Care of the Native American Woman: Strategies for Practice, Education, and Research

Global Indigenous gender concepts, gender-based violence and resilience: A scoping review

BACKGROUND & OBJECTIVE

The legacy of colonialism includes ongoing trauma and disruption of traditional teachings on relationality, which has contributed to Indigenous populations being disproportionately exposed to gender-based violence (GBV). GBV in Indigenous populations is explored to consider gender-specific findings and points of resilience in relational networks.

PARTICIPANTS & SETTING

Included articles sampled Indigenous groups in Canada, US, Mexico, Guatemala, and Israel. All participants self-identified as Indigenous, and were either GBV survivors or service providers working in GBV contexts.

METHODS

A scoping review was conducted in OVID Medline, Embase, APA Psycinfo, and Informit Indigenous Collection, using keywords for Indigenous peoples, gender concepts, and GBV. Articles were screened and extracted by two reviewers; a third reviewer resolved conflicts.

RESULTS

Our search yielded one mixed-method study and seven qualitative studies, all published since 2016. North American studies identified colonial, patriarchal disruptions (e.g. residential schools) to positive pre-contact gender norms (e.g. non-hierarchical roles) that contribute to emerging GBV. Studies conducted in Guatemala and Israel also described local patriarchal cultures contributing to GBV. Lack of understanding of the Two-Spirit identity (i.e. supra-binary gender identity used by Indigenous persons) led to harmful attitudes and stigma. Interpersonal support and return to traditional matriarchal practices were identified as key resilience processes.

CONCLUSIONS

There is limited literature on Indigenous gender concepts and GBV, particularly regarding GBV against males and Two-Spirit persons. Colonization-related violence and/or patriarchal gender norms were identified as precursors for GBV. Decolonization processes should be further explored to address GBV in Indigenous populations.

Prioritizing Connectedness and Equity in Speech-Language Services for American Indian and Alaska Native Children

PURPOSE

American Indian and Alaska Native (AI/AN; Indigenous) students are at a high risk for language and learning disorders. This article aims to highlight how clinicians can use decolonization and Indigenization pedagogies when planning and delivering speech-language services to Indigenous students from the perspectives of Indigenous professionals. These efforts can help promote student resilience, well-being, and identity and are critical to addressing educational inequity and provide culturally responsive services to Indigenous children. Many AI/AN students receive IDEA Part B special education services including speech and language therapy. Many of these students are misidentified as needing special education due to unique learning and language environments (Soto-Boykin et al., 2021). These students bring a unique cultural heritage that is vital to their identity, well-being, health, and school success. Therefore, the goal should be to provide evidence-based services that are culturally tailored and meet the whole child. Using a precision public health approach to consider social determinants of health and historical trauma allows for leveraging of a multilayered, trauma-informed approach to addressing educational inequities.

CONCLUSIONS

An Indigenous connectedness framework can be used to indicate how connectedness is essential to AI/AN child well-being. This framework can be interlaced with existing learning theories to shape instruction where indigenization is a cornerstone of learning. Further examined was the influence of historical trauma, racism, socioeconomic status, and culture loss on learning and language development in AI/AN children in the context of settler colonialism. Strategies on how to use Indigenous knowledge and evidence-based teaching practices were applied to therapeutic services offered by speech-language pathologists and educators.

"Mothers are Medicine": U.S. Indigenous Media Emphasizing Indigenous Women's Roles in COVID-19 Coverage

As COVID-19 surged in 2020, non-Indigenous media had a chronic disease of its own: sparse pandemic news from Indian Country. Within this inadequate coverage, there was an erasure of sources: Indigenous women were missing. This study evaluates the role of gender in U.S. Indigenous news coverage during the early stage of the COVID-19 pandemic. In a qualitative thematic textual analysis, 161 Indigenous media news articles were analyzed to examine gendered news coverage themes from the time the United States instituted a nationwide quarantine until the autumn of 2020. U.S. Indigenous media amplified voices of the Indigenous women on the COVID-19 frontlines. This study focuses on Indigenous media as the benchmark for telling ethical diverse Indigenous community-focused stories, illustrating how women's voices led media coverage and amplified issues. U.S. tribes are often matriarchal. As Europeans wielded disease and genocide as extermination tactics on these communities, women's voices served as medicine to guide narratives to community solutions and healing. As such, this study seeks to add to current theoretical understanding of how Indigenous women's roles were portrayed in COVID-19 coverage.

Representation of American Indian and Alaska Native Individuals in Academic Medical Training

IMPORTANCE

Identifying gaps in inclusivity of Indigenous individuals is key to diversifying academic medical programs, increasing American Indian and Alaska Native representation, and improving disparate morbidity and mortality outcomes in American Indian and Alaska Native populations.

OBJECTIVE

To examine representation of American Indian and Alaska Native individuals at different stages in the 2018-2019 academic medical training continuum and trends (2011-2020) of American Indian and Alaska Native representation in residency specialties.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional, population-based analysis was conducted using self-reported race and ethnicity data on trainees from the Association of American Medical Colleges (2018), the Accreditation Council for Graduate Medical Education (2011-2018), and the US Census (2018). Data were analyzed between February 18, 2020, and March 4, 2021.

