to health and well-being research. METHODS: Using Group Concept Mapping, Indigenous health researchers (N = 27) participated in three-phases. Phase 1: Participants provided 218 unique responses to the focus prompt "Indigenous Strengths-Based Health and Wellness Research…" Redundancies and irrelevant statements were removed using content analysis, resulting in a final set of 94 statements. Phase 2: Participants sorted statements into groupings and named these groupings. Participants rated each statement based on importance using a 4-point scale. Hierarchical cluster analysis was used to create clusters based on how statements were grouped by participants. Phase 3: Two virtual meetings were held to share and invite researchers to collaboratively interpret results. RESULTS: A six-cluster map representing the meaning of Indigenous strengths-based health and wellness research was created. Results of mean rating analysis showed all six clusters were rated on average as moderately important. CONCLUSIONS: The definition of Indigenous strengths-based health research, created through collaboration with leading AI/AN health researchers, centers Indigenous knowledges and cultures while shifting the research narrative from one of illness to one of flourishing and relationality. This framework offers actionable steps to researchers, public health practitioners, funders, and institutions to promote relational, strengths-based research that has the potential to promote Indigenous health and wellness at individual, family, community, and population levels.

The Health Effects of a Cherokee Grounded Culture and Leadership Program.

INTRODUCTION: Indigenous youth and young adults endure some of the highest rates of physical and mental health problems in the United States compared to their non-Indigenous counterparts. Colonization, oppression, and discrimination play a substantial role in these inequitable disease rates. However, culture (e.g., identity, participation, and connection) relates to the prevention of and recovery from illness in Indigenous populations. The Remember the Removal program aims to teach Indigenous youth and young adults tribally specific culture, history, and language to put them on a trajectory to become informed and culturally connected community leaders. We examined the program's effects on health. METHOD: Thirty Remember the Removal program participants, mainly young adults, completed surveys four times: before the program's start, at the end of the training period, at the program's end, and at a six-month follow-up. Various indicators of physical, mental, spiritual, and cultural health and well-being were measured at each time period. Paired t-tests were completed to compare baseline scores to each subsequent time interval. RESULTS: At program completion, and as indicated with an asterisk at the six month follow-up, participants had statistically significantly improved diet and exercise measures (e.g., reduced sugary, salty, and fatty foods, reduced soda consumption, increased fruit consumption, and improved self-efficacy for exercise), improved mental health indicators (e.g., reduced stress, anxiety, depression*, anger*, post-traumatic stress disorder, and microaggressions*, and improved positive mental health) and improved social and cultural connection (e.g., social support, Cherokee identity*, Cherokee values). DISCUSSION: This is one of the first quantitative studies to demonstrate the profound effects that cultural learning and connection have on the health and well-being of Indigenous people and practices. It also demonstrates the specificity and effectiveness of a program created by and for tribal citizens. Future programs with Indigenous populations should work to center cultural connection and ensure that programs are created and directed by tribal community members.

Stress and Cardiometabolic Disease Risk for Indigenous Populations throughout the Lifespan.

BACKGROUND: Indigenous people experience the greatest cardiometabolic disease disparity in the Unites States, yet high cardiometabolic disease risk factors do not fully explain the extent of the cardiometabolic disease disparity for Indigenous people. Stress, trauma, and racism occur at high rates within Indigenous communities and have not been well explored as significant contributors to cardiometabolic disease disparities despite emerging literature, and therefore will be described here. METHODS: This descriptive study explores the relationship between cardiometabolic disease risks and Indigenous-specific stressors (e.g., early childhood stress and trauma, adulthood stress and trauma, and historical and intergenerational trauma) using current literature. Indigenous-specific protective factors against cardiometabolic disease are also reviewed. RESULTS: Increasing research indicates that there is a relationship between Indigenous-specific stressful and traumatic life experiences and increased cardiometabolic disease risk. Mental health and psychophysiology play an important role in this relationship. Effective interventions to reduce cardiometabolic disease risk in Indigenous communities focus on ameliorating the negative effects of these stressors through the use of culturally specific health behaviors and activities. CONCLUSIONS: There is increasing evidence that cultural connection and enculturation are protective factors for cardiometabolic disease, and may be galvanized through Indigenous-led training, research, and policy change.

Adipokines and Subclinical Cardiovascular Disease in Post-Menopausal Women: Study of Women's Health Across the Nation.

Background The menopausal transition is characterized by increased cardiovascular risk, weight gain, and increased adiposity for many women. The adipose-derived secretory proteins adiponectin and leptin are associated with insulin resistance, metabolic syndrome, and cardiovascular disease but their role in subclinical atherosclerotic disease is unclear. This cross-sectional study evaluated the associations of adiponectin and leptin with carotid artery intima-media thickness, adventitial diameter, presence of carotid plaques, and brachial-ankle pulse wave velocity (baPWV) in women aged 54 to 65 years. Methods and Results Participants were 1399 women from SWAN (Study of Women's Health Across the Nation), a community-based study of women transitioning through menopause. Carotid ultrasound and baPWV measures were obtained at SWAN follow-up visits 12 or 13, when 97% of participants were post-menopausal. Adipokines were assayed from serum specimens obtained concurrently at these visits. Linear and logistic regression models were used to evaluate adiponectin or leptin, both log-transformed attributable to skewness, in relationship to carotid artery intima-media thickness, adventitial diameter, baPWV, and presence of carotid plaque. Covariates included age, race, study site, smoking, alcohol use, obesity, cardiovascular disease risk factors, and menopausal status. Lower levels of adiponectin were related to greater carotid artery intima-media thickness, wider adventitial diameter, and faster baPWV; associations were attenuated after adjusting for cardiovascular disease risk factors. Higher levels of leptin were associated with greater carotid artery intima-media thickness and wider adventitial diameter in minimally and fully adjusted models, and contrary to expectation, with slower baPWV, particularly among women with diabetes mellitus or obesity. Conclusions Adiponectin and leptin are 2 important inflammatory pathways that may contribute to adverse subclinical cardiovascular disease risk profiles in women at midlife.

