Healthy People is a national program that sets goals and objectives to improve the health and well-being of Americans. Healthy People 2030, the fifth edition of the initiative, seeks to eliminate health disparities, thereby improving the health and well-being of all people.1 Health disparities are health differences in groups who experience obstacles to health because of factors such as their racial or ethnic group, socioeconomic status, or geographic location.2 People identifying as American Indians/Alaska Natives (AI/ANs) have many of the worst health disparities in the US.3 For example, accidents in the AI/AN population caused 11.6% of total deaths in 2017 compared with 6.0% of total deaths in the overall US population. Diabetes led to 5.8% of deaths for AI/ANs compared with 3.0% in the general population, and chronic liver disease/cirrhosis contributed to 5.5% of AI/AN deaths compared with 1.4% in non-Hispanic White Americans.3 Life expectancy for AI/ANs is 77.5 years compared with 79.8 years for non-Hispanic White Americans.4 These inequalities can be attributed to “disparities in money, power, and resources that have existed since colonization.”5 During colonization, tribes were decimated by warfare, disease, and government policies, which led to lasting effects that are termed historical trauma.6 The purpose of this article is to help NPs understand historical trauma and its effects on the physical, mental, social, and environmental determinants of health for AI/ANs. NPs can then provide culturally appropriate interventions to improve health outcomes.
The AI/AN population is growing despite challenges faced by the community. In 2010, AI/AN individuals numbered 5.2 million (1.7% of US population) of which 2.9 million identified as AI/AN alone and 2.3 million identified as AI/AN in combination with one or more other races.7 The AI/AN alone or in combination population grew by 26.7% from 2000 to 2010, while the total US population grew by only 9.7%. Of the total AI/AN population, the largest percentage resided in the west (40.7%) with 78% living off reservation (see Fast facts about the AI/AN population in the US).7,11 There are 573 federally recognized tribes in the US who qualify for services from the Indian Health Service.4 Additionally, there are other AI/AN tribes recognized only by states, and some tribes that are not recognized by any federal or state agency.4 This article overviews the etiology of historical trauma and the main health disparities stemming from historical trauma leading to chronic illness and poor health outcomes (see Health disparities in AI/ANs).3,6,8-34
Historical trauma and health disparities
Health disparities for AI/ANs began with the 15th century arrival of Europeans.6 Traumatic events from colonization that affected the community included warfare, community massacres, genocidal policies, forced relocation to reservations that restricted traditional hunting and agricultural activities, dependence on government food programs, prohibition of cultural customs (language and spiritual practices), and spread of infectious diseases (diphtheria, smallpox, tuberculosis).6,8-12 In 1819, Congress passed the Civilization Fund Act, which established residential boarding schools for AI/ANs.6 The boarding schools flourished from the 1890s to the 1930s.6 Children were abused (physically, sexually, and emotionally) and many died from disease, as well as inadequate food and healthcare.6 Children living in the schools failed to acquire knowledge about traditional AI/AN family structures and develop adequate parenting skills.6 The parenting lessons that they did learn reflected the boarding school culture of abuse rather than loving familial relationships. The lasting legacy of the schools and other AI/AN colonization events are believed to contribute to the population's high rates of alcohol and other substance use disorders, domestic violence, child abuse, and suicide.6,8-12 Evans-Campbell suggested that “in a community that has lost its spiritual compass...people might be more susceptible to drugs, or children raised in families that have lost their ability to parent might experience increased levels of abuse and neglect.”9 The transmission of these events to succeeding generations, known as intergenerational trauma, has given rise to psychological problems in AI/ANs.6,9 The cumulative effects of historical trauma have led to current physical, mental, social, and environmental health problems for tribes.8,11-13
Historical trauma and physical health
As a result of colonization with changes in environment and diet, AI/ANs experience high rates of obesity, diabetes, and metabolic syndrome (MBS).14-16 In 2018, 48.1% of AI/ANs were obese with a body mass index of 30 kg/m2, in contrast to people identifying as Black (38.0%), Hispanic (34.9%), White (31.0%), and Asian (13.0%).17 Diabetes and MBS also disproportionally affect AI/ANs. The prevalence of diabetes in AI/ANs was 15.1% compared with people identifying as non-Hispanic Black (12.7%), Hispanic (12.1%), White (7.4%), and Asian (8.0%).16 Diabetes is the fourth leading cause of death for AI/ANs compared with seventh for the US population.3
AI/ANs also have the highest smoking rates across all ethnic/racial groups.18 On average, 24% of AI/AN adults reported smoking cigarettes, relative to people who identified as non-Hispanic White (15.2%), non-Hispanic Black (14.9%), Asian (7.1%), and Hispanic (9.9%).18 AI/AN women also exhibit a high rate of smoking during pregnancy (26.0%).19 Historical trauma can lead to poverty and mental health disorders, which are identified risk factors for tobacco use in AI/ANs.6,9-11,20,21 Tobacco products are less expensive on tribal lands, and some tobacco products are marketed specifically to AI/ANs, which might increase consumption.20 Consequently, relocation to tribal reservations from colonization led to higher smoking rates in AI/ANs.