EXPOSURES

Enrolled trainees at specific stages of medical training.

MAIN OUTCOMES AND MEASURES

The primary outcome was the odds of representation of American Indian and Alaska Native individuals at successive academic medical stages in 2018-2019 compared with White individuals. Secondary outcomes comprised specialty-specific proportions of American Indian and Alaska Native residents from 2011 to 2020 and medical specialty-specific proportions of American Indian and Alaska Native physicians in 2018. Fisher exact tests were performed to calculate the odds of American Indian and Alaska Native representation at successive stages of medical training. Simple linear regressions were performed to assess trends across residency specialties.

RESULTS

The study data contained a total of 238 974 607 White and American Indian and Alaska Native US citizens, 24 795 US medical school applicants, 11 242 US medical school acceptees, 10 822 US medical school matriculants, 10 917 US medical school graduates, 59 635 residents, 518 874 active physicians, and 113 168 US medical school faculty. American Indian and Alaska Native individuals had a 63% lower odds of applying to medical school (odds ratio [OR], 0.37; 95% CI, 0.31-0.45) and 48% lower odds of holding a full-time faculty position (OR, 0.52; 95% CI, 0.44-0.62) compared with their White counterparts, yet had 54% higher odds of working in a residency specialty deemed as a priority by the Indian Health Service (OR, 1.54; 95% CI, 1.09-2.16). Of the 33 physician specialties analyzed, family medicine (0.55%) and pain medicine (0.46%) had more than an average proportion (0.41%) of American Indian and Alaska Native physicians compared with their representation across all specialties.

CONCLUSIONS AND RELEVANCE

This cross-sectional study noted 2 distinct stages in medical training with significantly lower representation of American Indian and Alaska Native compared with White individuals. An actionable framework to guide academic medical institutions on their Indigenous diversification and inclusivity efforts is proposed.

Trust and world view in shared decision making with indigenous patients: A realist synthesis

INTRODUCTION

How shared decision making (SDM) works with indigenous patient values and preferences is not well understood. Colonization has affected indigenous peoples' levels of trust with institutions, and their world view tends to be distinct from that of nonindigenous people. Building on a programme theory for SDM, the present research aims to refine the original programme theory to understand how the mechanisms of trust and world view might work differently for indigenous patients.

DESIGN

We used a six-step iterative process for realist synthesis: preliminary programme theory development, search strategy development, selection and appraisal of literature, data extraction, data analysis and synthesis, and formation of a revised programme theory.

DATA SOURCES

Searches were through Medline, CINAHL, and the University of Saskatchewan iPortal for grey literature. Medline and CINAHL searches included the University of Alberta Canada-wide indigenous peoples search filters.

DATA SYNTHESIS

Following screening 731 references, 90 documents were included for data extraction (53 peer reviewed and 37 grey literature). Documents from countries with similar colonization experiences were included.

RESULTS

A total of 518 context-mechanism-outcome (CMO) configurations were identified and synthesized into 21 CMOs for a revised programme theory. Demographics, indigenous world view, system and institutional support, language barriers, and the macro-context of discrimination and historical abuse provided the main contexts for the programme theory. These inspired mechanisms of reciprocal respect, perception of world view acceptance, and culturally appropriate knowledge translation. In turn, these mechanisms influenced the level of trust and anxiety experienced by indigenous patients. Trust and anxiety were both mechanisms and intermediate outcomes and determined the level of engagement in SDM.

CONCLUSION

This realist synthesis provides clinicians and policymakers a deeper understanding of the complex configurations that influence indigenous patient engagement in SDM and offers possible avenues for improvement.

Creating a safe space for First Nations youth to share their pain

Introduction:

Indigenous children and youth may be quiet about the way they express their pain and hurt which is in contrast to how health professionals are trained to assess it.

Objectives:

The aim was to understand how youth from 4 First Nation communities express pain using narratives and art-based methods to inform culturally appropriate assessment and treatment.

Methods:

This qualitative investigation used a community-based participatory action methodology to recruit 42 youth between 8 and 17 years of age to share their perspectives of pain using ethnographic techniques including a Talking Circle followed by a painting workshop. Physical pain perspectives were prominent in circle conversations, but emotional pain, overlapping with physical, mental, and spiritual pain perspectives, was more evident through paintings. Art themes include causes of pain and coping strategies, providing a view into the pain and hurt youth may experience. Youth were more comfortable expressing emotional and mental pain through their artwork, not sharing verbally in conversation.

Results:

Circle sessions and artwork data were themed using the Indigenous Medicine Wheel. Content of the circle conversations centered on physical pain, whereas paintings depicted mainly emotional pain (eg, crying or loneliness; 74% n = 31) with some overlap with physical pain (eg, injuries; 54%), mental pain (eg, coping strategies; 31%), and spiritual pain (eg, cultural symbols; 30%). Common threads included hiding pain, resilience, tribal consciousness, persistent pain, and loneliness.