The Effects of an Indigenous Health Curriculum for Medical Students.

PURPOSE: Indigenous patients experience a variety of healthcare challenges including accessing and receiving needed healthcare services, as well as experiencing disproportionate amounts of bias and discrimination within the healthcare system. In an effort to improve patient-provider interactions and reduce bias towards Indigenous patients, a curriculum was developed to improve first-year medical students' Indigenous health knowledge. METHOD: Two cohorts of students were assessed for their Indigenous health knowledge, cultural intelligence, ethnocultural empathy, and social justice beliefs before the lecture series, directly after, and 6 months later. RESULTS: Results of paired t test analysis revealed that Indigenous health knowledge significantly improved after the training and 6 months later. Some improvements were noted in the areas of cultural intelligence and ethnocultural empathy in the second cohort. CONCLUSIONS: It is feasible to teach and improve Indigenous-specific health knowledge of medical students using a brief intervention of lectures. However, other critical components of culturally appropriate care including social justice beliefs and actions, ethnocultural empathy, and cultural humility may require increased and immersed cultural training.

Evaluation of a Native Youth Leadership Program Grounded in Cherokee Culture: The Remember the Removal Program.

Indigenous youth suffer from high rates of comorbid mental and physical health disease. The purpose of this research was to evaluate an existing intervention aimed at empowering Indigenous youth, using a qualitative, community-based participatory research method. We completed focus groups with 23 program participants, and analysis revealed positive improvements in physical, emotional, social, and cultural domains. Participants noted that key social, familial, and cultural aspects of the intervention were most impactful for them. Informed by the participants' experiences, these findings offer guidance for developing interventions to reduce and/or prevent mental and physical health disparities for Indigenous youth and young adults.

Integrated Care with Indigenous Populations: Considering the Role of Health Care Systems in Health Disparities.

INTRODUCTION: There is increased evidence for the effectiveness of integrated behavioral health care, however, it is unknown if integrated care is effective or culturally appropriate for Indigenous populations-the population with the largest health disparities in the nation. METHODS: We conducted a literature review to analyze the state of Indigenous health care focusing specifically on the appropriateness of integrated care in this population. RESULTS: Integrated care could improve access to comprehensive care, quality of care, and may be a promising model to reduce health disparities for Indigenous people. DISCUSSION: Indigenous people experience significant barriers to effective health care services that require strategic, systemic, and collaborative interventions to close these gaps. Integrated care appears to be an appropriate solution but additional research is needed to determine this. Further, any health intervention must be carried out in collaboration with tribal communities and nations to ensure success.

Integrated Care with Indigenous Populations: A Systematic Review of the Literature.

INTRODUCTION: The integration of behavioral health into medical care is related to positive results including improved patient health outcomes, provider satisfaction, and cost-offset. Indigenous people suffer from the highest health disparities in the nation and disproportionately experience barriers to health care; yet it is unknown if integrated care is effective for this population. METHODS: A systematic literature review was completed on the state of integrated care at Indigenous-serving health care sites in 2014 and was updated in 2016. Three databases were selected (Eric, Medline, and PsycInfo) and keywords pertaining to an Indigenous population and integrated care services (e.g., Native American, American Indian, or First Nations with integrated care, primary care, or family medicine) were used. After inclusion and exclusion criteria were applied, nine articles were selected out of the 2,889 articles found. Five additional articles were added in the 2016-update search. The selected articles were then evaluated using standards of integrated care. RESULTS: The selected articles demonstrated wide-ranging and positive results including improved physical and mental health symptoms, reduced substance use, improvements in education and employment status, as well as a decreased involvement with the criminal justice system. It appears that interventions that additionally integrated culturally relevant health beliefs and practices experienced the largest gains in health outcomes. DISCUSSION: Integrated care appears to be an intervention that can ameliorate these disparities by reducing stigma for those seeking care and providing coordinated care to prevent or reduce health care disparities in this population. While integrated care appears to be an effective system of care for Indigenous people, it must be noted that integration of local Indigenous health beliefs and practices is equally necessary.

Not all drinking events are the same: Exploring 21st birthday and typical alcohol expectancies as a risk factor for high-risk drinking and alcohol problems.

Alcohol expectancies are a central construct in understanding college student typical alcohol use. However, to our knowledge, there is no research addressing how alcohol expectancies for specific events (i.e. 21st birthday) are different from expectancies regarding typical drinking. We examine the extent to which 21st birthday alcohol expectancies differ from general alcohol expectancies and how 21st birthday expectancies are associated with actual alcohol use and consequences experienced on 21st birthdays, above and beyond expectancies for typical drinking. Participants were college students (N=585; 54% women) who were turning 21 within a week, and intended to drink 4/5 (female/male) drinks on their birthday. All negative expectancies (impairment, risk and aggression, negative self-perception) and positive expectancies (social, liquid courage, sex) except tension reduction were significantly greater for 21st birthday drinking than for typical drinking. While 21st birthday expectancies were not uniquely related to actual birthday drinking, several positive and negative 21st birthday expectancy subscales were associated with 21st birthday drinking-related consequences, even when controlling for typical drinking expectancies. Expectancy challenge interventions aimed specifically at these subscales may be effective at attenuating alcohol-related consequences that result from 21st birthday drinking.