Historical trauma, social determinants of health, and mental health
Social health determinants contribute to health disparities for AI/ANs, including mental health disparities. As previously mentioned, these disparities are linked to historical trauma and include high rates of depression, alcohol consumption, suicide, violence, lack of education, and poor socioeconomic status.6,9-13
Depression is a common problem among AI/ANs. AI/ANs were 2.5 times more likely than non-Hispanic White individuals to have had severe psychological distress in the past month, which is used to indicate presence of mental health problems severe enough to impact functioning.22,23 Risk factors for depressive symptoms in AI/ANs include childhood neglect, abuse, and household dysfunction (that is, witnessing intimate partner violence), which can be linked to poor parenting as a result of boarding school experiences.6,22 Social support, including support from family, friends, and significant others, can mitigate and safeguard against depression by promoting resilience to the effects of traumatic events.22
Alcohol use in AI/ANs is complex with multiple causes including mental and social factors with roots in historical trauma. Alcohol consumption contributes to AI/AN accident mortality, the third leading cause of death, and chronic liver disease/cirrhosis, which is the fifth leading cause of death.3 While accidents are also the third leading cause of all US mortality, chronic liver disease and cirrhosis ranks 11th as the cause of death for non-Hispanic White Americans.3 One study using data from Contract Health Service Delivery Area (CHSDA) counties found similar rates of binge and heavy drinking between AI/AN men and White men, but AI/ANs had higher rates for alcohol-attributable death than White individuals (98.5/100,000 versus 29.9/100,000).24,25 AI/ANs living in the Northern Plains' CHSDA counties had the highest rate of death.24,25
Social factors can influence alcohol consumption. In a study of adolescent AI/ANs, for example, protective factors against excessive alcohol intake included school attendance, stable family relations and parenthood, strong ethnic identity and traditions, and social problem-solving skills.26,27 However, adolescent AI/ANs who were aggressive, impulsive, had alcohol-consuming friends, and lived in dysfunctional family households were more likely to engage in heavy binge alcohol use.26 These factors can originate due to the effects of historical trauma, which destroyed traditional AI/AN lifestyle and culture.8,28
Suicide is another significant health disparity for AI/AN individuals with both mental health and social components. The suicide death rate for AI/ANs is 16.9/100,000 (male: 27.1; female: 7.2) compared with 13.1/100,000 for White individuals (male: 21.5; female 5.3).29 AI/ANs had the highest increase in suicide rate (65.2%) among racial and ethnic groups from 1999 to 2010.29 Suicide risk factors for AI/ANs include history of abuse, access to a gun, past suicide attempts, anxiety, depression, substance use disorder, unemployment, and a low educational level.8,29,30 Distrust of health services among AI/ANs and lack of access to mental health services as well as marginalization and poverty from historical trauma pose barriers to suicide prevention.8,29 Protective factors include cultural identity and spirituality, which are related to resilience in spite of historical trauma.29 Isolated reservations may not have mental health services to help prevent suicide among AI/ANs.29 The eastern region of the US, however, has a lower AI/AN suicide rate (7.5/100,000), which may reflect better access to healthcare.29 Culturally appropriate prevention should include improvement of coping skills, reduction of the stigma of mental health services, and increased community engagement in suicide prevention programs that incorporate social, cultural, and spiritual values.30
Violence is another health determinant for AI/ANs. In a survey funded by the National Institute of Justice, 84.3% of AI/AN women reported experiencing violence in their lifetime including sexual violence (56.1%), intimate partner physical violence (55.5%), stalking (48.8%), and intimate partner psychological aggression (66.4%).31 Approximately 82% of AI/AN men have also experienced violence in their lifetime, such as sexual violence (27.5%), intimate partner physical violence (43.2%), stalking (18.6%), and intimate partner psychological aggression (73.0%). Unfortunately, 38.2% of women and 16.9% of men were not able to receive needed services, such as healthcare, legal, or housing services, as a result of violence. Another area related to violence is the number of AI/AN individuals reported missing. In 2018, 9,914 AI/ANs were reported missing.32 As mentioned previously, poor parenting skills and other social factors related to historical trauma can lead to violence, which may contribute to these numbers.