Conclusion:

Once a safe space was created for First Nation youth, they provided a complex, culturally based understanding of the pain and coping experience from both an individual and community perspective. These engaging, culturally sensitive research methods provide direction for health providers regarding the importance of creating a safe space for young people to share their perspectives.

Development and evaluation of an enhanced diabetes prevention program with psychosocial support for urban American Indians and Alaska natives: A randomized controlled trial

Diabetes is highly prevalent, affecting over 25 million adults in the US, yet it can be effectively prevented through lifestyle interventions, including the well-tested Diabetes Prevention Program (DPP). American Indian/Alaska Native (AIAN) adults, the majority of whom live in urban settings, are more than twice as likely to develop diabetes as non-Hispanic whites. Additionally, prevalent mental health issues and psychosocial stressors may facilitate progression to diabetes and hinder successful implementation of lifestyle interventions for AIAN adults. This 2-phased study first engaged community stakeholders to develop culturally-tailored strategies to address mental health concerns and psychosocial stressors. Pilot testing (completed) refined those strategies that increase engagement in an enhanced DPP for urban AIAN adults. Second, the enhanced DPP will be compared to a standard DPP in a randomized controlled trial (ongoing) with a primary outcome of body mass index (BMI) and a secondary outcome of quality of life (QoL) over 12months. Obese self-identified AIAN adults residing in an urban setting with one or more components of the metabolic syndrome (excluding waist circumference) will be randomized to the enhanced or standard DPP (n=204). We hypothesize that addressing psychosocial barriers within a culturally-tailored DPP will result in clinical (BMI) and superior patient-centered (QoL) outcomes as compared to a standard DPP. Exploratory outcomes will include cardiometabolic risk factors (e.g., waist circumference, blood pressure, fasting glucose) and health behaviors (e.g., diet, physical activity). Results of this trial may be applicable to other urban AIAN or minority communities or even diabetes prevention in general.

Colonialization: A Health Determinant for Pregnant Dogrib Women

Childbirth for many Aboriginal women living in remote communities of the Northwest Territories, Canada, includes separation from their family and community for weeks at a time. This colonialization of childbirth, enforced for decades, is true for Dogrib Dene. Colonialization produces serious social consequences on the everyday lives of pregnant Aboriginal women, which results in lower health outcomes. This article provides a literature review of colonialization in Canada’s far north establishing the position that colonialization is a determinant of health. The purpose of this article is to generate knowledge that will inform health professionals and ultimately reduce health disparities as experienced and evident among Dogrib women. By highlighting the concept of colonialization and establishing this concept as a determinant of health, nurses and midwives will identify disparities created through stressors of power and control. From there, culturally meaningful health promotion strategies will be developed and implemented within their nursing practice.

Embodied meanings of early childbearing among American Indian women: a turning point

INTRODUCTION

American Indian women often have poor perinatal outcomes and are at risk for early childbearing. The purpose of this qualitative study was to understand the experience and meaning of early childbearing among American Indian women.

METHODS

Employing interpretive phenomenology and a semistructured interview guide, we interviewed 30 adult American Indian women residing in a northwestern American Indian reservation about their experiences and meaning of early childbearing.

RESULTS

Three overarching themes were tied to their eventual positive evaluation of the experience: 1) mourning a lost childhood, 2) seeking fulfillment, and 3) embodying responsibility.

DISCUSSION

Women indicated that despite their tumultuous childhoods, early childbearing presented an opportunity to effect positive change in their lives. Women's health care providers are positioned to help women change their lives, thereby, improving health outcomes.

A value-based approach to increase breast cancer screening and health-directed behaviors among American Indian women

American Indian/Alaska Native (AI/AN) women have the lowest cancer-screening rate of any ethnic or racial group; AI/AN women in all regions are less likely than non-Hispanic white women to be diagnosed with localized breast cancer; and those AI/AN women presenting with breast cancer have the lowest 5-year survival rate compared to other ethnic groups. This study found that cultural beliefs are more of a factor in mammography screening behavior than other barriers such as access; and that a more holistic educational intervention designed by AI/AN women prompted individual intent and actions to seek mammograms among AI/AN women >40 and to change unhealthy eating and sedentary lifestyles.

Participant experiences of Talking Circles on type 2 diabetes in two Northern Plains American Indian Tribes

The Talking Circle, a culturally appropriate, 12-week educational intervention, was employed on two Northern Plains American Indian reservations to provide information on type 2 diabetes. In a phenomenological study, funded as a minority supplement to the Talking Circle intervention, the authors asked 8 American Indian participants of the Talking Circle to describe their experience of being an American Indian Talking Circle participant. Seven common themes describe the phenomenon of participating in a Talking Circle diabetic intervention. The Talking Circle technique was effective in providing information on type 2 diabetes through culturally appropriate community sharing. Type 2 diabetes is viewed by both outsiders and those involved as a chronic disease of the utmost concern in American Indian communities.