Education and socioeconomic status
Socioeconomic status and educational level are independent predictors of health status with lower status associated with worse health outcomes.28 In 2011, approximately 19% of AI/ANs in the US did not complete high school and 19% reported incomes below the federal poverty level compared with 13% for the general population.33 Research suggests these factors may contribute to chronic illness and disparities and stem from historical trauma.28
Historical trauma and environmental determinants of health
Finally, the location of AI/AN reservations engenders health disparities and is directly related to the effects of colonization. AI/AN reservations are often in isolated areas that are poor in resources (hunting, fishing, agriculture) needed to promote the traditional lifestyle of many AI/ANs.28 While Indian Health Service was established by the US government to provide healthcare for AI/ANs, access to Indian Health Service facilities can be limited by geographic distance to a clinic or lack of healthcare staff.24 The Indian Health Service is also chronically underfunded. The US government expends more per capita for Medicaid, Veterans Administration, and the Bureau of Prisons, respectively, than for the Indian Health Service.28,34
Implications for NPs
NPs have the opportunity to improve healthcare for AI/ANs. As stated by one author, “we cannot change the events of the past; however, we need to acknowledge, validate, and respect the emerging science of historical trauma.”6 The National Culturally and Linguistically Appropriate Services (CLAS) Standards in Health and Health Care combined with the goals of Healthy People 2030 to eliminate health disparities provide a framework for developing successful interventions to improve healthcare for AI/ANs.1,35 The CLAS standards emphasize culturally appropriate healthcare that respects cultural healthcare beliefs and practices in regard to governance and leadership, communication and language assistance, and management accountability.35 For example, an updated Cochrane Review found that culturally appropriate education for diabetes in ethnic groups was effective in improving blood glucose control and knowledge.36
Community-based participatory research (CBPR) is an effective method for implementing healthcare interventions for AI/ANs. The model works collaboratively with researchers and tribes. Culturally appropriate interventions using a CBPR paradigm are seen to improve health outcomes for AI/ANs by building on cultural, community, and personal strengths as identified in the CLAS standards.28,37
For example, one CBPR project explored developing culturally appropriate interventions for AI/AN youth based on the Diabetes Prevention Program (DPP).38 The DPP was a clinical trial that randomized either placebo, metformin, or lifestyle changes (diet and exercise to reduce 7% of initial body weight) among more than 3,000 adults without diabetes, but with elevated blood glucose levels (prediabetes).38 The results found that the lifestyle intervention was more effective (58% reduction in incidence of diabetes) than metformin (31% reduction in incidence of diabetes) or placebo.38
In the CBPR study, culturally appropriate exercise interventions included AI/AN activities such as gardening, berry and herb gathering, horseback riding, hunting, hiking, dancing, and AI/AN games. Another suggested intervention was learning to prepare healthy meals using government commodity foods (that is, frozen meat, canned or frozen fruits and vegetables, pastas, cereals, cheese, flour, beans, peanut butter).39
Another identified problem was lack of access to grocery stores with healthy food options such as fresh fruits and vegetables. Strategies for healthy eating entailed restriction of unhealthy foods at home and education about low-cost healthy food. Similarly, another study used a diet plan based on the AI/AN Medicine Wheel, which corresponded to areas of the wheel: 1) north-hunting: buffalo, deer, elk, and rabbit; 2) south-growth: corn, beans, potato, and squash; 3) east-renewal: seeds, nuts, fruits/berries, greens, and roots; and 4) west-rain: water and teas.40
Burnette and Figley proposed a conceptual framework of “historical oppression, resilience, and transcendence,” which NPs can utilize.41 The strategy presupposes that promoting resilience can help overcome the effects of historical oppression (or historical trauma) and promote wellness. The losses from historical oppression lead to unresolved grief, which triggers health problems such as suicide, alcoholism, violence, and anger. Resilience is grounded in the interaction between a person and the environment (individual; family; community and cultural; and society) and determines how well a person adapts to adverse circumstances to achieve wellness.40 Protective factors enhance resilience and transcendence of historical oppression effects.
Societal protective characteristics include spirituality, organization, unity, and cooperation.41 NPs can translate this knowledge into interventions for their AI/AN patients by learning about and supporting use of tribal or spiritual practices to promote resilience. The Indian Health Service and tribal health departments can provide insights into culturally appropriate care. Current treatment for the ill effects of historical trauma is based on revival of cultural practices and traditions, including tribal healing initiatives, rather than antipsychotic medications or cognitive-behavioral therapy.11 Events involving cultural practices, such as beading, prayer, and Native cooking, are protective factors at a community level.42
Similarly, protective factors at the family level are supportive and affirming families.41 Interventions that support stable family and parental relationships are important. Protective individual characteristics include inner strength, optimism, and education.40 Suggested interventions comprise activities previously described to support these strengths. NPs can use this model combined with the CLAS standards and CBPR projects to improve healthcare for AI/ANs. (See Toolkit for NPs working with AI/ANs.)
AI/ANs have experienced significant adverse historical events that have traumatized their lives. These events and accompanying losses are responsible for many of the health disparities experienced today by AI/ANs. By understanding the nature of disparities and the underlying historical trauma, NPs can help eliminate health disparities and achieve the goals of Healthy People 2030.
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